Women's Heart And Health: Stroke And Cardiovascular Health In Women Discussed By Dr. Lewis Morgenstern

Tue, 02/28/2006 - 12:35pm

When: February 3, 2010 at the Downtown Library: Multi-Purpose Room

According to the American Heart Association: Cardiovascular disease (CVD) ranks first among all disease categories in hospital discharges for women. Nearly 37 percent of all female deaths in America occur from CVD. Yet, misperceptions still exist that CVD is not a real problem for women. Dr. Lewis Morgenstern, professor in the departments of Emergency Medicine, Neurology, and Neurosurgery at the University of Michigan, as well as director of the U-M Stroke Program, will examine this important issue. He will cover current trends and treatments in women's stroke and cardiovascular health issues, and what is being discovered through research. This event is made possible through Partners In Research grants R03 NS065493 and R03 NS065491-0 from the National Institute of Neurological Disorders and Stroke of the National Institutes of Health and is co-sponsored by the Michigan Institute for Clinical and Health Research and the UM Health Sciences Libraries.For more information on stroke take a look at our books and videos on the subject. Articles and current research can be explored in our research databases MEDLINE and Health and Wellness Resource Center.

Transcript

• [00:00:22.27] CELESTE CHOATE: Hello, welcome again. My name is Celeste Choate I'm one of the associate directors here at the Ann Arbor District Library and this is --
• [00:00:30.47] DORENE MARKEL: Hello, I'm Dorene Markel. I'm the associate director at the Michigan Institute for Clinical and Health Research at the University of Michigan.
• [00:00:38.92] CELESTE CHOATE: The reason that Dorene and I are up here together to give you a quick introduction tonight is that the Ann Arbor District Library and MICHR and the U of M Health Sciences libraries together received a grant from the National Institutes of Health. It's called a Partners in Research grant and it combines a community partner, the library, with a research institution, University of Michigan, to provide a better impact in the public arena. Whether its by direct research or community forums and direct research like we doing here now. So I'm going to tell you a little bit about that project.
• [00:01:14.12] We are trying here and having a series of forums on different health topics to raise awareness in the public of what is out there available to you regarding clinical research, what it can do for you, and hopefully what you can do for clinical research if you are so interested. There's a wonderful website, it's called engage. It's through the University of Michigan and if you're interested they had some slides up before. The web site is www . um . engage . org and they have fliers about it outside on the table. You can register on the website and take a look and see what type of clinical research is available right now going on that you can participate in if you are so inclined. So, if you're interested, please do that. We are very interested in having you here tonight and asking questions and so please make sure that you write them down. Complete your surveys which are an important part of our grant; finding out whether or not these community forums help raise awareness and help answer questions that you have about clinical research. If you are interested in participating in a focus group about this we would really like to have you do so. So, I will pass the microphone over to Dorene.
• [00:02:28.47] DORENE MARKEL: I think as was mentioned earlier, the questionnaires you have, have a few questions you answer before the presentation and then questions you answer again at the end. So, if you can take a moment while I'm providing introductions to take a look at that. It only takes less than thirty seconds to answer. So it's our pleasure this evening during hearty healthy month and a focus on heart healthy issues and women to have Dr. Lewis Morgenstern with us who's going to speak about stroke and women.
• [00:03:00.98] Dr. Morgenstern is the director of the stroke program and the medical director of the stroke unit at the University of Michigan health system. He is a professor of neurology, emergency medicine, and neurosurgery at the U of M and a professor of epidemiology at the U of M School of Public Health. He received his medical degree from the University of Michigan with distinction in research and did his neurology residency at Johns Hopkins Hospital and then a stroke fellowship that followed at the University of Texas at Houston. Dr. Morgenstern is an NIH funded principal investigator in studies that aim to reduce stroke health disparities with respect to race, ethnicity, and gender. His research group has published many studies identifying gender specific disparities with respect to stroke symptoms and differences in the quality of stroke care. Dr. Morgenstearn's other research focuses on the treatment of intercerebral hemorrhage and mobilizing healthcare professionals in communities to treat acute ischemic stroke. He has an extensive publication record as well. Dr. Morgenstern is also a fellow of the American Academy of Neurology and the American Heart Association and a number of the editorial board of a journal called Stroke. You can see that he is certainly an expert in this field and we are really delighted that he has taken the time this evening to be with us. Dr. Morgenstern.
• [00:04:28.69] DR. MORGENSTERN: Thank you very much. It's a pleasure to be here. I'd like to thank MICHR and Ann Arbor District Library for sponsoring this event and I'd like to thank all of you for coming out tonight on this relatively chilly evening to learn a little bit about stroke and share some of your ideas with me. The format is, I'm going to give a presentation of probably about 50 minutes or so that kind of introduces various aspects of stroke, tells you a little bit about the research that we and others have done, specifically related to stroke in women. As you'll learn, stroke seems to have a propensity, unfortunately, for women and there is many very important gender differences with respect to this disease that are worth knowing about. Then when we're done, I'm happy to answer your questions, hear your comments and make this as interactive as possible.
• [00:05:25.70] This is how I got started in this business. This remarkably adorable child is me, many, many, many decades ago. Seriously, the really remarkable person in this photo is this person here who's my grandmother. I grew up in a small apartment in midtown Manhattan and my grandmother was an immigrant from Eastern Europe, had a very thick accent and was really very instrumental in raising me. When I was 12 years old she had a stroke that I now know affected the left side of her brain. It made this very brilliant eloquent woman not be able to speak. She was paralyzed on the right side of her body and she had those deficits for a couple months; she had another stroke and she passed away. That was obviously a big impact on me and I'm sure they just about everybody in this room has had a personal experience with either yourself or people that you know and loved having stroke. It's an incredibly common disease.
