Use the labels in the right column to find what you want. Or you can go thru them one by one, there are only 34,367 posts. Searching is done in the search box in upper left corner. I blog on anything to do with stroke. DO NOT DO ANYTHING SUGGESTED HERE AS I AM NOT MEDICALLY TRAINED, YOUR DOCTOR IS, LISTEN TO THEM. BUT I BET THEY DON'T KNOW HOW TO GET YOU 100% RECOVERED. I DON'T EITHER BUT HAVE PLENTY OF QUESTIONS FOR YOUR DOCTOR TO ANSWER.
Changing stroke rehab and research worldwide now.Time is Brain!trillions and trillions of neuronsthatDIEeach day because there areNOeffective hyperacute therapies besides tPA(only 12% effective). I have 523 posts on hyperacute therapy, enough for researchers to spend decades proving them out. These are my personal ideas and blog on stroke rehabilitation and stroke research. Do not attempt any of these without checking with your medical provider. Unless you join me in agitating, when you need these therapies they won't be there.
What this blog is for:
My blog is not to help survivors recover, it is to have the 10 million yearly stroke survivors light fires underneath their doctors, stroke hospitals and stroke researchers to get stroke solved. 100% recovery. The stroke medical world is completely failing at that goal, they don't even have it as a goal. Shortly after getting out of the hospital and getting NO information on the process or protocols of stroke rehabilitation and recovery I started searching on the internet and found that no other survivor received useful information. This is an attempt to cover all stroke rehabilitation information that should be readily available to survivors so they can talk with informed knowledge to their medical staff. It lays out what needs to be done to get stroke survivors closer to 100% recovery. It's quite disgusting that this information is not available from every stroke association and doctors group.
It is your doctor's responsibility to get a cardiologist involved in your treatment, assuming that your hospital has a protocol to do this testing(bad assumption). A 21% incidence rate should be enough to have a protocol created on testing for this, if your hospital is competent at all.
Cardiac
biomarkers, such as high-sensitivity cardiac troponin T (hs-cTnT), are
frequently elevated in ischemic stroke patients but the mechanisms
underlying this elevation are insufficiently understood. We determined
the presence of cardiac damage, assessed using cardiac MRI (CMR), in
stroke patients with elevated hs-cTnT and brain natriuretic peptide
(BNP).
Methods
This is a post-hoc analysis of the
prospective, investigator-initiated, cross-sectional HEBRAS (HEart and
BRain interfaces in Acute Stroke) study. All patients underwent
measurement of hs-cTnT and BNP as well as gadolinium-enhanced CMR in the
acute phase of ischemic stroke. We performed unadjusted and adjusted
logistic regression models to assess the association between hs-cTnT and
BNP elevation and the presence of pathological CMR findings.
Results
Two
hundred and thirty three stroke patients (median age 67 years, 33%
female) were included, of whom 43 (21%) had elevated hs-cTnT and 109
(47%) had elevated BNP. 100 of the 233 (43%) patients had pathological
findings on CMR had focal fibrosis as detected by late-gadolinium
enhancement (LGE) in 51 (23%), left-ventricular hypertrophy (LVH) in 38
(16%), reduced LVEF in 32 (14%) and left atrial dilatation in 34 (15%).
After adjustment for potential confounders, both hs-cTnT (adjOR 5.0
(95%CI 2.1-11.7), p<0.001) and BNP (adjOR 4.1 (95%CI 2.3-7.3),
p<0.001) were significantly associated with pathological findings on
CMR. Hs-cTnT was associated with LGE, LVEF and LVH, whereas BNP was
associated with left atrial dilatation and LVEF, LVH.
Conclusion
Elevated
cardiac biomarkers in acute stroke including CMR are strongly
associated with pathological findings on CMR. In acute stroke patients,
elevation of cardiac biomarkers may identify patients who require a more
thorough cardiology work-up.
In recent years it has become clear that heart health and brain health are linked.
Data from various studies have indicated that tighter BP control is associated with improved cognitive outcomes.
Annabelle Santos Volgman, MD, FACC, FAHA, from Rush University Medical Center, discusses connections between heart health and brain health. Source: Rush University System for Health. Reprinted with permission.
