Many at risk for stroke don’t get anti-clotting drugs

Stroke prevention can save a life. Yet, many at risk for stroke don’t get anti-clotting drugs:

More than four in five stroke patients with a history of heart rhythm problems didn’t get any blood thinners, or didn’t take enough to help prevent a stroke before they had one, a U.S. study suggests.

Most strokes occur when a clot blocks an artery carrying blood to the brain, known as an ischemic stroke. The study focused on more than 94,000 stroke patients with atrial fibrillation, an irregular rapid heartbeat that can lead to stroke, heart failure and chronic fatigue.

Fewer people now rely on rat poison anticoagulant

Before smartphones, I had a voice-recorder device that gave me reminders and recorded lists and notes. I could record a reminder and tell it when to remind me. So every day around 5 in the afternoon, I'd get this reminder: "Take the rat poison."

That is, warfarin, also know as Coumadin. And it really can be - in a somewhat different dosage - rat poison. Read here about that.

I took warfarin for years after my stroke in 1998, requiring monthly blood tests to make sure it was effective in preventing blood clots that could lead to a stroke.

Problem is, it also had its own dangers - bruising, bleeding excessively from even a small cut, and internal bleeding, to name a few. I had some pretty ugly bruises myself during my warfarin years.

Wrong medicine for your particular stroke risks?

A few posts ago, I mention an article about the value of aspirin for those who experienced a mini-stroke.

Now, here's another article about when perhaps NOT to use aspirin when patients at risk for stroke get wrong medicine:

Researchers analyzed data on more than 500,000 people with atrial fibrillation, an irregular rapid heartbeat that can lead to stroke, heart failure and chronic fatigue.

Roughly 40 percent of these patients got aspirin instead of prescriptions for blood thinners – also called anticoagulants.

“By prescribing aspirin, we may be fooling ourselves

Aspirin a day? Before you start (or stop) read further ...

Do you take an aspirin a day?

I used to, sometimes in combination with Plavix or warfarin as physician-directed. Aspirin sellers, of course, pitch this idea in advertising. I stopped taking it after a heart procedure that reduced my stroke risk and, with no other risk factors aside from age, my cardiologist told me it's not necessary.

Turns out that lots of people take a daily aspirin to prevent a stroke or heart attack. One recent story says a daily aspirin is taken by more than half of older U.S. adults:

Most appear to start taking daily aspirin after discussing the matter with a health care provider, said study lead author Craig Williams, a pharmacotherapy specialist at Oregon State University in Portland.

Is something right happening in health care?

Something right might be happening.

In catching up on stroke-related news of late, I was reminded about a story showing that emergency departments are seeing fewer strokes and TIAs:

The rate of adult emergency department (ED) visits for ischemic stroke or TIA fell 35%, from 40 to 26 per 10,000 persons from 2001 to 2011 in the National Hospital Ambulatory Medical Care Survey (NHAMCS) data. The rates fell across age groups -- a relative 51% in the 55-to-74 range and 26% for those ages 75 and older, Anjali Talwalkar, MD, MPH, and Sayeedha Uddin, MD, MPH, both of the CDC's National Center for Health Statistics in Silver Spring, Md., reported in the March issue of NCHS Data Brief.

But among younger people who came to the ED for ischemic stroke or TIA, fewer were arriving by ambulance.

Strokes are generally preventable, with fairly common-sense diet, exercise and medication use leading those methods of prevention. I've put links under each of those categories, where you can read more about stroke prevention.

Stroke treatment is still vitally important, and improving stroke treatment through better medication, better therapy techniques and tools are key elements of stroke treatment. But preventing a stroke is the best treatment of all. So do what you can - the life you save could be your own.

Right combo of aspirin and blood thinners found safe

I stopped taking blood-thinners seven years ago, after a heart procedure removed my extra-high stroke risk.

However, I always took them when ordered, despite the trouble of tests, diet-watching and bruising/bleeding risk.

Turns out, that's what you're supposed to do. Experts reported earlier this month that long-term use of aspirin plus blood thinner is safe:

The blood-thinning combination won't increase a patient's risk of early death, according to a new study presented Sunday at the annual meeting of the American Heart Association in Chicago. The report was also published online Nov. 16 in The Lancet.

Could warfarin temporarily raise stroke risks?