• [00:06:31.83] The interesting thing about stroke is that it's arguably the most preventable and most treatable of all catastrophic conditions. We know a lot about this disease and we still do very little at preventing it or treating it. So the knowledge is there but the behavior to get it done has not really matched and so that's really important. I'm not going to talk a lot about the risk factors for stroke and prevention, although I'd be more than happy to answer your questions later on about that. There are some aspects on this slide here that tells you about the risk factors for strokes. This was our cigarette case here, in my house, and the heart shaped ashtray which is really kind of an oxymoron. The other risk factors are heart disease, high blood pressure and the number one risk factor for stroke diabetes, is very, very important as well. So, the facts about stroke: stroke is the number one because of adult disability in the United States, the number one reason that people end up in nursing homes, it's the 3rd leading cause of death in the U.S., really all Western countries, there are 720,000 strokes each year in the United States. As I've said it's very treatable and very preventable. For us as researchers, it's a very good model disease; it's common, it's severe, and it has a predilection for populations that are at high risk and which we could do something about with proper therapy and proper aggressive treatment. So there are three types of stroke. I'm going to take you through the first year of medical school here in the next five minutes.
• [00:08:17.90] So this is the most common type of stroke, it occurs in 85% of patients. This is like if you were looking at my brain straight on. This is the normal part of the brain over here and this part, as you see, it's kind of red and black down here and ugly looking has had a stroke and that part of the brain has died. So what a stroke is when we use that term is that, blood cannot get to part of the brain. As you know blood brings oxygen and sugar and nutrients and when part of the brain is robbed of that, it dies. So a stroke is a little bit of the brain dying, depending upon the location and the artery that is bringing blood, it can be small or it can be big. This is actually a pretty big one. This is the most common type of stroke called cerebral infarction 85%. Now when you come to the emergency department with strokes symptoms, the first thing we do is get a CAT scan. And what we're looking for is this; and this is the normal side over here, and this is the abnormal side over here. And you'll have to take my word for it but this side is full of water, it's swollen and doesn't have the clear demarcation that you can see over here. And when we see something like this we know that the brain has been very badly injured, in this case by a stroke, and so that's the purpose of imaging. We have a lot of different ways to image the brain this is a CAT scan. As you know, CAT scans have been around for decades. The more powerful tool that we have is MRI scans. There's a bunch of other types of imaging as well but predominately CT scans and MRI's are what we do.
• [00:10:02.22] The second type of stroke which occurs in 10% of patients and one that is a particularly bad type is called an intercerebral hemorrhage. Instead of having the blood vessel get clogged up like the previous type I told you about, this is where the blood vessel actually ruptures and bleeding goes into the brain. What you can see here is blood that has gotten into the brain. This is the normal side over here and this is the abnormal side. The surrounding area that's pink here is angry, it's swollen and not very happy and that's what happens in an intercerebral hemorrhage. On a CAT scan that looks bright white, so when you look at a CAT scan it doesn't look red for blood, it looks white. This area all around here is blood that doesn't belong there.
• [00:10:51.58] The third type of stroke is called the subarachnoid hemorrhage. It's the rarest type. It results from the rupture of an aneursym. An aneursym is a blister on the artery and it can break open and cause leakage of blood all around the brain. Here's a little diagram of that. Here's the artery at the base of the brain, it's had a little blister and it ruptured and the blood has kind of leaked over here, so this is like a drawing. On a CAT scan you guys all now know the radiology of this, blood is bright white on a CAT scan and this classics star shaped pattern is what we see in a subarachnoid hemorrhage, none of that belongs there, this is all blood. For those of you that are wondering, what's all that white stuff on the outside, that's the normal skull. Calcium is what causes things to be white in this particular circumstance so this is normal but this is not normal.
• [00:11:48.72] That's the easy stuff, now let's get into the complex research about women and stroke. And so these are the questions that I hope to answer this evening. Is stroke an important disease in women? Obviously I wouldn't be standing here unless the answer was yes. Are the symptoms of stroke the same in both men and women? Are men and women allocated the same healthcare resources to prevent and treat stroke? Do men and women have the same stroke outcomes? How can we deliver better stroke care for women? So that's what we're going to discuss.
• [00:12:23.21] So is stroke an important disease for women? Absolutely. This was one of the first papers that I ever wrote and you don't have to read any of the small print. This is just a marker for me to kind of show you what our research papers look like and for you to just see the headline. So I'm going to show you a lot of slides like that, if you just read the headline that would be that would be perfect. We did a study back in the years that I lived in Texas and we were interested In trying to figure out who had the most stroke: African Americans, Hispanic Americans, or non- Hispanic whites. We found as others have found, at that time and since, that African Americans have a dramatically high rate of stroke. It's actually a medical tragedy the amount of stroke that occurs in the African American community and something that we really need to do something about. We also found somewhat serendipitously, that women have a very, very high rate of stroke. In this study we use vital statistics, that is data on people who have died from stroke and we did the study back in the late 80's and early 90's and we found that 61% of all stroke deaths occur in women. Right now the national average is 62%. Across the United States 62% of all deaths from stroke occur in women. So it's obviously a very important disease.
• [00:13:48.14] The second question that I have to answer is, are the symptoms of strokes the same in both men and women? We've actually done a lot of research on this issue and we're still not sure about that. We think that there are commonalities but there also are differences. So the first bit of work we did was in a relatively rural part of east Texas. We did a study comparing the symptoms of stroke in men and women who lived in this community. There were a lot of patients in the study 1,124 from 1998 to 2000. We found that the symptoms of stroke were different. So the traditional strokes symptoms, the ones that we learned about in medical school, the ones that you hear about from the federal government, are weakness and numbness on one side of the body. I'll come back to these at the end of the talk as well. Weakness and numbness on one side of the body, difficulty speaking our understanding, sudden unexplained confusion, sudden unexplained falling. So like my grandmother who was unable to speak and couldn't move one side of her body, that's a very classic stroke something.
• [00:15:03.27] So we found that men and women have those common strokes symptoms but women also have something else. They had more of what we labeled as non traditional stroke symptoms and those were pain in a part of the body and a change in consciousness. These were reported more by women. Now it turns out in this study that the women had more of the bleeding type of stroke that I told you about earlier than the men did. Some of these symptoms are kind of more common to the bleeding type of stroke than they are to the infarction, the more common type of stroke. So we said, I don't know maybe this is one of the many strange things about Texas or maybe this is something about this study. We need to try to figure this out by doing it again. So one key aspect of good clinical research is that you never believe your first finding, right, you gotta do it again, you gotta do it in a different population.