“We learn more and more about the connection between the heart and
brain every day — I always tell my patients that what is good for your
heart is good for your brain,” Jeff D. Williamson, MD, MHS,
chief of the section of gerontology and geriatric medicine in the
department of internal medicine at Wake Forest School of Medicine in
Winston-Salem, North Carolina, told Cardiology Today. “We know
for certain that controlling blood pressure reduces the risk for heart
disease and heart failure and reduces the risk for heart attack and
death from heart attack. During the past few years, emerging science has
shown this same heart-healthy behavior, controlling blood pressure, is
also good for the brain. Preventing and treating hypertension reduces
the risk for early dementia and certainly reduce the chance for stroke
dramatically. There is a strong connection here.”
In the SPRINT MIND study, patients assigned intensive BP control had a
significant reduction in risk for mild cognitive impairment compared
with those assigned standard BP control (18.3 cases per 1,000
person-years vs. 14.6 cases per 1,000 person-years; HR = 0.81; 95% CI,
0.69-0.95). The same was observed in the risk for combined rate of
either probable dementia or mild cognitive impairment (24.1 cases per
1,000 person-years vs. 20.2 cases per 1,000 person-years; HR = 0.85; 95%
CI, 0.74-0.97).
Other data from the PESA cohort showed that hypertension and other CV
risk factors were associated with cognitive impairment in patients with
atherosclerosis.
Several societies, including the American Heart Association and the
American Stroke Association, have devoted funding in recent years to
further study the connections between heart health and brain health.
Carl J. Pepine, MD, MACC,Cardiology Today Chief Medical Editor, added that participating
NIH Institutes and Centers are inviting applications to expand existing
awards that are not currently focused on Alzheimer’s disease and its
related dementias (AD/ADRD) to allow the research to develop such a
focus. This represents a considerable investment of public funds, he
said. Multiple health determinants (social, environmental,
biological/genetic/epigenetic, psychosocial, economic, health care, etc)
contribute to AD/ADRD risk, incidence, age of onset, morbidity and
mortality among cohorts with CVD and health disparity populations. Just
how these contribute to CVD and AD/ADRD risk, resilience and adverse
outcomes in these various populations across the life course is
critically important, Pepine said.
Cardiology Today spoke with cardiologists and neurologists
about how heart health and brain health are connected, the impact on
counseling patients, and what this connection means for future
collaborations between the cardiology and neurology communities.
The connection explained
The connection between heart health and brain health is not a new
concept, but experts said there is still much more to be learned.
Jeff D. Williamson
“As scientists and clinicians, we shouldn’t be surprised by the
connection. Mechanisms that impact the risk for heart disease, such as
circulatory function and epithelial integrity in blood vessels, are
exactly the same mechanisms that helps us preserve brain function from
both stroke and dementia,” Williamson said.
The AHA Stroke Council issued a scientific statement in June to aid
primary care physicians in identifying and assessing modifiable risk
factors for cognitive decline, including factors that also affect the
heart such as hypertension, diabetes, lack of physical activity,
obesity, poor diet, hyperlipidemia, smoking and excessive alcohol use.
Annabelle Santos Volgman, MD, FACC, FAHA, professor of
medicine and senior attending physician at Rush Medical College and Rush
University Medical Center and medical director of the Rush Heart Center
for Women, and others have done work showing how the same preventive
measures that improve heart health can also improve brain health.
“I have been practicing cardiology for more than 30 years and am also
an electrophysiologist by training. During my career, I have diagnosed
many patients with arrhythmias, especially atrial fibrillation,”
Volgman, who is also a member of the Cardiology Today Editorial
Board, said in an interview. “In the beginning of this work, we noticed
there were a lot of men and women with atrial fibrillation, which is
associated with the risk for stroke. My mother had a stroke, and it
ruined her life and altered our family life, which is what led me to be
passionate about decreasing the risk for stroke in every individual. We
know that stroke leads to cognitive impairment, but it also goes above
and beyond stroke.”
Volgman said her patients who never experienced a stroke would complain of cognitive impairment.
“They thought it was the medications that I had prescribed them that
was causing it,” Volgman said. “We would perform genetic testing on
patients at the Rush Heart Center for Women, and if genetic tests were
negative, we would then perform APOE genotyping testing. We know that an
isoform of APOE is a marker for early predisposition to Alzheimer’s
disease. When we began receiving positive results, I worried that these
patients were not just at risk for heart disease but also for
Alzheimer’s disease, and so I started referring these patients to my
colleague, Neelum T. Aggarwal, MD, FAMWA, and we became entrenched in this field together.”
