medical advice for hooboy and other recent stroke victims

[mattgunther]

Hooboy,

I think you site is great and hope you have a quick recovery. I have taken care of many stroke patients and there a few things I always recommend to make sure my patients do not have another stroke. I'll describe them here since all doctors are not aware of them. Having had a stoke means you are at high risk for another one but there things you can do to dramatically reduce the risk. First, you want to rule out two things that often cause strokes: Atrial fibrillation(a funny heart rhythm) and carotid artery stenosis (a narrowing of the blood vesssels that bring blood to the brain). A simple test called a holter monitor can go a long way to checking if you have atrial fibrillation. It may miss some cases but overall its a good first step. A cardiologist can prescribe this test. If you have atrial fibrillation you should start taking a blood thinner called coumadin. This is much better than the, much more expensive, drugs that try to "fix" your heart.

A second common cause of stroke is carotid artery stenosis, basically a narrowing of one of the main arteries that carries blood to to the brain. A cardiologist or radiologist can easily check for carotid artery stenosis with a ultrasound, a simple, noninvasive, painless test that takes about half an hour. Carotid artery stenosis can be fixed with surgery. However, stenting is growing increasingly popular and safe.

The other advice is stuff you've probably heard before and may already be doing: eat right, exercise, stop smoking and any use of cocaine, control your blood pressure and cholesterol and control your blood sugar if you have diabetes. All of this is very difficult. But even if you can not do all of it, the more you can do, the more you reduce your risk of a serious stroke. If all you can do is control you blood pressure or stop smoking, you've done a lot.

I tell my patients who have had a stroke or heart attack that God has given them a warning. If you heed the warning, you'll make dramatically reduce the chance of a serious stroke. And a serious stroke is one of the worst things that can happen to a person.

[mattgunther]

some more specific recommendations

 

I assume you either had an ischemic stroke or a transient ischemic attack. Our primary treatment for most patients like you is to start them on daily aspirin, aggrenox, check them for atrial fibrillaiton and carotid stenosis as I describe above. In addition we recommend

 

Cholesterol: the Optional goal is LDL below 70 mg/dL

Both dietary modification and drug therapy should be used to achieve the goals.

 

Statins like Lipitor, should be tried first. They should be started before you are discharged from the hospital.

 

 

Ideally blood pressure should be below 120/80 mmHg. You should try to keep your blood pressure below this level by cutting back on salt, weight reduction in the obese, avoidance of excess alcohol intake, and regular aerobic exercise (if you have heart problems a stress test may be warranted before you start exercising).

 

Diuretic, which are cheap, have been shown to be highly effective and often safer than more expensive drugs for blood pressue like ACE inhibitors. However, you may need more than one drug to control your blood pressure.

 

Many patients need two or more drugs to reach goal blood pressure, especially if the blood pressure is greater than 20/10 mmHg above goal.

 

SMOKING CESSATION — Smoking cessation is an important component of risk reduction for secondary prevention in all patients. The main modalities to attain and sustain smoking cessation are referral to a smoking cessation program and the use of nicotine patches or gum and bupropion.

 

Obesity:

Recommendations — All patients with CVD should have measurement of waist circumference and calculation of body mass index. The 2001 AHA/ACC guidelines for secondary prevention and the 2004 ACC/AHA STEMI guidelines recommended a target BMI of 18.5 to 24.9 kg/m2 (show table 3) [5,7]. Patients with an increased waist circumference (greater than 40 inches in men and greater than 35 inches in women) should undergo evaluation for the metabolic syndrome and implementation of weight reduction strategies. Weight reduction is optimally achieved with a multimodality approach including diet, exercise, and possible pharmacologic therapy. (See "The metabolic syndrome (insulin resistance syndrome or syndrome X)" and see "Overview of therapy for obesity").

 

PHYSICAL ACTIVITY — Regular physical activity has a variety of cardiovascular benefits that may include weight loss, an improvement in the lipid profile, a reduction in blood pressure, and treatment and possible prevention of type 2 diabetes. Furthermore, exercise capacity (fitness) is a powerful predictor of mortality in patients with or without a history of CVD [48]. (See "Preventive cardiology: Role of exercise" and see "Efficacy of cardiac rehabilitation after myocardial infarction").