• [00:16:02.90] So we did it in a different population; we did it in Ann Arbor. This was a study that was just published last year by my colleague Lynda Lisabeth and our group where we looked at patients who came to the University of Michigan emergency department who had a stroke and we found whether what their symptoms where; We compared men and women with symptoms. Actually we did the study a lot better than the Texas study because we went immediately to the emergency department when the patients came. We interviewed them right away and so we got the information in a much more believable fashion.
• [00:16:40.52] Interestingly, again there were 461 patients, 224 women, 237 men and we found the same thing again. Very interestingly, non traditional symptoms were reported more commonly by women then men, not a huge amount, but nonetheless a significant difference of 8%. The things that we found especially were that altered mental status, kind of a change in consciousness or just not quite being with it was more common in women than men. That's a relatively rare symptom; usually when people have stroke they're awake and they may have problems speaking and they may be confused but they're not sleepy and they're not losing consciousness. This was something that was more common in women than men by 8%. So what we say now is that the symptoms, the traditional symptoms can happen in both men and women: weakness and numbness on one side of the body, difficulty speaking or understanding, sudden unexplained falling, sudden unexplained clumsiness. This additional stuff of kind of not quite being with it, falling asleep, passing out and perhaps some pain, can also be a symptom in women. That's a picture of my eldest daughter, 15 years ago actually.
• [00:18:10.11] The next question is, is there a gender difference in healthcare resource allocation? That is are we spending more medical services, are we doing more to evaluate men than we are for women? The answer to that -- and this was a pretty shocking thing for us -- is yes, really big time, except if you live in Canada. I put in the really for this audience. Usually when I talk in other places just saying Canada envisions cold but so does Michigan. So, this was a study that we did in Houston, Texas. It was looking at how long it takes people to get to the hospital because one clear message you should get from tonight is that as soon as you have any symptoms of stroke, -- the ones that I mentioned -- you should immediately call 911 to get to the hospital. We have very effective treatments but they only are effective for a couple of hours so you must immediately call 911 or if you see anybody else having those symptoms, calling 911 is very important. So again, we did this particular study because we were interested in the delay time it took from when people had symptoms to when they got to the hospital and we were particularly focused on African Americans and Hispanic Americans because those were the populations that we were studying. Once again we found a very interesting gender affect by accident.
• [00:19:39.73] So this was a study of 241 stroke patients at this large hospital in Houston in the 90's and what we found was that women got the hospital slower than men. Why would women get to the hospital slower than men? Many women live alone and it's hard when you have a symptoms of stroke to pick up the phone and call 911. The second part of it was especially disturbing. When we looked at men and women who got to the emergency department and we control for the severity of their symptoms, the doctor saw the men faster then they saw the women. The interesting thing about this particular hospital is about 80% of the doctors in the emergency department were women. So can't blame everything on men, most things yes, but not this particular one. So here's the numbers: so in delay in getting to the hospital it took women 263 minutes, on average, so you know more than four hours, compared to 200 minutes for men. Then once they hit the emergency department, it took doctors 14 minutes to see women and eight minutes to see men. Now you may not be wowed by these absolute differences but when you have a stroke, we move very quickly in emergency moments. The quintessential medical emergency because the medications we have, have a very short window of efficacy. So we want to treat people as quickly as possible and there should be no reason that women are seen slower than men are. In another study, this is now in a population that we've been doing a lot of research for many years in Corpus Christi, Texas, we compared after people have had a stroke and when they're in the hospital what kind of evaluation they have. So was there a difference in the evaluation of patients once they had a stroke? Again, in this particular study we study Mexican Americans. Predominantly we found no difference by ethnicity but again we found a very interesting gender effect. So this is where we do our research and you can imagine this is a really nice place for me to escape in January, February - the Gulf Coast of Texas. It's a great place to do our work and we've been fortunate to be funded for 15 consecutive years by NIH to do this work. It's a community of 300,025 about 56% are Mexican American. What we found in the study was that women received fewer diagnostic test than men despite adjusting for all the clinical reasons why that might be. We looked at all the neurologic reasons and we put them all into our analysis, we couldn't figure it out. The doctors there just ordered more tests for the men then they did for the women. We found very interestingly that carotid artery disease, which is a common cause of stroke, that the doctor's ordered those tests much more for men than they did for women. We couldn't explain that by anything about the strokes that these people were having. Our conclusion was that we needed some sort of intervention to increase the access to quality stroke care for women and dispel the myth that stroke is a male disease. One of the things that we learn in medical school is that vascular disease, heart disease, stroke, those kind of things happen to men they don't happen to women. So numbers like 62% of all deaths from stroke occur in women is not a very commonly known. So it's really important that you guys hear this message and that you tell other people about the message so that we can continue to disseminate the idea that stroke is a disease that affects both genders. We also have to do better in the medical community to make sure that doctors and nurses understand this too. So the next question, do men and women have the same stroke outcome? So clearly, and this is a very interesting fact this is just adding insult to injury, women do much worse than men when they have a stroke. We again don't know whether this is because of what I just finished saying. Maybe if doctors were more aggressive it treating, evaluating, and preventing stroke in women, they wouldn't have worse outcomes. We know that stroke outcome is worse in women than it is in men. And so this was a study that was a multinational registry that was reported in 2003 and basically what they found was, and what this number means, is that women were 40% less likely to recover from stroke than men were. That's a huge difference, 40% difference. There's many reasons that, that can be possible: the stroke could be more severe, it cannot be evaluated properly, maybe there's less social support because women are older when they have stroke. There's many different possible reasons for that but there's also a lot of ways to deal with it. So we think that it's very important to be aware of these statistics.