Neelum T. Aggarwal
Aggarwal, a cognitive neurologist in the department of neurological
sciences at Rush Alzheimer’s Disease Center at Rush University Medical
Center, said she sees many women who are diagnosed with Alzheimer’s
disease who also have CVD.
“This connection piqued my interest, and when Dr. Volgman referred
these patients to me, I had it in the back of my mind that if we could
control their CV risk factors, then maybe we could prevent the
development of dementia,” she said.
Aggarwal later joined the Rush Heart Center for Women, serves as the
Center’s Research Director, and began formally screening cardiology
patients with memory concerns.
“This collaboration has allowed us to introduce concepts to our
patients about the link between brain health and heart health and
introduce these patients to clinical trials, which are so important,”
Aggarwal said.
“Through the SPRINT MIND clinical trial, researchers found that when
blood pressure was lowered and intensely monitored, the white matter
hyperintensities, that we often see on scans and monitor in neurology,
were less, which is a good indicator that we can modify the negative
effects from the brain through blood pressure management.
“Through SPRINT MIND, we are also continuing to learn that changes in
cognition can be modified if we intensely modify blood pressure
management in these patients,” she added. “SPRINT MIND in itself has
been pivotal for how we are thinking about blood pressure and cognition,
and it gives the practicing clinician, and especially the cardiologist
and the primary care physician, good reason to consider it and to
consider talking about brain health when they’re talking about blood
pressure management with their patients.”
Collaboration is key
The heart-brain connection necessitates collaboration between cardiologists and neurologists, Deborah A. Levine, MD, MPH,
associate professor of medicine and director of the Cognitive Health
Services Research Program at University of Michigan in Ann Arbor, told Cardiology Today.
Deborah A. Levine
“Many vascular risk factors can cause problems with both brain health
and heart health. For example, atrial fibrillation increases the risk
for cognitive decline. Through collaboration between cardiologists and
neurologists, we can make larger strides in improving patient care and
research then we would without collaboration,” Levine said.
“Cardiologists could include the goal of maintaining brain health as one
of the motivating factors to diagnose and treat vascular risk factors
in their patients, to exercise regularly and to eat healthy, in addition
to maintaining cardiovascular health and avoiding the risk for
cardiovascular events such as stroke and heart attack.”
In the PESA study, researchers examined the association between
cerebral metabolism with CV risk factors and atherosclerotic plaque
burden in carotid and femoral arteries among 547 asymptomatic
participants with evidence of subclinical atherosclerosis (mean age, 50
years; 82% men).
Results showed global brain 18F-fluorodeoxyglucose uptake had an
inverse correlation with 30-year Framingham Risk Score, which
researchers determined was mainly driven by the presence of
hypertension. Additionally, carotid plaque burden was inversely
associated with global brain 18F-fluorodeoxyglucose uptake, even after
adjustment for 30-year Framingham Risk Score.
“The more we learn that the same behaviors and interventions in heart
health can reduce the risk for loss of brain health, then the more
powerful our message becomes,” Williamson said. “Cardiologists should
discuss with their patients that what is being done for their heart is
also good for their brain and can reduce their risk for Alzheimer’s
disease and related dementia in the future. Similarly, neurologists,
family practitioners and general internists should relay to their
patients that what they are doing to lower their chance for dementia and
Alzheimer’s disease is also good for their heart. We all need to be
giving the same messages to patients, which will add an incentive to our
patients to be even more careful in following risk prevention
strategies.”
Alan S. Maisel, MD, emeritus professor of medicine at
the University of California, San Diego, and a co-founder of the
Evermore Medical Foundation, said clinicians should tell their patients
that “if they want to live into their 70s and 80s and not experience
issues with brain health, then they better start paying attention to
good blood pressure control.”
“We know how difficult it can be to get our middle-aged or older-aged
patients to take their blood pressure medicine. But now, we can
definitively tell them that we know that uncontrolled blood pressure
will hasten cognitive decline and even possibly lead to dementia or
other diseases, like Parkinson’s disease,” Maisel said. “This
information may lead to better compliance with taking their medications.