 

The potential benefit of regular physical activity in patients with CVD has been demonstrated in a number of studies [49-52]. In the National Exercise and Heart Disease Project 651 men with a myocardial infarction were randomly assigned to a supervised regular exercise program for three years or no exercise [50,51]:

 

After a three-year follow-up, there was a nonsignificant 37 percent reduction in mortality in those who exercised (4.6 versus 7.3 for the no exercise group) [50]. There was no difference in the incidence of MI.

 

The benefit of physical activity on mortality diminished with increasing time since participation; the relative risk for exercisers compared with nonexercisers at 10, 15 and 19 years was 0.95, 1.02, and 1.09, respectively and the same trend was seen for cardiovascular mortality [51]. This could have been due, in part, to crossover between the two groups, since increased work capacity was associated with survival benefits for up to 19 years.

 

 

Recommendations — A symptom-limited exercise test is essential in all patients before starting an exercise program [5]. The AHA guidelines on physical activity in secondary prevention after myocardial infarction (MI), bypass surgery and clinical ischemia recommend attendance at supervised facilities where symptoms, heart rate, and blood pressure can be monitored [5,53]. The 2004 ACC/AHA STEMI guidelines also gave specific recommendations for the components of an appropriate exercise program [5]:

 

Exercise should involve an aerobic activity such as walking, jogging, or cycling.

 

Exercise should be performed for a minimum of 30 minutes per day, preferably daily but at least three or four times per week.

 

Exercise should be supplemented by an increase in daily lifestyle activities (eg, walking breaks at work, gardening, and household work).

 

 

(See "Components of cardiac rehabilitation and exercise prescription").

 

GLYCEMIC CONTROL IN DIABETES — The benefits of glycemic control in patients with type 1 and type 2 diabetes were demonstrated in the Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study (UKPDS) [54,55]. However, the effects on macrovascular disease are less clear:

 

The DCCT trial found a nonsignificant trend toward fewer cardiovascular events with intensive therapy (3.2 versus 5.4 percent, p = 0.08) [56].

 

The primary analysis in UKPDS found no difference in macrovascular disease in the intensive and conventional therapy groups [55]. However, a subanalysis suggested that reducing the HbA1c value by 1 percent was associated with an 18 percent reduction in MI and a 15 percent reduction in stroke. (See "Glycemic control and vascular complications in type 1 diabetes mellitus" and see "Glycemic control and vascular complications in type 2 diabetes mellitus").

 

 

A separate issue is the value of glycemic control after an acute MI. In a systematic overview of cohort or clinical trials, in-hospital blood glucose concentrations 180 to 196 mg/dL (10 to 11 mmol/L) in diabetic patients were associated with a moderately increased risk of death (relative risk 1.7) [57].

 

The potential value of glycemic control in such patients was addressed in the DIGAMI trial in which 620 diabetic patients with an acute MI were randomly assigned to intensive insulin therapy (insulin-glucose infusion for 24 hours followed by subcutaneous insulin four times daily for 3 months) or standard treatment with insulin therapy only if clinically indicated. Mortality was significantly lower in the intensive insulin therapy group at one year (19 versus 26 percent) and at 3.4 years (33 versus 44 percent) [58,59]. (See "Treatment of acute myocardial infarction in diabetes mellitus", section on Glycemic control).

 

Recommendations — Strict glycemic control is recommended in all diabetics because of the benefits on diabetic complications as well as a possible benefit in patients who have had a myocardial infarction. The 2004 ACC/AHA STEMI guidelines recommended that the goal of therapy should be to achieve a hemoglobin A1C less than 7 percent [5], which is consistent with the general treatment goal for patients with type 2 diabetes mellitus. (See "Treatment of blood glucose in type 2 diabetes mellitus", section on Degree of glycemic control).

 

Among patients with type 2 diabetes, rigorous control of both hypertension (goal systolic pressure below 130 mmHg) and of LDL-cholesterol (goal less than 100 mg/dL [2.6 mmol/L] may be as important as glycemic control. (See "Treatment of hypertension in diabetes mellitus" and see "Treatment of dyslipidemia in diabetes mellitus").

 

OTHER DRUG THERAPIES — The administration of a number of drugs is beneficial for secondary prevention. The evidence is strongest for aspirin, beta blockers, and ACE inhibitors and, in some clinical settings, clopidogrel and warfarin.

 

Aspirin — Long-term aspirin therapy reduces the risk of subsequent myocardial infarction (MI), stroke, and vascular death among patients with a wide range of prior manifestations of CVD. (See "Benefits of aspirin in cardiovascular disease").

