Guidelines recommend multipronged approach to prevent secondary stroke

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Two Upstate Medical University doctors were part of a national team that wrote a new practice advisory about stroke treatment for the American Academy of Neurology.

With me to explain the significance of this new guideline is Dr. Gene Latorre. He's a professor of neurology at Upstate and the medical director of neurology for the stroke team at Upstate University Hospital. Welcome back to "The Informed Patient," Dr. Latorre.

Gene Latorre, MD: Thank you, and good to be back, Amber.

Host Amber Smith: Now, these guidelines have to do with preventing secondary strokes in people who've already had a particular type of stroke. Is that right?

Gene Latorre, MD: Yes, you are correct. This guideline specifically targets intervention to prevent another stroke from happening in patients who already experienced a prior stroke.

Host Amber Smith: So how big of an issue are secondary strokes?

Gene Latorre, MD: About one out of four strokes in the United States are actually due to recurrent stroke. It is a pretty big problem, that amounts to about approximately 200,000 people a year. And a majority of the strokes can be prevented.

Host Amber Smith: Are they the same type of stroke that the person might've had the first time, or do secondary strokes have different characteristics?

Gene Latorre, MD: Usually, these secondary strokes are resulting from the etiology (cause) of the stroke that they had the first time. So if your stroke is related to atrial fibrillation, then your recurrent stroke, your secondary stroke, is most likely going to be related to the same cause.

Host Amber Smith: So, let me ask you how this has been commonly treated before the new guideline. What did doctors typically do to try to prevent secondary strokes?

Gene Latorre, MD: Well, the current guideline for preventing strokes from happening again involves a multidisciplinary approach, including prevention and maximization of risk factor controls. These risk factors include hypertension, diabetes, physical inactivity, obesity, as well as maintaining patients on anti-clotting medication, such as aspirin, and also, lowering cholesterol, with the use of a statin. And these are all very important in stroke prevention. And that also includes reducing your exposure to smoking. Quitting smoking is probably the best approach to preventing another stroke from happening.

Host Amber Smith: So it sounds like it would be very individualized to the person. I mean, some of those would apply to some people more than others.

Gene Latorre, MD: That's correct. And the more risk factors you have, the more intensive the treatment should be. These risk factors can be controlled by either medication or just by other, nonmedical maneuvers, such as regular physical exercise, weight reduction, watching the diet and having a healthy lifestyle.

Host Amber Smith: So, what is the new treatment guideline that you worked on?

Gene Latorre, MD: So this new treatment guideline addresses the best treatment we have for this type of stroke, related to narrowing of the blood vessels inside your brain. This type of stroke is quite hard to treat because it is a progressive condition, and it's related to a number of risk factors.

In the past,because this looks like a mechanical problem, where your blood vessel becomes narrow, it was intuitive to think that opening up the narrow blood vessel could work with reducing the chance of having another stroke. And people have used a number of procedures, such as stenting (inserting a tiny tube to keep an artery open) or surgery, to clean up the artery.

These procedures are being done in other parts of your body, OK? If your blood vessel in your leg gets narrow, you can go to a vascular surgeon and have it cleaned up, or have a stent placed. The same for your heart. When your heart blood vessel gets narrow, you can have a stent placed toopen up the artery, and then, you're like good as new.

Unfortunately, the evidence has shown that if you do the same thing with the blood vessels in the brain, the result is not as good as what we experienced in other parts of the body, so this guideline specifically addresses the current best treatment we have, which is medical therapy.

Host Amber Smith: So medication has been proven, then, to be better or more effective than a surgical intervention?

Gene Latorre, MD: That's correct. Part of our guideline development involves gathering all of the available evidence to support or refute the efficacy of one type of intervention or the other.

And the current evidence suggests that best medical management, which includes a multimodal approach with multiple risk factor prevention and control, are as good, if not better, than doing some type of surgery.

Host Amber Smith: So, neurologists and primary care doctors in America, do they generally follow these guidelines from the American Academy of Neurology?

For the most part, they do. I mean, most neurologists would try to be adherent to the most current guideline recommendation. The art is in individualizing these guidelines through their specific patients. The guideline is the guideline. It's there to provide you with a framework of diagnosing and treating your patient in general, but individual patients have individual risk factors that require individualized patient management. And so, there is some level of individualization that may need to be done. This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with Dr. Gene Latorre. He's a neurologist at Upstate and the medical director of neurology for the stroke team at Upstate University Hospital. And he was one of the authors of a new practice advisory about stroke treatment.

Now, let me be clear: Does this apply to someone who had a stroke that was caused by a brain bleed, or is this just applicable to someone who had a clot that causes stroke?

Gene Latorre, MD: Yeah, it's a very good qualification. This guideline applies to a patient who had an ischemic (blockage-related) stroke, OK? So these are patients who did not have any hemorrhage or a hemorrhagic stroke. This is specific to ischemic strokes.

Host Amber Smith: OK, so the new guidelines for anti-clotting medications, medications to reduce blood pressure, (and) cholesterol, paired with safe levels of exercise. How do you know for sure that these measures work?

Gene Latorre, MD: Good question. Well, part of our guideline activities involved gathering all of the available evidence we have. And I'm happy to say that multiple studies have been published, and they're actually included in the summary of evidence in this guideline, showing the positive impact of this intervention, including the multiple risk factor management, which results in reducing recurrent stroke, with the control of these various factors.

And these are all part of our guideline recommendation: medications to lower cholesterol, medications targeting the control of blood pressure, controlling diabetes and blood sugar, medications for anti-clotting, including aspirin and other blood-clotting preventive medication, as well as a healthy dose of regular physical exercise. These are all interventions that our guideline committee have found to be quite effective.They're effective in and of its own, but if you combine all of these, interventions, their effect is significantly increased, more than what you would expect for individual interventions.