We must be aware of the ever-growing importance between heart health
and brain health as neurologists and cardiologists.”
Volgman agreed but said that in a busy cardiologist’s office,
discussions about the link between heart and brain health may be missed.
“Some do not realize the connection is something that we should be
addressing,” Volgman said. “Unfortunately, right now, we do not have
very many good trials on this, which is why Dr. Aggarwal and I are
involved in a variety of different trials on the topic.”
One ongoing NIH-funded trial is comparing physical activity or brain
health games, physical activity alone, brain health games alone or
neither intervention (usual care) among 250 women at Rush Heart Center
for Women.
“We will follow participants for 6 months and test their memory
function. We are currently halfway through the study, and I am excited
about this work,” Volgman said. “This could give us ammunition if the
data are positive for physical activity because we know that
observational studies have shown that physical activity is associated
with less cognitive dysfunction, but this has never been tested in a
randomized controlled study. Hopefully, we will get interesting results
so that we can emphasize to our patients the importance of physical
activity on cognitive function.”
COVID-19 and the brain
When the COVID-19 pandemic hit, much was learned about the impact of
the virus on the heart and the brain. An ever-growing amount of research
is underway looking into the heart-brain connection among individuals
with COVID-19 long-hauler syndrome.
“This is a story that is still to be written and understood. We use
the term ‘long-hauler,’ but we haven’t had a long-haul yet, so we really
don’t know the long-term impact just yet,” Williamson said. “There is a
lot of conjecture and a lot of very important science being done to
understand what the long-term effects of COVID-19 are, but we are just
entering the cusp of understanding it all. Patients certainly tell me
that they are still feeling symptoms from COVID-19, but we are just
beginning to understand what the biology of that is, and we need to be
careful to not speak before we understand. I can conjecture that just as
COVID-19 has had vascular effects on the heart and vascular effects on
the kidneys, there are likely vascular effects on the brain as well as
is the case for many viral pathogens. This is where the focus of
scientific work needs to be in the next 5 years.”
Alan S. Maisel
Maisel agreed.
“There is a lot of ongoing research on COVID-19, especially with
treatments, but we have to understand the etiology of the ‘long-hauler,’
which we still do not know,” Maisel said.
Maisel and colleagues are conducting an ongoing study examining the
use of ivabradine (Corlanor, Amgen) in patients with COVID-19
long-hauler syndrome.
“Ivabradine seems to work in patients with tachycardia, and so we
think it will work for individuals with post-COVID-19 tachycardia,” he
said. “There are other already available agents that we plan to study as
well. We still need to explore the pathophysiologic mechanisms, but we
do have treatments to test for these patients.”
The ongoing INSPIRE study is another trial that aims to learn more about the long-term health effects of COVID-19.
“We started to work with a team here at Rush University on the
CDC-funded INSPIRE study, which is a multisite trial of patients who had
COVID-19 and want to be followed for potential long-hauler syndrome,”
Aggarwal said. “The cognitive ‘brain fog’ seems to be one of the bigger
issues that people are facing once other symptoms go away.”
Other neurological symptoms observed among COVID-19 long-haulers,
including loss of smell and taste, suggest the central nervous system is
affected, Volgman said.
“Years ago, when researchers were studying polio, they had no idea
the types of negative neurological complications that these individuals
would have in the future,” she said. “This is the message that we need
to give to people who do not want to get vaccinated. They may not die,
but we do not know what neurological or other organ complications they
may experience long term.”
‘Prioritizing the connection’
Experts told Cardiology Today that there have recently been greater efforts to address the heart health and brain health connection.
“The American Heart Association is prioritizing the connection
between the brain and heart, which will be a good resource for
practicing cardiologists going forward,” Levine said. “We still do not
know at what age to start treating high blood pressure to prevent
dementia, and we also need to know whether intensively lowering blood
pressure to optimal levels in adults with low or moderate cardiovascular
risk will reduce the risk for cognitive decline and dementia later on
in life.”
Knowing this could change patient care and policy, Levine added.
“We do not have evidence that intensive blood pressure lowering can
improve cognitive outcomes later in life for low- to moderate-risk
groups,” Levine said. “Most adults have low or moderate cardiovascular
risk, and it is possible that intensive blood pressure lowering could be
beneficial for adults with low or moderate cardiovascular risk to
prevent the combined endpoints of cardiovascular events and cognitive
decline and dementia. My group is currently working on this research,
which could change clinical practice.”