 

The magnitude and range of benefit was illustrated in the Antithrombotic Trialists' Collaboration overview, which analyzed the results of 195 randomized trials of antiplatelet therapy among more than 135,000 high-risk patients with prior evidence of CVD, including prior or acute MI, prior or acute stroke or transient ischemia attacks (TIA), and other high-risk groups such as unstable angina, stable angina, peripheral vascular disease, coronary artery bypass graft surgery (CABG), percutaneous coronary intervention (PCI), atrial fibrillation, and valvular disease [60]. The following observations were noted; the results are for all antiplatelet drugs but the great majority of trials were performed with aspirin (show table 10):

 

Antiplatelet therapy reduced the risk of subsequent vascular events (nonfatal MI, nonfatal stroke, and vascular death) by approximately 22 percent.

 

In absolute terms, antiplatelet therapy led to avoidance of approximately 36 vascular events per 1000 patients with a prior MI treated for a mean of 27 months; 38 events per 1000 patients with an acute MI treated for one month; 36 events per 1000 patients with a previous stroke or TIA treated for 29 months; and 9 events per 1000 patients with an acute stroke treated for 0.7 months, and 22 events per 1000 patients with other high-risk features treated for 22 months.

 

 

The most widely tested regimen in the secondary prevention trials was "medium dose" aspirin (75 to 325 mg/day). Higher doses of aspirin were not associated with increased benefit [60-62]. In an analysis of three trials, aspirin doses below 75 mg/day showed only a nonsignificant trend toward benefit (13 percent odds reduction) [60].

 

Aspirin doses in the lower part of the recommended range (75 to 150 mg/day) may be preferred in most patients. Several observations support this recommendation. (See "Benefits of aspirin in cardiovascular disease", section on Recommendations and dosing).

 

In the Antithrombotic Trialists' Collaboration, the 12 trials using an aspirin dose of 75 to 150 mg/day noted the same benefit as 19 trials using 150 to 325 mg/day (odds reduction 32 and 26 percent, respectively); there was no dose dependent increase in side effects until above 325 mg/day [60].

 

In a nonrandomized subgroup analysis from the CURE trial that evaluated the efficacy of clopidogrel added to aspirin in patients with non-ST elevation acute coronary syndromes, there was a dose-dependent increase in major or life-threatening bleeding in both the placebo and clopidogrel groups with increasing doses of aspirin (75 to 100, 100 to 200, and 200 to 325 mg), without any difference in efficacy [63].

 

In the BRAVO trial, lower rates of major bleeding (2.4 versus 3.3 percent) and of blood transfusion (1.0 versus 2.0 percent) were seen with 75 to 161 mg/day versus 162 to 325 mg/day [64].

 

 

Based upon these data, the preferred dose of aspirin is 75 to 150 mg/day. Clopidogrel is an alternative in patients who cannot tolerate aspirin [65,66].

 

Recommendations — The ACC/AHA and the Sixth ACCP Consensus Conference on Antithrombotic Therapy recommend indefinite oral aspirin therapy (75 to 162 mg/day) in patients at high risk for a subsequent vascular event, including those with chronic stable angina, unstable angina, or prior MI, coronary revascularization, occlusive stroke, or a TIA [5,67]. Clopidogrel (75 mg/day) is an effective alternative in the approximately 5 percent of patients who cannot tolerate aspirin [65,66]. Patients who cannot tolerate aspirin or clopidogrel can be treated with warfarin with a goal INR of 2.5 to 3.5 [5].

 

Clopidogrel — Based upon the results of the CURE trial, patients with unstable angina or a non-ST elevation acute MI are given clopidogrel (300 mg loading dose followed by 75 mg/day) in addition to aspirin[68]. Clopidogrel is continued for at least nine to twelve months. Some physicians recommend continuing clopidogrel beyond one year or even indefinitely as long as the drug is well tolerated and expense is not an issue. This approach is primarily considered in patients with more severe vascular disease (eg, prior MI or cerebrovascular event or peripheral vascular disease).

 

Clopidogrel therapy is also recommended in addition to aspirin in all patients who undergo percutaneous coronary intervention, based upon data from the PCI-CURE and CREDO trials [69,70]. (See "Antiplatelet agents in unstable angina and acute non-ST elevation (non-Q wave) myocardial infarction" and see "Antithrombotic therapy following intracoronary stent implantation").