Host Amber Smith: Do the interventions, is the goal to eliminate the plaque buildup, or is it just going to prevent new plaque from forming, or how do these actually work?

Gene Latorre, MD: Unfortunately, we don't have any medication that makes the plaque disappear, OK?

Gene Latorre, MD: These interventions are primarily designed to prevent further buildup of plaques. And so, what you have there, you're probably going to have there for some time. But the intervention is designed to prevent progression of the disease. Sometimes we see some reduction in plaque formation, but we believe that this is probably your body's mechanism of repairing itself.

We don't think it's the medication per se, but if your medication is helping to prevent plaque from buildup, then your body's able to optimize its ability to repair itself. And then, over time, sometimes we see a reduction in the plaque or an improvement in the lumen (blood-flow passageway) of these blood vessels.

Host Amber Smith: Are there some patients for whom stents or surgery may still be recommended to prevent secondary strokes?

Gene Latorre, MD: Yes. Not all patients respond to this intervention. In fact, there are patients who continue to experience stroke despite (the) best medical management. So these are patients who could be considered for either stenting or surgery as a last resort, OK? So the guideline states thatour first option would always be to maximize medical management. Some patients look like they are failing medical management, but if you look at them closely, they might be noncompliant with either their blood pressure medication, or they might not be doing as much exercise as you would want them to.

So, sometimes it could be that, just emphasizing to the patient the importance of having not just one strategy, but multiple strategies. Some people swear that they're taking all their medications, but they're also continuing to smoke. So sometimes, you may think that they're doing very well, you know, they're exercising, but then you can sometimes see, like, one risk factor that you could optimize further. And so it's very important to have a good, expanded review of all the risk factors that are present in your patient before you can say that they're failing this medical management, and only then would you need to consider additional intervention, such as stenting or surgery.

Host Amber Smith: So regarding medical management of people who've had previous strokes who are taking these medications, how often do they check in with a neurologist, or are they followed by primary care doctors, or what does their management look like, going forward?

Gene Latorre, MD: Patients who have had a previous stroke, and especially strokes related to a narrowing of the blood vessels in the brain, they're typically followed by both the primary doctor and the stroke neurologist. Sometimes a different type of stroke neurologist would be following them, the neurointerventional neurologist, because these are other specialties within stroke who are expert in not only following up at managing these patients who are having a specific type of stroke, (such as one one caused by) intercranial stenosis, and these patients normally would require some type of follow-up imaging to determine if their blood vessels continue to be open, whether their blood vessels are having more narrowing,related to the plaque buildup. And so that allows for individualization of management, you know, sometimes maybe the blood pressure control might need to be tightened up a bit more. Your diabetic control might need to be controlled even further. You may need to have a different type of anti-clotting medication. Some blood tests might need to be ordered to determine how well your body is responding to the anti-clotting medication. We now have a blood test that determines whether you are responding to aspirin. Sometimes, when you are taking a medication such as clopidogrel or ticagrelor, there are blood tests that allow us to determine whether your body is responding to it, or whether you have some genetic condition. Maybe your body's just not designed to respond to this type of medication. So there is a new way of following these patients by making sure that they are responding well to the treatment. So they are typically followed by both the primary doctor and a stroke neurologist.

Host Amber Smith: Now the guidelines say "safe levels of exercise," but I'm curious about what that means for someone who has survived a stroke. Because I imagine the idea of exercising may be really scary for someone that maybe feels a little fragile. So how do you counsel your patients?

Gene Latorre, MD: Safe levels of exercise means that you are doing what your body can tolerate, or what your body can do. Patients who have survived a stroke can have some physical limitations that prevent them from doing one type of exercise or another. So it's very important to work with a physiatrist (doctor specializing in physical medicine and rehabilitation), with a physical and occupational therapist, to help to design an individualized exercise program that would be not only safe for the patient but also can optimize their rehabilitation potential as well as their recovery. Symptoms of lightheadedness or shortness of breath or worsening of their weakness after an exercise are symptoms that they are probably overdoing it. When you're on that level of exercise where you're very exhausted, you're almost out of breath, that level of exercise probably will need to be downgraded or adjusted to a more tolerable level. Some other equipment might be a factor as well. So, some patients might think of maybe investing in a treadmill to do some exercise at home. If you are limping on one side, and if you do a treadmill, this treadmill is continuously running, and so you might not have enough time to adjust your balance, and so people who are having difficulty with balance, they probably would be better off not doing the treadmill. Instead, regular walking would be better because you can adjust your pace, and you can hold on to your family, if you're there walking with them. Other things would include using a dumbbell. If you are doing some weight training and you have weakness in your hand, or you're unable to grasp because of the stroke, using a dumbbell might, make you drop those dumbbells, which could result in an injury. So those things are typically things that I'm wanting to be cautious about when they're starting their exercise program. And as I said, a consultation and working with the physical, occupational therapist, as well as the physiatrist, would be the best bet in making sure that their exercise program is not only safe, but also designed to optimize their rehabilitation.

Host Amber Smith: Well, Dr. Latorre, I really appreciate you making time for this interview.

Gene Latorre, MD: Of course. Happy to be here.

Host Amber Smith: My guest has been Dr. Gene Latorre. He's a professor of neurology at Upstate and the medical director of neurology for the stroke team at Upstate University Hospital. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe.

Find our archive of previous episodes at upstate.edu/informed. This is your host, Amber Smith, thanking you for listening.