Warfarin might be phased out for many patients - maybe - with some unpleasant or worse side effects. And perhaps that is a good thing. From a few days ago, here's a snippet  of a story titled "Start Warfarin, Have a Stroke?":

Starting warfarin for preventing stroke in patients with atrial fibrillation appeared to be associated with a transiently increased risk of ischemic stroke before the preventive effects kicked in, a large case-control study showed.

Compared with not taking any antithrombotics, initiating warfarin was associated with a greater risk of ischemic stroke in the first 30 days ... , with a peak at 3 days, according to Samy Suissa, PhD, of McGill University in Montreal, and colleagues.

But after that, the well-known stroke-cutting effects were seen ... .

I've always been told that warfarin takes three days to take effect, which fits at least part of the story. Click on the story link to read more.

Developing new class of blood thinners continue

For a few years, I took warfarin (also known as Coumadin) daily. I had to be careful in diet, in the timing of the medication and getting blood tests monthly to make sure my blood was not too thick, not too thin, but rather, to paraphrase Goldilocks, "just right."

The drug, also famously used as rat poison, has been in use to prevent clot-type strokes for decades. You might have seen the TV commercials lately for new drugs coming on the market to replace warfarin. Now, new blood thinner edoxaban was found safer, as effective as warfarin:

"Personally, I think it will be used. We know this drug is safer than warfarin," said the study's lead investigator, Dr. Robert Giugliano, a cardiologist at Brigham and Women's Hospital in Boston.

But it will enter a market that already has three other new medicines vying to displace cheap, decades-old warfarin. 

It aims to compete with Xarelto, sold by Bayer AG and Johnson & Johnson, and Eliquis sold by Bristol-Myers Squibb Co. and Pfizer Inc., which belong to the same class of drugs as edoxaban, as well as a similar medicine from Boehringer Ingelheim called Pradaxa. ...

"If you look at the four new drugs, they're more similar than different," said Dr. Mark Link, a professor at Tufts University Medical Center in Boston, who was not involved in the trial. "All these drugs are safer than warfarin."

Warfarin, of course, can cause bleeding, bruising and other medical problems. On the downside of the new drugs, costs will be far greater than the cheap generic warfarin. Still, worth discussing with your doctor.

(Photo from the National Library of Medicine)

New stroke prevention pill might be safer

More news on potentially better stroke prevention medication. Downside: Might be considerably more expensive. Given its safety vs. warfarin (also known as Coumadin), however, if you or someone you know is currently taking the major blood-thinner, it's a good idea to keep track of the progress on this medication. A recent one from USA Today:

New pill prevents strokes with less bleeding risk for atrial fib patients

The study of 14,000 patients found that a new one-a-day pill, rivaroxaban, prevents strokes as effectively as the current mainstay of treatment, Coumadin, without the need for routine testing to monitor patients' ability to make blood clots and avoid unwanted bleeding, says Robert Califf, of the Duke Clinical Research Institute in Durham, N.C.

Atrial fibrillation affects approximately 2.3 million people in the USA, and has been linked to a five-fold increase in the risk of lethal strokes. The reason: when a heart goes into atrial fibrillation, its upper chambers quiver rather than contract 60 to 90 times a minute as they're supposed to, moving blood through the heart and blood vessels.

Is closing the hole in the heart really best idea?

A recent study brings into question whether stroke survivors with a hole between the two upper chambers of the heart - called a patent foramen ovale - should have the hole patched:

Full final results from the first randomized controlled trial of patent foramen ovale (PFO) closure for stroke/transient ischemic attack (TIA) to reach completion have found no differences in the primary end point of stroke or TIA at two years, all-cause mortality at 30 days, and neurological mortality between 31 days and two years.

[Dr Anthony] Furlan [University Hospitals Case Medical Center, Cleveland] said it's "too soon to say" what impact the results will have on PFO-closure procedures: several trials are still ongoing, and while the devices are investigational in the U.S., they are market-approved in Europe and elsewhere.

"Ultimately I think CLOSURE I, if the other ongoing trials show similar results, will obviously ratchet down the number of endovascular PFO closures [performed]," he said.

"The challenge now, in my view, for the endovascular community is to refine the selection criteria and not so liberally be closing these holes in cryptogenic-stroke patients."

I have an interest in this because I had my PFO closed in 2007 and no longer take blood-thinners. Before that, I had been on both warfarin and Plavix, plus aspirin.