 

Warfarin — Warfarin therapy has not been routinely recommended in patients with an acute myocardial infarction treated with aspirin. However, newer trials, including WARIS II, ASPECT-2, and APRICOT-2 have shown benefit at an attained INR above 2.0. One limitation of all of the warfarin trials is that the patients were not treated with aspirin and clopidogrel. Whether warfarin therapy is beneficial in comparison to aspirin and clopidogrel, or in addition to aspirin and clopidogrel, is not known. At present, warfarin therapy in the absence of an indication is not recommended for patients who have had an MI and are treated with aspirin and clopidogrel. (See "Chronic anticoagulation after myocardial infarction").

 

The primary indications for warfarin in stable patients are the presence of atrial fibrillation and, for those in sinus rhythm, a previous thromboembolic event. Although less well established by evidence, warfarin may also be beneficial in patients who are at high risk for a thromboembolic event as defined by: the presence of a large akinetic region of the left ventricle or mural thrombus following myocardial infarction; symptomatic heart failure with a markedly reduced LVEF (30 percent), regardless of the etiology; and the presence of a left ventricular thrombus. All patients considered for warfarin therapy must have minimal risk factors for bleeding and a stable hemodynamic profile without evidence of liver synthetic dysfunction.

 

In other patients with stroke, three randomized controlled trials (SPIRIT, WARSS, and WASID) compared warfarin to aspirin (not placebo) [71-73]. Long-term anticoagulation with warfarin was not superior to aspirin for secondary stroke prevention and, in SPIRIT and WASID, increased the risk of major hemorrhage.

 

Beta blockers — Beta blockers improve survival and should be part of routine therapy in patients with an acute myocardial infarction or heart failure due to systolic dysfunction. Very low doses are used initially in patients with heart failure to minimize the risk of an acute worsening of cardiac function. The evidence supporting these recommendations is presented elsewhere. (See "Beta blockers in acute myocardial infarction" and see "Use of beta blockers in heart failure due to systolic dysfunction").

 

ACE inhibitors or ARBs — Angiotensin converting enzyme (ACE) inhibitors improve survival in patients with systolic dysfunction of all severities and in most patients with an acute myocardial infarction. They also slow the rate of progression of chronic renal failure in patients with diabetes. An angiotensin receptor blocker (ARB) can be substituted if the ACE inhibitor is not tolerated. The evidence supporting these conclusions is presented elsewhere. (See "Angiotensin converting enzyme inhibitors and receptor blockers in acute myocardial infarction: Recommendations for use", see "ACE inhibitors in heart failure due to systolic dysfunction: Clinical use", and see "Antihypertensive therapy and progression of renal failure").

 

Based upon the results of the HOPE, EUROPA, and LIFE trials, administration of an ACE inhibitor or an ARB has been recommended in all high-risk patients who fulfill the criteria of these trials [36,37,74]. It has been suggested by some experts that the benefit seen in these trials was a consequence of blood pressure lowering rather than a specific effect of blockade of the renin-angiotensin-aldosterone system. Nonetheless, most cardiologists have concluded that ACE inhibitors or, if not tolerated, ARBs should be given to virtually all patients for secondary prevention. (See "ACE inhibition or angiotensin II receptor antagonism in patients at high risk for a cardiovascular event").

 

Antioxidants — The potential value of the antioxidants vitamin E, beta carotene, and vitamin C for secondary prevention has been evaluated in a number of clinical trials with largely no benefit. This included a lack of benefit from vitamin E in the HOPE and GISSI Prevention trial, and from combined therapy in the Heart Protection Study [75-77].

 

The Heart Protection Study consisted of 20,536 patients who had a history of cardiovascular disease (coronary cerebrovascular or peripheral vascular disease), diabetes mellitus, or treated hypertension. One arm of this lipid-lowering trial consisted of random assignment to antioxidant vitamin supplementation (600 mg vitamin E, 250 mg vitamin C, and 20 mg beta carotene) or matching placebo [77]. At five-year follow-up, there was no difference between the groups in any end point, including all-cause of cardiovascular mortality, nonfatal myocardial infarction or stroke, or the incidence of cancer.

 

The third United States Preventive Services Task Force (USPSTF) found insufficient evidence to recommend for or against supplements of vitamins A, C, E, or antioxidant combinations for the prevention of cardiovascular disease, and recommended against the use of beta carotene supplements for this purpose [78]. The 2004 ACC/AHA STEMI guidelines recommended against the use of antioxidant vitamins after STEMI [5]. (See "Antioxidants in coronary heart disease").