• [00:24:56.13] So back to Canada here for a second to show you a couple of things. It seems that when you cross the border everything is OK. The reports from Canada -- this being one of them reported just a couple of years ago -- was that in Canada, the evaluation of men and women are equal. They spend the same amount of money and they do the same number of tests by gender. The outcome from stroke is also equal. So very interesting that our neighbors to the north don't seem to have the same issues that we have here.
• [00:25:33.79] One of the things I think is really important for those of you who interact with the healthcare system -- which is probably all of us -- is you gotta know when to be aggressive and you gotta know when to be conservative. So doing something isn't always on the right answer. We believe very strongly, in our stroke program, in following the scientific evidence and offering tests and procedures only when it's been shown to be effective and when the risk is worth it. So here's a very good example of a problem and that is that when women have blockage in the carotid arteries but have not had symptoms, so we call asymptomatic. So have not had any of the symptoms I mentioned before but they have blockage in the carotid arteries, the data clearly says that a more conservative approach is better than it is for men. Women do not benefit from surgery for asymptomatic carotid artery disease anywhere as much as men do. So most of us are pretty conservative about recommending aggressive treatments. There's been a series of studies about this and this is just one of them that basically shows that if you don't do anything, men are much more likely to have strokes than women are overtime.
• [00:27:04.32] So are there areas where women on the other side should be treated even more aggressively? The answer to that is acute stroke therapy or in the first few hours after stroke symptoms occur. Once stroke symptoms have occurred women are especially helped by the medications that we used to treat stroke. The medication that we use is a drug call tPA or tissue plasminogen activator. It's a substance that our body makes naturally and a pharmaceutical company has figured out a way to have bacteria make it in big quantities. It's a clot busting drug. It goes in and breaks open the clot that I told you about so blood flow can be restored to the brain and the brain can survive. In studies about this, it's been found that, that clot busting drug is much more likely to open up the clot. Here in this study 94% had the vessel opened up compared to 59% of men. So 94% of women and 59% of men. In this study, a very interesting study by David Kent who trained here in Ann Arbor and moved to Boston, he did a study to see who actually benefited the most from tPA for acute stroke. What he found was that if you look at men, these are the men that got tPA and these are the men that got a placebo drug. You know the way we do studies, it's totally without us knowing it, we hang a bag and we don't know what's in the bag. It could be the real stuff or it could be a placebo. The placebo group here, and the treated group; for men there was a very minimal difference, didn't seem to help all that much. For women there was this astounding benefit. There's really a big difference between these bars. If you look at it really carefully, the interesting thing is that the women who don't get the drugs do very badly. The real difference here is the two placebo groups rather than the two treatment groups. So what this means is if you come to the emergency department within three hours -- which is when we can give you tPA -- and I don't treat you, your chance, if you're a woman, of having recovery is much less than if you're a man. That's really the message from the slide and David Kent showed this in this really nice study. So a number of different lines of evidence that suggested that once people have a stroke women don't do as well as men.
• [00:29:45.73] So conclusions: women have worse stroke outcome than men, pretty clear. Stroke is a larger public health problem in women than men. Stroke symptoms probably do differ, I'm a little cautious here, but they may differ by gender. They share some commonalities but women have some extra stuff that may make it difficult for doctors and nurses to determine. So one of the things that we think, the reason why doctors don't take care of women as quickly as they do man is they're confused. Men come in, they're paralyzed on one side of their body, their face is drooping, everybody knows it's a stroke. Women come in and they may have those symptoms but they're also complaining of pain, they have some alteration in consciousness. The doctor doesn't know what's going on so it takes longer to do the stuff. So those are some of our theories. Finally, women are treated less aggressively than men. We cannot come up with any explanation for that. That doesn't make any sense and it's obviously not best medical practice. So those are the conclusions of the research that we and others have done at this point. Here are some of the speculations: vascular disease is still thought of as a male disease, both by the public and by the medical community, physicians are more aggressive with male patience than female patients, male spouses are worse advocates than women, and women are more likely to live alone at the they have a stroke. So both of those things are possible. As I just finished saying symptom differences confuse physicians.
• [00:31:25.07] So how do we fix this? What are the different things that we can do to try to remedy the situation? So what we doing in the stroke program at the University of Michigan is we do a lot of studies like this, epidemiology where we try to identify the problem. We have a very involved group that actually goes and tries to work in communities to try to fix the problem. The community that we do a lot of our work and is this community in Texas because it's geographically isolated. We've been working there a very long time. We'd like to do more in Michigan and we do a lot of our research in Michigan but we've got most of our data so far from this Texas community. So healthcare intervention research projects that advocate guideline based practice for all patients. So we need to do better on the medical side. We need to further evaluate symptom differences and we need more advocacy for women's health and equal care. One of the things that the stroke community has lacked for a long time is an advocacy approach. There are other diseases that we all know of that you can clearly identified the messages and the pink ribbons and a bunch of other things. Stroke for some reason has never had that and I don't understand why. Maybe it's because neurologists are inherently conservative and quiet but we lacked the advocacy, we lack the grassroots citizenry saying, this is important, look what it's done to our community, we need to get the word out. So venues like this are very important. We also have to deliver the proper message; we can't get the message wrong. I think that in many respects, the agencies that have taken this on like the Ad Council and the National Institutes of Health and others, have made a serious mistaken in stroke education. Just like these guys painting the school sign, they've gotten the name wrong. What these programs have done -- and you probably have seen them -- is they scare people. The Ad council is famous for trying to get kids not to use drugs by taking an egg and frying it in the frying pan. The behavior research will tell you that if you want to prevent a behavior it's OK to scare people. You can scare people out of a behavior but it's really hard to scare people into a behavior. So for stroke we want people to call 911 if they have stroke symptoms or they see somebody else having stroke symptoms. It's hard to scare people into that. By telling people about death and disability and being very bleak, it's not going to happen. So our group has used a very different approach. We've taken people who have done very well after stroke, who have gotten treatment and effectively have gotten better. We promoted that very positive message to the community so that people understand that when you have a stroke it doesn't mean that you're going to be disabled or die. It means that you need to do something about it and that you really are in control of your own destiny. So I want to show you some of the work that we've done.