My understanding of my own case is that the PFO was just one of two factors; the other was an atrial septal aneurysm. That's when the wall between the two upper chambers of the heart - which normally should be fairly straight and smooth - is bulging. Basically, I was told, it had a divot, where blood clots could gather. Then, when chest pressure increases by something as simple as a sneeze, a clot could go from one side of the heart to another, through the hole, to the brain, causing a stroke.

This research points out the need to have intelligent conversations with your doctor(s) about any medical procedure, including discussion of possible outcomes, factors in your particular case, risks and alternative treatements.

New blood-thinners - potentially in the works

If you know someone who went through a stroke or heart-related ailment, you might know someone who takes the drug warfarin, also knows as Coumadin. Another wide use of the same chemical, and I kid you not: rat poison.

This isn't designed to scare people off taking warfarin. I was on it for years and while it's exceedingly difficult to prove a negative, it very well could have prevented multiple strokes or mini-strokes. If your doctor prescribes this medication, follow the instructions to the letter.

That being said, the medication requires frequent blood draws and can result in excessive bleeding. It plays badly with several other medications and even some foods. So medical experts have been working on replacements for years.

Now, some good - although muddled - news. Analysis: No clear winner in 3-horse anticoagulant race:

Industry analysts estimate the warfarin-replacement market at more than $10 billion a year and possibly up to $20 billion.

Medical experts have cheered the arrival of a new generation of anti-clotting drugs, since it is hard to maintain the right balance of warfarin in patients and the drug also interacts badly with certain foods and other medicines.

"Patients and physicians have been begging for a warfarin replacement," according to Ralph Brindis, president of the American College of Cardiology.

 (Image from the National Institutes of Health; not a real photo of warfarin, by the way)

Perhaps soon - a safer blood thinner

From a U.S. News and World Report article not long ago:

New blood thinner could replace warfarin

The new study, published early online Dec. 6 by the New England Journal of Medicine, follows on the heels of two other promising reports presented at the American Heart Association meeting in Orlando, Fla., last month. Those studies found that dabigatran appeared safe and effective in preventing blood clots when patients were treated for acute coronary syndrome, a cluster of symptoms that might indicate a heart attack; it was also found superior to warfarin in preventing strokes in patients with the irregular heartbeat known as atrial fibrillation.

In the new trial, warfarin and dabigatran seemed to perform equally well in helping patients with potentially dangerous clots in their veins avoid a subsequent clot or death over the next six months.

But it is in its ease of use that the newer drug appears to outshine warfarin, the authors of this latest study say.

Remember: Take that medicine!

Are stroke survivors taking their medicine?

People who have had an ischemic stroke are at higher lifetime risk for another stroke, but several types of medication can reduce that risk. One of the simplest regimens involves antithrombotic medications, otherwise known as blood thinners, of which the most common is aspirin.

But a new UCLA study to determine whether the use of antithrombotic medications among stroke survivors increased over a seven-year period found that in each of the years, approximately 20 percent of survivors were not taking these medications — a figure that did not decrease during the time period. The study also found that individuals who were younger, female or Hispanic were less likely to be taking antithrombotic agents.

The findings appear in the January 2010 issue of the American Journal of Preventive Medicine.

(Image from National Library of Medicine)

Cautionary note about mixing drugs, supplements

An article from MayoClinic.com recently gives a needed warning, starting with a question: Is it safe to take ginkgo with ibuprofen? Answer: Probably not.

The reason, wrote Mayo Clinic hypertension specialist Sheldon Sheps, M.D.:

Ibuprofen (Advil, Motrin, others) is a nonsteroidal anti-inflammatory drug (NSAID). NSAIDs can impair blood clotting, typically by blocking the ability of platelets to form clots. Ginkgo — a dietary supplement used to treat memory problems, dementia and various other conditions — may also affect the clotting process. Bleeding may be a particular concern when ginkgo is taken with other medications that can affect bleeding, such as ibuprofen. In fact, at least one fatality has been linked to the use of ginkgo and ibuprofen.

Gingko, of course, is appealing to many stroke survivors at first blush because of it's supposed powers of helping with concentration. But many are on blood thinners far more aggressive than ibuprofen. In fact, we've got a link to a study reported not long ago. But please, talk to your doctor and pharmacist before taking any supplement. This kind of mistake can kill.