 

Homocysteine and folic acid — Homocysteine has primary atherogenic and prothrombotic properties, and evidence from observational studies suggests that moderate hyperhomocysteinemia is an independent risk factor for atherosclerotic vascular disease [79]. (See "Overview of homocysteine").

 

Vitamin supplementation with folic acid lowers homocysteine levels [80]. The metabolism of homocysteine also requires pyridoxal phosphate (vitamin B6) and cobalamin (vitamin B12) as cofactors. As a result, supplementation with folic acid, with or without vitamin B6 and vitamin B12, has been proposed for the secondary prevention of cardiovascular disease. However, the results of major randomized trials of vitamin therapy to lower homocysteine levels have been conflicting with both a decrease and an increase in risk being reported [81,82].

 

Differences in trial design may account for the conflicting results. In the former study, only about half of the patients received a stent; in the latter trial, a much higher dose of vitamin B6 was used (48 mg/day) [81,82]. (See "Overview of homocysteine", section on Secondary prevention).

 

Based upon the available evidence to date, it remains unclear whether lowering plasma homocysteine levels will decrease risks of cardiovascular disease [83]. Until the results of further studies are available, we do not recommend the use of vitamin supplementation with folate, vitamin B6 or vitamin B12.

[Holden]

RE: some more specific recommendations

 

huh?

 

sure beats a visit to the doctor

[+ Lucky]

RE: some more specific recommendations

 

Does it? The poster is the very same person who trashed the escort who was upset about getting stuck on a fee, and the poster just allowed the other day how tired he was of Benjamin Nicholas's postings. Hooboy wasn't happy with that, so I doubt he is following any advice from this poster.

If Hooboy is with Totally Oz, he is in good hands and will recover soon enough.

[giovoni]

What Doctors don't know this?

 

That was all great advice but I'm concerned about your assertion that many doctors don't know most of it. What circles are you running in? There was nothing in that entire post that a good 2nd year or an average 3rd year medical student wouldn't know (or that anyone who knew how to use 'uptodate' couldn't find either apparently) If any of you have doctors that don't know everything that is in the above post you need to run not walk to another doctor.

[Guest sniper]

RE: some more specific recommendations

 

May I suggest you "dumb it down" a little here for the lay readers?

 

You used somewhat heavy terminology for your assumption, which if not the case, renders some of your advice dangerous. Someone who had a hemorrhagic stroke might not actually know that they did NOT have an ischemic stroke, since they likely have only been told what happened to them, not what didn't.

 

(ischemic - blood clot or blockage; hemorrhagic - blood seeping into brain from vessels that leak or burst - so blood thinners are bad for hemorrhagic stroke patients)

[Flower]

RE: What Doctors don't know this?

 

>That was all great advice but I'm concerned about your

>assertion that many doctors don't know most of it. What

>circles are you running in? There was nothing in that entire

>post that a good 2nd year or an average 3rd year medical

>student wouldn't know (or that anyone who knew how to use

>'uptodate' couldn't find either apparently) If any of you have

>doctors that don't know everything that is in the above post

>you need to run not walk to another doctor.

I was thinking the same thing, although what I was really wondering was why didn't he just emphatically tell Hoo to see A GOOD CARDIOLOGIST and FOLLOW THAT DOCTOR'S ADVISE, as opposed to parroting back what anyone could read on the HealthOne or Health-Nexus websites or the many texts on the subject. We have a lot of docs on this sight and I've seen most of them acknowledge that remote diagnosis and treatment is to be avoided and to see a hands on doctor. At least that's what I think a good doctor would say }(

[bigguyinpasadena]

RE: some more specific recommendations

 

Y'all think he typed all of that himself hmmmmm?

Looks like a cut and paste job to me.

But he is an arogant ass(as proved by his earlier post)so if he is not really a MD(just playing one on a message board)he does have the attitude(condescending know-it-all)of a real one.

[Chuck50]

RE: some more specific recommendations

 

I don't really give a shit about all this talk and what should or shouldnt be done and when. I just want to know that Hooboy has had some medical attention. It is very critical at the stage that sounds like where he is. I would not classify it as a very slight stroke but more like a mild one and I am not a DR. I just hope that Dr's are involved and that they prescribe some type of therapy. HUGS Love ya Hoobaby. HUGS Chuck

[giovoni]

Cut and Paste

 

Of course it's a cut and paste.. it's from a site called "UpToDate" the style is classic as are all the "see blah blah blah" which on the site would be hypertexted to the subjects mentioned... he could log into it from any medical library with public computers or he's a real doctor or student with a subscription.