Aggarwal and Volgman will host a session on the connection between
heart and brain health at the American College of Cardiology Scientific
Session in April.
“We need to start thinking about research models that will put
specialists together where we are working collaboratively and where we
are able to bring best practices together, because ideas come when we
collaborate in close proximity,” Aggarwal said. “We also have to
consider the types of trials we are designing. Representation in
clinical trials is important, not only with diversity by race and
ethnicity but also by sex and gender and making sure that the trials
that we embark on are inclusive. If we think about this with our
cardiology colleagues and neurology colleagues together, we can design
better trials.”
Volgman agreed.
“Research is needed looking into treatments to help decrease
cognitive decline progression. This is not something that we as
cardiologists will solve alone, but our big role is to ensure that we
are treating cardiovascular disease so that it does not affect the
brain,” Volgman said. “This includes atherosclerosis and blood pressure
control, and we still need to figure all of that out, and then, of
course, stroke reduction from the atherosclerosis and atrial
fibrillation, which will be our main contribution to decreasing
cognitive impairment in our patients. The field is ultimately richer
when we work together.”
References:
Cortes-Canteli M, et al. J Am Coll Cardiol. 2021;doi:10.1016/j.jacc.2020.12.027.
Lazar RM, et al. Stroke. 2021;doi:10.1161/STR.0000000000000367.
Williamson JD, et al. JAMA. 2019;doi:10.1001/jama.2018.21442.
How many decades before your hospital puts a protocol in place for this? Maybe in time for your children and grandchildren? OR, if we had survivor led associations it would be spread across the world in one month.
Report from the ESC Heart & Stroke Conference 2020, by Wolfram Doehner, Chair of the ESC Council on Stroke
Introduction
We cardiologists need a better understanding of stroke
Although we appreciate stroke as a
life-threatening disease, many of us have little understanding of stroke
beyond the consideration as a cardiovascular endpoint.
Stroke
is not only the second most important cause of death in our society, it
is also the leading cause for disability in adult life. The strong link
between multiple cardiovascular pathologies and ischaemic strokes (85%
of all strokes) or haemorrhagic strokes (15%) is clearly established (Figure 1).
Around half of ischaemic strokes may be directly caused by heart
disease and cardiovascular risk factors may be involved in most other
strokes. In fact, stroke may often be the initial event to indicate an
underlying cardiovascular disease. Clearly, cardiologists should be
aware of pathophysiological and clinical aspects of stroke, and
cardiologic expertise needs to be included regularly in all phases of
stroke care, from prevention to acute diagnostics and treatment to
long-term care (Figure 2).
Cardiologists' contribution to stroke care according to stroke phases.
The
ESC addressed this clear need for a better understanding of stroke
among the cardiology community with the foundation of the ESC Council on
Stroke in 2016. As of today, over 2000 clinicians, scientists, nurses,
and other medical professionals enrolled for the free membership
in the Council on Stroke
(https://www.escardio.org/Councils/Council-on-Stroke). The unique
characteristic of this council is its strict interdisciplinary concept
throughout, from the Board composition to the working agenda of the
council. It brings together clinicians and scientist from all
specialties that are involved in stroke care including partner societies
such as ESC, ESO, ESVS, EANS, ESMINT, EAN, and others.
The 3rd annual conference ‘ESC Heart and Stroke’: an ambitious interdisciplinary concept
The interdisciplinary concept is particularly
visible at the annual conference of the Council that was held this year
in Barcelona (23–25 January 2020). Participants from 63 countries
attended this conference and engaged with a faculty as multidisciplinary
as the audience. A wide range of aspects of the stroke–heart
interaction were targeted in the 2-day programme. Debates confronted the
cardiologist’s perspective with the neurologist’s view, offered
neuroradiologist concepts and presented newest evidence from stroke
interventional pioneering work. Workshops provided mechanistic insights
of risk factors and discussed tricky or challenging cases in the light
of modern therapy and guidelines.