Another stroke-prevention medication in the works?

Blood-thinning medication can be tricky - bruising and other side effects. But they can also prevent strokes and death.

So some news from The New York Times the other day - European Drug Watchdog Supports New Pill by Bayer - indicates that another stroke prevention tool might become available for certain patients.

Outside Europe, regulatory filings for Xarelto have been submitted in more than 10 countries, including Canada and China. It is expected to be submitted for approval soon in the United States, where it will be marketed by Bayer’s partner Johnson & Johnson.
Although the initial use of Xarelto will be in preventing blood clots after hip- and knee-replacement surgery, the big commercial potential lies in using it to prevent strokes in people with atrial fibrillation, a common heart arrhythmia.
The medicine, which is also known by the generic name rivaroxaban, is taken as a single tablet, once daily.

Worth watching for future developments.

(Image from National Library of Medicine)

Anniversary of hole repaired

Close to the end of the day today, June 25, 2008, remembered that this is the first anniversary of the procedure that plugged a hole in my heart.

My 1998 stroke was likely caused by a small hole between the two atrial chambers, called a patent foramen ovale. Everyone is born with the hole and most of the time, it seals up shortly after birth. And add another defect: The wall between the two chambers, called the atrial septum, should be smooth and flat. If so, even a patent foramen ovale is unlikely to cause a problem. In some instances, though, the atrial septum is misshaped, called an atrial septal aneurysm. The hole and the aneurysm combination increases the chances of a problem.

Normally, the right atrium receives blood from the vein side of the circulatory system, then passes it along to the lungs. In addition to processing oxygen for the blood supply, the lungs also use a filtering mechanism to remove debris, such as clots. From the lungs, the blood is moved back to the other side of the heart and pumped out to the arterial system, supplying oxygen-rich filtered blood to the body. However, if the atrial septum has a divot, if you will, then debris can collect. When pressure builds up in the chest -- say, from coughing or sneezing -- then blood and debris can move through the patent foramen ovale from the right atrium to the left atrium, circumventing the lung's filtering system. Unfiltered blood is pumped out into the body, including the brain.

Because of this, 10 years ago I experienced a cryptogenic stroke -- that is, a stroke with no obvious cause. In April 2007, a much more minor episode occurred, which triggered a round of tests. As long as the conditions remained, my risk of stroke was several percentage points higher than the rest of the population, despite the fact that I don't smoke, have low cholesterol levels, excellent blood pressure readings and, being a distance runner going on 20 years, am generally quite fit.

Thus, a year ago, I went through a procedure, in which a doctor snaked a couple of tubes through some arteries and deployed a device that plugged the hole. Within six weeks, I was back to normal. After six months, I received a final OK that the hole was completely sealed. No more restrictions, no more prescription blood-thinner, no higher stroke risk than the rest of the population.

Found a video about the procedure, including the very same doctor who did the work at Barnes-Jewish Hospital in St. Louis. If nothing else, I hope this gives someone reassurance that even a hole in the heart can be defeated.

All about stroke resources

An often-updated Web resource for stroke survivors, caregivers, loved ones and families: All About Stroke.

One good, educational article is about blood thinner medication - which clot-type stroke survivors often take - and the side effects. It covers aspirin, Aggrenox, warfarin, Plavix, heparin and enoxaparin, a particular form of heparin.

With the exception of enoxaparin (as far as I know), I've used them all and glad they're available to help with stroke prevention. The article does a good job of going quickly through the primary side effects to watch out for. Click on the drug names (or the photo of the pills) for additional links.

You can also sign up for an e-mail newsletter about stroke-related news from the site.

(Image from National Library of Medicine)

Q&A article on blood-thinning medication

A good article titled "Warfarin (Coumadin) diet: What can I eat?" from the Mayo Clinic's Web site goes through the basic information on how one's diet could influence the level of blood-thinning properties of warfarin.

"Warfarin is used to prevent blood clots from forming or growing larger in your blood and blood vessels," according to the MedLinePlus, an online resource from the U.S. National Library of Medicine and the National Institutes of Health. It's commonly prescribed to prevent strokes.

I was on warfarin - also the main ingredient for some rat poisons - for a few years, and it's important to get your blood tested periodically as your doctor directs. Blood too thin, and you could bruise or bleed too easily. Not thin enough, and the medication isn't doing all it can do for preventing strokes.