 

He left out all the references from the end of the article, but you can see all the endnotes throughout the piece. Again all the advice given is good for someone with any sort of stroke which was caused by a restriction of blood flow, like vessels spasm-ing from cocaine, a blood clot from the heart caused by atrial fibrillation or a clotting disorder, etc. As another poster pointed out, if the stroke was caused by a blood vessel breaking some of the advice could KILL anyone who followed it (taking blood thinners). This is exactly why, as Flower pointed out, remote diagnosis is VERY VERY dangerous and shows how sometimes doctors with the best of intentions can let arrogance and an eagerness to help get in the way of good sense.

 

Gio

 

"I do not love the bright sword for its sharpness, nor the arrow for its swiftness, nor the warrior for his glory. I love only that which they defend."

[Rick Munroe]

RE: Cut and Paste

 

>Of course it's a cut and paste..

 

No, it's actually a "copy and paste." "Cutting" is usually done by the original author in the editing phase. Now, carry on with your kvetching....

[giovoni]

RE: Cut and Paste

 

>No, it's actually a "copy and paste." "Cutting" is usually

>done by the original author in the editing phase. Now, carry

>on with your kvetching....

 

Actually I checked and the article is now missing from UpToDate... I bet you've been waiting to correct something I've said for the last two years haven't you :-P. But you're correct.. it was a "copy" and paste job... now everyone who has been completely confused by my entire post can now understand what I was getting at thanks to you.

 

Gio

 

"I do not love the bright sword for its sharpness, nor the arrow for its swiftness, nor the warrior for his glory. I love only that which they defend."

[Guest Mikel]

RE: Cut and Paste

 

I thought "cutting" was what they did to unsuspecting infants when they get circumsized. But I'm neither a doctor or a journalist!

[Luv2play]

RE: some more specific recommendations

 

All this concern about HooBoy, which I share, has to be taken in the context of his postings in the Asia forum below. He apparently is in Thailand with Oz and they are having a riotous time with numerous boys, both before and after Hoo's "stroke". Hoo says he's in pain but somehow continues to enjoys boys with 8 inch cocks in his bed (but no sex, mind you). I am unable to comprehend it all...

[giovoni]

Health setbacks don't void the right to have fun.

 

I'm not sure I see your point. The best way to get better from a stroke is to do as much as you can as quickly as you can with the effected limbs/skills. As you've pointed out he's not having sex but enjoying the company of people with 8" dicks. I'm not sure why the measurment is important. If I ever have a stroke I sure hope I can still count on enjoying the company of people I enjoyed before I had it.

[Luv2play]

RE: Health setbacks don't void the right to have fun.

 

There is some debate here about what kind of stroke HooBoy suffered. The kind that results from high blood pressure runs in my family so I know a little about what NOT to do when you suffer one. And that is to carry on as if nothing has happened to you. High blood pressure is exacerbated by excess drinking, too much stress, smoking, etc, i.e. the "high" life. You have to slow down, get exercise, good diet (avoid salt) etc. And you have to go on drugs in most cases to get your pressure down.

 

I've got a friend who is 59 that I see every once in a while. He is in a wheelchair, having suffered a massive stroke 3 years ago. He is confined to his apartment (he had to sell his house as it was too difficult to get around in), he has a new car fitted out for him that he can't drive because he is incontinent now, and believe me, his life is no bowl of cherries.

 

Why bring him up? Because he ignored his first "little" stroke, which hardly slowed him down, and then the BIG one came. Well, it's no joke now.

[Luv2play]

RE: Health setbacks don't void the right to have fun.

 

There is some debate here about what kind of stroke HooBoy suffered. The kind that results from high blood pressure runs in my family so I know a little about what NOT to do when you suffer one. And that is to carry on as if nothing has happened to you. High blood pressure is exacerbated by excess drinking, too much stress, smoking, etc, i.e. the "high" life. You have to slow down, get exercise, good diet (avoid salt) etc. And you have to go on drugs in most cases to get your pressure down.

 

I've got a friend who is 59 that I see every once in a while. He is in a wheelchair, having suffered a massive stroke 3 years ago. He is confined to his apartment (he had to sell his house as it was too difficult to get around in), he has a new car fitted out for him that he can't drive because he is incontinent now, and believe me, his life is no bowl of cherries.