• [00:34:39.97] So the first bit of work was from a study that we did in rural east Texas where we took this very positive approach instead of showing things very bleak, we showed somebody who came to the emergency department. There's a friendly doctor, the wife and everybody is encouraged, that they call 911 right away. You can see at the end of this little video that we played on the TV -- I think 1,100 times -- the patient actually is recovered and doing the things that he wants to do.
• [00:35:12.46] - I think my wife's had a stroke.
• [00:35:16.96] - I told him not to call.
• [00:35:18.96] - Would you send an ambulance?
• [00:35:19.96] - I told him it wasn't necessary. I told him it wasn't an emergency.
• [00:35:27.97] - You're gonna be OK.
• [00:35:28.97] [OVERLAPPING VOICES]
• [00:35:29.97] - I told him not to make a fuss.
• [00:00:00.00]
• [00:35:31.97] - Are you on any medications?
• [00:35:33.97] - Now I'm glad he did because it was a stroke.
• [00:35:38.47] - If you notice weakness on one side of the body, difficultly speaking or understanding, loss of vision or severe dizziness, call 911.
• [00:35:46.93] DR. MORGENSTERN: So again, kind of dealing with the barriers, that people don't want ambulances to come to their house and all these other things and spinning it in a very positive way. So that's a big part of what we're doing. So I'm going to tell you about another project that we did and actually -- Kate, where are you -- Kate Maddox is in the back and Kate is our nurse practitioner who was very instrumental in this particular project. She has a lot of information about stroke when we're done, about what we do in our stroke program at U of M and about stroke prevention too. What we did in this community in Texas is that we decided we needed to train a new generation about strokes symptoms. So we took the message to schools and we taught middle school children about stroke. We have them, through homework assignments, bring that information back to their parents. So here is an interactive computer game where kids learn about stroke and learn about how important is to call 911 when they see somebody having stroke symptoms. I want you to notice here that the middle school kid is the hero and the person who represents the father, uncle is obviously the villain, comes up with a wrong answer. So this is very much in middle school lingo. So it starts with them at this very typical event that they have in their community where they are dancing to a local band and the woman has stroke symptoms. So the question is what are the things to do? So if you listen to the uncle here:
• [00:37:35.06] - I'll take you home so you can rest. You'll probably feel better in the morning.
• [00:37:38.55] DR. MORGENSTERN: So that's obviously not the right answer.
• [00:37:41.98] -I think you should call her doctor to see what the doctor says to do.
• [00:37:44.87] DR. MORGENSTERN: That's not the right answer either and let's see what the hero would do.
• [00:37:49.59] - I think we should call 911.
• [00:37:51.55] - Choose which one you would do.
• [00:37:53.72] DR. MORGENSTERN: So if we listen to the uncle and we go home and rest. - Rita went home and slept through the night. In the morning she was still weak on her right side and was also having trouble talking. Joe took her to the emergency room later that morning. Rita did not get to the hospital on time for tPA. She's still getting better but will need to get therapy to help improve her speech and to try to walk on her own.
• [00:38:14.96] - Choose which one you would do.
• [00:38:25.81] - Congratulations! Calling 911 is the best thing to do when you see someone who has stroke signs and symptoms. Rita is doing really well because she got tPA quickly. She's leaving the hospital after only a few days. She has no symptoms left from having a stroke.
• [00:39:06.36] DR. MORGENSTERN: So you can see the positive and the comparison before she's coming out of the wheelchair and here she's coming out, you know, holding hands with her husband. So again a very positive message. I think this is where it gets stuck, let's see here. My aunt's trying to remind you that we should be active in this process.
• [00:39:39.21] Let me end with again, going over the symptoms of stroke: very importantly, sudden blurred or decreased vision particularly in one eye, numbness, weakness, or paralysis of the face or one side of the body, maybe just one limb and maybe arm and leg, difficulty speaking or understanding, unexplained clumsiness, sudden onset of clumsiness, dizziness, or unexplained falling and severe kind of thunder clap onset of the worst headache of your life. Those are the symptoms of stroke. This is a slide that's now about a decade old and if anything, I think the problem has gotten worse. It's always very difficult to compare diseases; all these diseases are very worthy of funding but stroke always seems to be last in funding and remains so. It's a very discouraging thing because certainly as the population ages this will continue to be a very important disease. For those of us that have taken care of stroke patients who are children, adolescents, young adults, we know that this is not only a disease of the elderly. It causes very severe disability which is a great expense no matter how you define that, either it be financially or in terms of great hardship to the patient, the family, and the healthcare system. So that's all I have and I'm hoping that you guys have lots of questions and comments at this point. Yeah so are we going to pass around the microphones or how do you want to? Maybe just raise your hand and we'll bring the mics to you.
• [00:41:20.76] AUDIENCE: Is there a pharmaceutical intervention like statins help prevent heart attacks, is there a drug you can take to prevent strokes?
• [00:41:29.67] DR. MORGENSTERN: Yeah so as you guys heard the question is, what are the medical prevention things for strokes? So the first thing I want to say before I talk about the drugs is the most important things you could do to prevent stroke aren't drugs, don't have anything to do with doctors, don't cost any money. Right? It's good exercise, proper diet, you know, not smoking, avoiding excessive alcohol consumption. So there's not always a medical therapy for all those things but hypertension, high blood pressure is the number one cause of stroke throughout the world. If there's ever a disease that we know how to beat, it's high blood pressure. As everybody knows here, you have no idea that you have high blood pressure unless you have your blood pressure checked. OK, so it's really important to get your blood pressure checked frequently, see your physician and try to tell your physician that you want to be very aggressive about getting your blood pressure under good control. Other medications that would be relevant or for people who have diabetes, make sure their sugar is under good control. Statins have been shown to be effective. Statins are cholesterol lowering medications, a particular type, and they have been shown to be very effective with stroke prevention too.