Highlights from the conference ESC Heart and Stroke 20
One topic of particular interest is the ESUS concept
(embolic stroke of unknown source) that fuelled the discussion with
recent data from two major clinical trials (REPSECT ESUS and NAVIGATE
ESUS). The unexpected neutral results from both trials confirmed once
more that better understanding of the cardiovascular pathophysiology of
stroke and careful individual diagnostic workup of cardiovascular risk
patterns is needed to assign optimum stroke treatment.
Professor
Hans-Christoph Diener, one of the fathers of the ESUS concept and a
founding member of the Council on Stroke, presented in his keynote
lecture a fascinating outline of the history of the ESUS concept. He
also offered illustrative background knowledge on the unexpected trial
results and analysed consequences and potential future direction to
overcome the limitations of the current ESUS concept. Discussions of
advanced anticoagulation strategies and the increasing complexity of
combination therapies in specific cardiovascular patient groups provided
clinically useful information that was well perceived by the audience.
Clearly, a systematic diagnostic workup of stroke aetiology and risk factors is and remains the key principle for optimal and individualized therapy. Improving strategies for arrhythmia detection,
a major cause of cardioembolic strokes, is therefore a permanent hot
topic. The president of the EHRA, Professor Hein Heidbuchel, engaged in a
compelling pro and contra debate on the long-term search of atrial
fibrillation using implantable loop recorders and further technological
innovations.
Another new and pressing topic in the field was discussed, namely the emerging evidence of acute interventional thrombectomy
as the most promising causal therapy of ischaemic stroke. While the
dramatic benefit of percutaneous thrombectomy is beyond doubt, optimum
techniques, imaging, surrounding therapy, and more were discussed and
the perspective from cardiologists, neurologists, interventionalists,
neuroradiologists, and intensive care unit specialists were put forward
to an eagerly listening audience and triggered vivid discussions. One
challenge of this demanding and complex interventional treatment rests
with its implementation into emergency care networks and health care
systems.
The stroke management in complex cardiovascular patients
was addressed in dedicated sessions. Elderly patients, those with heart
failure, with cancer or with further complex comorbidities clearly
represent high-risk patients for stroke. Examples for complex and
challenging clinical situations were discussed in interactive workshops
by an experienced faculty presenting real clinical cases and including
personal experience and guideline perspective to the lively discussions.
The
role of cardiologists in the acute phase of stroke was another focus in
the conference programme. Not only the immediate diagnostic workup to
identify underlying causes for the stroke but in particular the firm
involvement of the cardiologist at the stroke unit was
discussed. Clearly, the need for cardiologist expertise in early
treatment decisions and management of complications became apparent. A
particular challenge and a fascinating current research focus is the
feedback myocardial injury secondary to a stroke that includes
electrical instability, calcium imbalance, mechanical coupling problems,
myocardial necrosis, plaque instability, and severe imbalance of
vegetative vascular pressure control. Emerging evidence led to the term Stroke-Heart Syndrome
and research is ongoing on the mechanisms of this myocardial injury
feedback that may in some cases trigger full myocardial infarction.
In organized poster sessions, all
poster presenters were asked to meet with chairmen from the faculty in
condensed poster presentations and discussions. The feedback of this
intense academic dialogue was excellent particularly from the younger
attendees (Figure 3). Among all posters, three poster prizes were voted on by an independent jury (Figure 4).
Summary
The overarching objective of the conference is
to bridge the gap between medical specialties and to join efforts to
provide comprehensive stroke care to the often elderly and multimorbid
patients. The strict interdisciplinary concept of the conference is a unique featurein the conference curriculum of the ESC.
The conference received excellent marks in the post-event survey from
all parties involved, attendants, faculty, and supporting industry.
Driven by the encouraging feedback the planning for the coming conference, ESC Heart and Stroke ‘21, has already started, to continue this successful format in the coming years.
More information on the Council on Stroke can be found at: https://www.escardio.org/Councils/Council-on-Stroke.
Is your stroke doctor coordinating with your cardiologist your preventative care? Mine obviously wasn't since the 80% carotid blockage was never found.
I was super fit at 50, Why did I have a stroke? Because my Dads' doctor did not tell him to have his children tested for blocked carotids when he was found to have 80% blockage. This notification should have rolled out to every cardiologist in the world, so it wouldn't happen again. So cardiologists seem to be as bad as neurologists in not talking to each other or have protocols to update.