 

Why bring him up? Because he ignored his first "little" stroke, which hardly slowed him down, and then the BIG one came. Well, it's no joke now.

[Guest Tampa Yankee]

RE: some more specific recommendations

 

lol.... this is all too funny. :7

[Guest Tampa Yankee]

RE: some more specific recommendations

 

lol.... this is all too funny. :7

[Bearman]

RE: Stroke Article I "Cut and Pasted"....

 

HooBoy, I found this article and I cut and pasted it here on the forum in case its of any help Best wishes and a speedy recovery!

 

 

 

Preventing Stroke Without Major Surgery

Updated 12/1/2004 8:26:43 PM

 

By Miranda Hitti

 

 

Dec. 1, 2004 -- When it comes to preventing stroke, traditional surgery isn't the only way to go. Newer methods are just as effective, say Italian researchers.

 

Finding ways to ward off stroke is urgent. Stroke is the No. 3 killer in the U.S, behind heart disease and cancer. More than 700,000 Americans have a stroke every year, according to the American Stroke Association.

 

Traditionally, blocked or narrowed carotid arteries - blood vessels that supply the brain -- have been cleaned out surgically to help prevent a stroke. The procedure, called carotid endarterectomy, is a major undertaking with risks, including actually causing a stroke or heart attack.

 

That's why less invasive procedures are appealing. Options include angioplasty and stenting, two techniques commonly used to treat heart disease.

 

Angioplasty uses a tiny balloon to reopen blocked or narrowed arteries. Stents are small, metal mesh tubes that prop arteries open after angioplasty.

 

For stroke prevention, angioplasty and stents are used in the carotid arteries. Blocked or narrowed carotid arteries can impair the brain's blood supply, causing a stroke.

 

But do angioplasty and stenting work as well as conventional surgery? Yes, say Italian researchers including Gianluca Piccoli, MD, of Santa Maria della Misericordia Hospital of Udine in Italy.

 

Piccoli's team studied 171 patients with carotid artery disease. Some patients had signs of decreased blood flow to the brain while others had suffered a previous stroke.

 

All the participants underwent angioplasty and stenting for their carotid arteries. The researchers monitored them for three years, comparing their results to those typically seen with carotid artery surgery.

 

Angioplasty and stenting measured up well.

 

Complication rates were similar to those seen with surgery. Angioplasty and stenting also equaled surgery at preventing the carotid arteries from narrowing again.

 

Findings Match Earlier Stroke Research

 

An earlier study conducted by Jay Yadav, MD, of The Cleveland Clinic, and colleagues had similar findings. That study was reported in the Oct. 7 edition of The New England Journal of Medicine.

 

"Carotid artery angioplasty is a safe procedure and the results are the same as surgical ones reported in literature," say the researchers. They presented their findings in Chicago at the Radiological Society of North America's annual meeting.

 

Piccoli says patients who undergo angioplasty and stenting have relatively short recovery times. "With surgery you need three to four days, sometimes even a week of recovery in the hospital," he says. "But with carotid angioplasty and stenting, you can go home the day after the procedure."

 

Angioplasty and stenting to prevent stroke will become common, predicts Piccoli.

 

"Today, these procedures are largely used for the heart, but I think that in the future they will be used for every artery and every part of the body," says Piccoli in a news release.

 

That trend may have already started. In August, the FDA approved a stent for use in the carotid arteries.

 

Meanwhile, a trip to the operating room isn't the only way to prevent stroke. Diet, exercise, and healthy lifestyles can also make a difference, if time is on your side.

 

Time also counts if the worst case happens and stroke occurs. Immediate medical attention is crucial. Stroke medications -- used to dissolve a clot that blocks blood flow -- must be used within three hours to help minimize brain damage from a stroke.

 

 

--------------------------------------------------------------------------------

 

SOURCES: Radiological Society of North America 90th Scientific Sessions and Annual Meeting, Chicago, Nov. 28-Dec.3, 2004. American Stroke Association. WebMD Medical Reference from Healthwise: "Stroke: What Happens." WebMD Medical News: "FDA Approves Tiny Device to Prevent Stroke." WebMD Medical News: Stroke Prevention: Stent as Good as Surgery." News release, Radiological Society of North America.

[mattgunther]

RE: What Doctors don't know this?

 

I wish all doctors did know everything they need to but unfortunately study after study has shown there are huge gaps in their knowledge. For example, a recent study found that americans were getting less than half the treatment they need. And the number of patients with atrial fibrillation who are not coumadin has long been a disgrace. As for a second or third year medical student knowing everything in my post, that certainly has not been my experience. I trained at one of the best hospitals in the country and while our medical students were very bright, they certainly were not ready to handle a stroke.