• [00:42:45.72] AUDIENCE: Who should be taking the statins? Who should be prescribed statins?
• [00:42:49.04] DR. MORGENSTERN: So there are general recommendations for people who have very high cholesterol and people have had other vascular disease whether it be heart disease or stroke. It depends upon the numbers you have of the different subtypes, you know, the total cholesterol HDL, and the LDL and what symptoms and what risk factors you have, whether you've had a stroke or heart attack before. So it's a little bit of a complicated formula and that's best discussed with your physician. There's got to be more.
• [00:43:25.00] AUDIENCE: I have a question.
• [00:43:26.17] DR. MORGENSTERN: Yes.
• [00:43:26.63] AUDIENCE: I had a friend whose grandmother was told she had a mini-stroke. What is a mini-stroke?
• [00:43:31.35] DR. MORGENSTERN: So usually a mini-stroke is a TIA, or transient ischemic attack. And it's the symptoms of stroke as we've talked about that go away within 24 hours. The concern with that is that you're at really high risk over the next two days to a week of having a major stroke where the symptoms stay permanently. So often people make the mistake when they have symptoms; let's say their are arm goes dead and it recovers in five or 10 minutes and they say, oh it's nothing and they don't go to the hospital and then they have a major stroke the next day. So those are especially the people we want to see because they have everything to gain by getting prompt medical attention. There's another question up here.
• [00:44:20.46] AUDIENCE: You mentioned that one of the symptoms is when a person has a severe headache, but it's so common to have severe headaches and you probably say, well it'll go away. How can you tell the difference with a headache for stroke and a headache that's normal?
• [00:44:35.59] DR. MORGENSTERN: So they headache that we're talking about is like a thunder clap onset. It just comes out and you fell like you've just been punched in the head. It's the worst headache of your life 10 out of 10. At most you're going to have one of those in your life, right? If it's the worst headache of your life? It's a different type of headache than the common ones that people have.
• [00:45:01.92] AUDIENCE: Has there been any good research done on aspirin in preventing stroke in women particularly?
• [00:45:07.09] DR. MORGENSTERN: Yeah, so there have been I think a 150 trials looking at aspirin and the prevention of stroke. Thank you for bringing that up. I neglected to mention that before when I was talking about medical therapies for stroke, aspirin is an effective preventative treatment for stroke. We know that people who have had a TIA or a stroke before should be on a medication that blocks the platelets, and that's how aspirin works. Platelets are those clumpy things that make blood clot and they should when hurt yourself, but they also do it erroneously when people have strokes. So aspirin is an effective, preventative treatment.
• [00:45:49.05] Now if you have not had a stroke or a heart attack before it gets a little bit complicated. Aspirin is a good preventative drug for heart attack but for stroke it seems to actually work a little bit better or be a little bit safer in women than it is in man. So we actually recommend for primary prevention, for women who are let's say, over 60 to take 81 milligrams of aspirin a day for stroke prevention, not necessarily for men but men take it anyway for heart attack prevention. What?
• [00:46:23.94] AUDIENCE: [INAUDIBLE]
• [00:46:24.87] DR. MORGENSTERN: Well it depends. So the question is about ulcers. It depends upon if you've had an ulcer or if you're at risk for an ulcer. If you haven't then you're OK but obviously, if you've had an ulcer that's something to talk to your doctor about.
• [00:46:37.38] AUDIENCE: Dr. Morgenstern, you pointed out a great deal of difference in Canada as far as stroke outcomes. What might your summation be of the reason for that? Could it be a different healthcare system in Canada?
• [00:46:52.20] DR. MORGENSTERN: Don't get me started.
• [00:46:56.70] AUDIENCE: That's what we're here for.
• [00:46:57.46] DR. MORGENSTERN: You want to talk about healthcare reform we could be here all night. So I don't know. Obviously Canadians have a very different healthcare system. We spend a lot more money, per capita, on healthcare here. They may not be doing the tests anyway so it's harder to tell. Just because it's equal in Canada doesn't mean Canada's doing it better than we are. So we don't know the answer to that. Good question.
• [00:47:24.81] AUDIENCE: You described women as having different kind of symptoms and several of the women in my family had strokes and they never had the classic symptoms. How did you just describe them? How did you say women described those?
• [00:47:39.20] DR. MORGENSTERN: So I think they important thing is that, at least our opinion is that, both men and women do have the classic symptoms but women have other stuff that kind of masks the classic symptoms. So the other stuff that I was talking about is what we label as an alteration in consciousness or altered mental status, they're kind of sleepy, they may pass out, they're just not with it. Usually when people have a stroke they're awake and alert. They may not be saying the right things, they may slur their speech, they made be confused but their eyes are open and they're awake. So stroke doesn't usually cause people to pass out. When somebody calls me to the emergency department and tells me that somebody has passed out, I usually am thinking that, that's not a stroke. Nine times out of 10 I'm right about that but women may have more propensity to have those changes in consciousness. They may also complain of pain. So when a limb is paralyzed, you know, men may be more likely to say it doesn't work; women may be more likely to say it hurts. So That's an interesting description and from a research standpoint, we don't know if women have different symptoms or they describe them differently or what the situation is. It's enough that I think that we've now found it in two very different populations, one in Texas one in Ann Arbor. I think it's enough to kind of throw off both the patients and the doctors in making the proper diagnosis. Yes.
• [00:49:19.06] AUDIENCE: A description --
• [00:49:21.48] DR. MORGENSTERN: Just talk right into it.
• [00:49:23.39] AUDIENCE: -- If it's not a question or description, what would be the reasons for having different symptoms? Is it hormones? Is it, what? That's one question. And the second question is --
• [00:49:33.28] DR. MORGENSTERN: You gotta ask me one at a time because I can't remember any more than one.
• [00:49:37.58] So if it's not a description it could be that different parts of the brains cause different feelings. In other words if on the left side of my brain, if that's blocked, it may cause me to feel numbness, for you it may cause pain. So it may just be that, that is a gender difference. So, that's why I was saying that I don't know if it's a description thing, if it's more of a psychological thing, or if it's more of an anatomy and physiology thing. So that's a possibility. I don't think that hormones play a role here. Hormones are very important in this story and I haven't talked about them. We know that estrogen seems to be protective of stroke in women early on but when estrogen levels decrease around menopause it causes the risk of stroke to go up in women.
• [00:50:38.48] AUDIENCE: That lead into the second question very well. What studies are there about the onset of the first stroke in men versus women?
• [00:50:47.15] DR. MORGENSTERN: Right, so, in any given age, men have a higher risk of stroke than women. We think that the 62% of deaths from stroke occur because women live longer than men. Men die from a bunch of other things: from heart disease to cancer. Women live longer and because they live longer they're likely to have a stroke. I think that women are relatively protected because of hormonal levels. I should also say that hormone replacement though seems to have the opposite effect. There have now been several studies that suggests that hormone replacement is not good, it increases the risk of stroke. Certainly when we see women who are on hormone replacement or on oral contraceptives and have strokes, we stop them immediately.
• [00:51:39.89] AUDIENCE: First, I'd like to thank you and you're colleagues of like throw the work that you're doing in this area. A year ago I had a stroke and I'm just wanting to comment that the drug that they gave me, the tPA is very effective and I have very limited side effects that most people don't even recognize. I just wanted to thank you for that.
• [00:52:09.96] AUDIENCE: Dr. Morgenstern, you talked about the funding that's going into research hope and the hope that there's more advocacy. Where do you see research going? If we had more money going into research, what are the opportunities?
• [00:52:23.68] DR. MORGENSTERN: Boy that's another kind of, you know, all evening kind of discussion. I think we've made some mistakes actually with the money that is around. There have been hundreds of studies of different new chemicals to treat stroke but very few people try to get people in the hospital fast enough to use the good chemical we have right now. I'm a big propoent of doing research in communities with people and trying to get them treated with existing therapies. As I started this I said, I think we know a lot about stroke but we're not using it. So I'd like to see a lot more community based research. I'd like to see a lot more effort in trying to prevent stroke and get stroke treated. We have another large study that is funded by the government where we've parternered with the Catholic Church to try to spread a prevention message to a Mexican American community in Texas they're hopeful that will be helpful. Those will be my highest priorities. My next priorities would be to continue the basic science work doing that we're doing genetics, et cetera, to try to figure out why this all happens and come up with better therapies. I think to an extent -- and I try to allude to this with the first question. We tend to look for magic pills to fix things and I think a clear message is that we all have to take responsibility for our own health and try to do the things that we should do to prevent the disease from happening or once it's happened, take care of each other in our community. I hope that if I have a stroke in Ann Arbor that somebody's gonna witness it and pick up the phone and call 911.
• [00:54:20.66] AUDIENCE: Lewis, I just wanted to follow up with a comment. The grant that's sponsoring this evening and a whole series of these community forums that we're doing is because it's so critical that our communities get involved in clinical research. Clinical research can't happen without the involvement of all of you. Can you comment if there's any clinical research studies going on right now that people may want to look up on our engage website or contact you about?
• [00:54:49.79] DR. MORGENSTERN: Yeah, fortunately, I think for healthy people there aren't and we have a number of different research projects that are going on for people who have had strokes. I don't know. Kate Maddox, do you have anything more to say about that?
• [00:55:06.33] AUDIENCE: [INAUDIBLE]
• [00:55:14.54] DR. MORGENSTERN: Right.
• [00:55:18.86] AUDIENCE: Because different studies come up at different times, so there may not be a study today but there may be a study six months from now or a year from now, one of the things that we've done with the Engage website -- where, there's brochures out in the forum area there -- there's a registry where you can register yourself. It's completely private. No one else gets access to the information except for the people who are conducting the studies thing you might be interested in and if a study comes online in the future, you will be contacted about that study. So you don't have to be checking everyday. It will let you know and it's not just stroke studies. There are studies in every possible health concern that you can imagine going on. So the registry is a wonderful way to -- and thing is that it's just for your information, if you get contacted and you have no interest in participating you don't have to do anything -- it's a way to keep informed if you want to get involved.
• [00:56:15.16] AUDIENCE: We have another question.
• [00:56:20.14] AUDIENCE: Is there a chemical explanation as to why sodium seems to have such an effect on blood pressure?
• [00:56:27.71] DR. MORGENSTERN: So good chemistry question, why does sodium effect blood pressure? I don't know the answer to that because the, you know, the body's usually pretty good at regulating sodium. It's the kidneys that are responsible for modulating how much sodium we have in the body. We do think that sodium is an important part of blood pressure and of stroke. As a matter of fact, this project that I mentioned were trying to do primary prevention in our partnership with the Catholic Church, the prime thing is to try to get people to eat less sodium. So we know it's important but why the kidneys kind of fail in getting rid of sodium and retain enough so that the blood pressure goes up is something that I don't know the answer to.
• [00:57:15.26] AUDIENCE: You talked about advertising messages and for a long time prior to this seminar I was remembering messages that talk about a brain attack being the same as like a heart attack except of the brain. I was under the impression they were the same process and basically the same doctors treated both. I notice back you kept talking about neurology. I kept thinking, well its cardiology that treated all these things. Is there a difference?
• [00:57:38.77] DR. MORGENSTERN: A heart attack or myocardial infarction is the heart and stroke or a brain attack is the brain. I think that, you know, medicine continues to realign itself and it used to be that cardiologists took care of the heart and neurologists took care of the brain. So my office is in the cardiovascular center of the hospital and I have a lot more in common with my cardiologist down the hall than I do with neurologists in the other building. So we basically take care of blood vessels and whether the blood vessels are in the heart or the brain, it's that sort of thing, we're the plumbers of the of the body.
• [00:58:23.14] AUDIENCE: You speak about how important it is to get to the hospital quickly, within that two hour period. I think that may be one of the reasons that women don't do this is because they don't want to be accused of being hypercondriacs or pampering themselves or something like that. You sit there and you think, geez I feel awful, but am I having something? Or should I go to the hospital? Or should I just take an aspirin and go lay down? Or what should I do? I live alone and I think a great many women live alone and lots of times I'll have some funky feeling and I think am I having something? Or what's going on with me? And I do nothing except take an aspirin and go lay down.