[giovoni]

What Doctors don't know this?

 

What study? less than half the treatment for what? If you REALLY trained anywhere as a physician you know better than to just throw out 'a recent study' without naming who did it what they studied.. where I could go find the article and the journal to read it and dispute what you're claiming or agree with you. Why are they getting less than half of their treatment? Because they don't want it, because they can't afford it? Because insurance companies withhold it? Or because as you seem wont to imply that all doctors are incompetent boobs who don't treat people enough? A combination of these reasons? How long ago was it published? How large a sample did they take to make this claim?

 

Also if you're really a Dr who trained at one of the nations leading hospitals you realize that throwing coumadin down everyone's throat is VERY difficult. Coumadin is one of the toughest drugs to manage and since it's used extensively in populations prone to falls and other injuries making their blood thin is not always the best idea. I'm not sure how you characterize the state of coumadin use as a 'disgrace' without some sort of backup as well.

 

Do your patients know how cavalier and arrogant you are with data meant to be used cautiously and wisely or do you save them that ordeal by being a surgeon?

[Flower]

RE: What Doctors don't know this?

 

For example, a recent study found that

>americans were getting less than half the treatment they need.

Well, tell that to the insurance companies who are citing "studies" (much the same way you do) that say patients for the most part are being "overly treated" due to the perceived need to CYA because of all the shark-like lawyers }( out there who seem to be able to make juries believe there is malpractice when none is there.

[mattgunther]

RE: What Doctors don't know this?

 

Gio posted:

 

>>Coumadin is one of the toughest drugs to manage and since it's

>>used extensively in populations prone to falls and other injuries

>>making their blood thin is not always the best idea.

 

I disagree. Five years ago Man-Son-Hing et al. (Choosing Antithrombotic Therapy for Elderly Patients With Atrial Fibrillation Who Are at Risk for Falls, Arch Intern Med. 1999;159:677-685) studied the risk of falls in patients with a fib and found "regardless of the patients' age or baseline risk of stroke, the risk of falling was not an important factor in determining their optimal antithrombotic therapy."

 

>>I'm not sure how you characterize the state of coumadin use as

>>a 'disgrace' without some sort of backup as well.

 

Here is some back up.

 

Brass et al. (Warfarin Use Following Ischemic Stroke Among Medicare Patients With Atrial Fibrillation Arch Intern Med. 1998;158:2093-2100) reviewed the charts of 635 patients who had atrial fibrillation and were discharged alive after a stroke. Only 147 (53%) of 278 were prescribed warfarin at discharge. Furthermore, among 130 (47%) of 278 patients not prescribed warfarin at discharge, 81 (62%) of 130 were also not prescribed aspirin. Even among those with an increased risk of stroke and a low risk for bleeding (ideal candidates), 38% were not discharge on warfarin.

 

Samsa et al. (Quality of Anticoagulation Management Among Patients With Atrial Fibrillation, Results of a Review of Medical Records From 2 Communities, Arch Intern Med. 2000;160 967 - 973) found only only 34.7% of eligible patients with AF received warfarin.

 

A survey of the literature by Bungard et al. (Why Do Patients With Atrial Fibrillation Not Receive Warfarin? Arch Intern Med. 2000;160:41-46) noted that available data show that of those patients with AF and no contraindication to warfarin therapy, only 15% to 44% are prescribed warfarin.

 

As for evidence that patients do not recieve all the care they need, both Asch et al. (Measuring Underuse of Necessary Care Among Elderly Medicare Beneficiaries Using Inpatient and Outpatient Claims JAMA. 2000;284:2325-2333) and Jencks et al. (Measuring Underuse of Necessary Care Among Elderly JAMA. 2000 Oct 4;284(13):1670-6) found that medicare benificiaries recieved appropiate treatment only 2/3 of the time.

 

These finding are not at all inconsistent with insurance company arguments that doctors often prescribe un-necessary treatment. Doctors who are ignorant of recent medical literature will often practice in a way that seems random-- they will prescribe many unnecessary treatments because they are unaware of research showing those treatments are not helpful. They may be motivated by out of date ideas, the sales pitch of a drug rep or the fact that the, useless, treatment is highly lucrative. And they will forgo prescribing helpful treatments because they are not aware of what is helpful.