• [00:59:17.05] DR. MORGENSTERN: OK, let me see if I can answer this one. So we're not talking about funky feelings. We're talking about things that I think are pretty recognizable. Of the thousands and thousands of stroke patients I've taken care of, I've yet to meet one who said, I didn't know what it was. OK, a lot of people say before they've had it, I'm not quite sure what it is and I'm not so sure what the symptom is but after you've had it, you know what it is. Now there are mild strokes and I just finished saying that with mini strokes or mild strokes it's really important get to the hospital because it could be a harbinger of a major stroke. For people who live alone I think some of those devices that carry with you or wear that you can push a button and ask for help; you laugh at it but they can be life savers and it's really important. The opportunity to be able to get help when you need it the problem with stroke -- we did a study I did not talk about -- is that over 95% of the time when somebody has a stroke they can't call for 911 themselves. By the nature of the disease, you can't speak, you can't move, how are you going to get to the phone? So having something where you can push a button and ask for help is, you know, really important. My goal is to try to get everybody in the community to know about it so that when people have a stroke in the supermarket or, you know, somewhere else, they can ask for help. If you're in your house by yourself, it doesn't work. You gotta have something that you have with you that you can use. Yes.
• [01:01:04.62] AUDIENCE: [INAUDIBLE]
• [01:01:11.32] DR. MORGENSTERN: Well, remember strokes occurs on one side of the body so if you had a cell phone with you and you could call 911 -- as you know the way -- cell phones are a little bit difficult and it depends upon where you are. It's harder for them to triangulate it. With your home phone they can always figure out where you are and get to you. So cell phones are probably not good enough.
• [01:01:40.85] AUDIENCE: Just a plug for the Heron Valley ambulance group that we have here. They do offer any inexpensive package, like an insurance plan. If you want to not have to think about how much an ambulance visit will cost you to get to the hospital. Because cost is certainly a factor for some people. They have a plan in which you pay a certain amount a year which gives you unlimited hospital ambulance trips. They also have a service where you can rent that red button that you press when you need it. So, cost being a factor for many people, those are some resources you have in your community.
• [01:02:14.13] AUDIENCE: How can you clearly differentiate between here your arm going to sleep and mostly when you're in bed or a stroke coming on?
• [01:02:24.75] DR. MORGENSTERN: Right, so, I don't know if the mic was on but the question is how can you tell your arm going to sleep from a stroke coming on. So, I think the key way is that stroke is a loss of function. So when I lie on my arm at night and it goes to sleep, it's tingly and it's kind of an active feeling and I can move it. I get up, I move it and start feeling better pretty quickly; it doesn't feel very good for awhile but it takes time. With a stroke there's a loss of sensation, sometimes people do have a little bit of tingling but usually it's just numb and it doesn't get better when you shake it. So if it doesn't get better in the first 60 seconds -- which I think when your limb is asleep it's going to get better, you're going to get more and more feeling -- than you need to call 911.
• [01:03:14.57] AUDIENCE: Dr. Morgenstern, thank you very much for this evening. Also, as a New Yorker, you have a mayor that is trying to do some very innovative things as far as salt restriction and salt intake. New York Times recently had some articles where they showed what some of the restaurants, fast food and others, if you would just go in and have a simple meal, you're already going way over what you should have for daily intake of salt, which I think is 2,000 milligrams or something like that. What would you project for people, for health, it salt is so important and influences blood pressure? What can we do to make it better for everyone? The mayor in New York is trying one way is that a good way?
• [01:04:01.04] DR. MORGENSTERN: Right, so, I'm in Ann Arborite. When I go to New York my blood pressure goes up 20 points just from the first time the first taxi cab honks at me. Yes, thank you, the those are excellent points. Our group got very famous last year because we wrote this paper about the association of fast food restaurants with stroke. Some of you may have read about it in the media and heard on CNN, et cetera. In this community in Texas, what we found was the closer you live to a fast food restaurant, the higher your stroke risk is. The density of fast food restaurants in your neighborhood was directly related to your stroke risk. Fast food has a tremendous amount of salt and fat and carbohydrates and those types of things. We just have to make healthier choices. We have those opportunities all the time: it's what you eat, it's do I walk to work, or drive to work? Do I take a bike? Do I go out for a walk at lunch or have another big mac? There are many choices that we can make. It's hard to legislate them. I think that various people have made attempts both locally and on national levels to think about legislating healthy behavior, cigarettes, all types of things; you can tax them. I must say, I'm not a politician but if I was, I think a good thing to do would be to make fast food that is not healthy more expensive than good food. As we know, it is more expensive to buy a healthy meal than it is to buy a not healthy meal. As long as that happens, if it's cheaper and faster, it's hard to say don't do it. So very good ideas and good points and things we need our politicians to improve. OK, oh, one more?
• [01:06:11.08] MODERATOR: Let me get over there. AUDIENCE: A little bit off the topic, but I understand there's a geographical difference, too, in strokes. And I'm just curious why this stroke belt exists. Is it all the salt and fat down in the south east?
• [01:06:31.79] DR. MORGENSTERN: A very good question. So there is a stroke belt and a stroke buckle of the belt. The southeast of the United States has a much higher risk of stroke than anywhere else. New York State, I think, has the lowest stroke rates in the country. We don't know what the reasons are. In preliminary examinations it doesn't appear to be related to race, ethnicity, hypertension, diet. It's hard to do those ecological type studies and figure out exactly what's going on. There's a large study going that funded by the NIH called, regards right now, that's trying to understand a little bit of the geographic predilection for stroke. Michigan is somewhat in the middle of the risk. Well Kate Maddox and I will be around for a little bit longer if you have any questions.
• [01:07:28.21] AUDIENCE: Yeah, thank you very much Dr. Morgenstern.