Where did your stroke happen? Geography might impact treatment

Photo from David Kessler via Flickr

Last week, the posting was about people born in the "stroke belt" region.

So for a related item, a look at cholesterol-treating drugs seem less likely to be prescribed in the stroke belt, with no statin prescribed for half of stroke survivors:

But inside the so-called Stroke Belt region, seniors were 47% less likely to be discharged on a statin, and men were 31% less likely to get a prescription for the lipid-lowering drugs than women. Neither association was seen outside the Stroke Belt.

"All survivors of ischemic stroke should be evaluated to determine whether they could benefit from a statin, regardless of the patient's age, race, sex, or geographic residence," lead author Karen Albright, PhD, DO, MPH, of the Birmingham VA Medical Center, said in a press release.

Where were you born? If you're from the 'stroke belt,' you might be in danger

Geography if often a key health indicator. Now, a recent study shows that being born in the U.S. "stroke belt" is tied to higher risk of dementia:

For the current study, researchers examined data on 7,423 adults living in Northern California, including 1,166 people born in high stroke-mortality states - all but one in the South: Alabama, Alaska, Arkansas, Louisiana, Mississippi, Oklahoma, Tennessee, South Carolina and West Virginia.

At age 65, the risk of developing dementia in the next 20 years was 30 percent for people born in these states, compared to 21 percent for those born elsewhere, the study found.

Too often, too many people don't get the right treatment

The clot-busting drug tPA has been available now for more than 20 years. But still, too many stroke victims don't get the drug:

Every year, patients were 11 percent more likely to be treated by tPA, even though across the entire period of time only 3.8 percent of total patients got the clot-busting drug, researchers reported.

The team found certain types of patients were less likely to receive tPA:

America's Stroke Belt and stroke risk factors

Do you live in the "Stroke Belt," or generally the southern/southeastern United States, plus Indiana?

Stroke risk factors - which we've talked about lately, are a big part of the problem. And strokes can hit young people, too, especially in the Stroke Belt. I ran across this story from Memphis about an unlikely stroke victim:

She blacked out. When she came around, her left side was going numb.

'Mind your risks' especially important for high-risk populations

The best way to "treat" a stroke is to prevent it. This is from someone who had one.

Of course, not every stroke is preventable. Mine was a cryptogenic stroke. But the great majority are preventable, and here's an item about efforts in the area of racial disparities in stroke:

"The prevalence of hypertension is higher in blacks, but its impact is even greater in the black population. An increase of 10mmHg in blood pressure is associated with an 8 percent increase in stroke risk among whites but a 24 percent increase in stroke risk in blacks," said Dr. Walter Koroshetz, director of NINDS.

Living too far away from stroke centers

Too far, too long.

Rural America is especially hard hit when it comes to stroke centers "over an hour away" for one third of Americans:

"Even under optimal conditions, many people may not have rapid access to comprehensive stroke centers, and without oversight and population level planning, actual systems of care are likely to be substantially worse than these optimized models," says Dr. Mullen.

Levels of access to care also varied in different geographical areas. Worryingly, access to care was lowest in an area often referred to as the "Stroke Belt" - 11 states where stroke death rates are more than 10% higher than the national average, predominantly situated in the southeast of the US.

"Reduced access to specialized stroke care in these areas has the potential to worsen these disparities," says Dr. Mullen. "This emphasizes the need for oversight of developing systems of care."

So the people who are most likely to need the care are also the most likely to be too far from care. We can - and must - do better.

Stroke prevention reminder for Stroke Belt folks

I spent my youth (and many adult) years in the Stroke Belt (Arkansas), and mine came a little over 15 years ago, also in Arkansas.

Does living in Arkansas (or other Stroke Belt states) guarantee a stroke? Of course not. But during Stroke Awareness Month, a reminder that taking stroke prevention measures can't start too soon.

Click here to read how teen years put the "Stroke" in "Stroke Belt":

Overall, the strongest predictor of stroke risk was the proportion of one's entire life spent in the so-called stroke belt, which encompasses much of the Southeast. After adjustment for other stroke risk factors, though, the proportion of adolescent years in the stroke belt remained the only significant predictor, increasing stroke risk by 17%.

"Our data suggest that living in the stroke belt during adolescence may contribute to the higher stroke mortality in the stroke belt, and the harmful effects associated with living in the stroke belt may be greater for black than white subjects," Virginia J. Howard, PhD, of the University of Alabama at Birmingham, and co-authors concluded in the April 30 issue of Neurology.

"Improvement in childhood health circumstances should be considered as part of long-term health improvement strategies.""

Southern states need stroke prevention priority

Being born a Southerner (now living in the Midwest), it's disheartening to hear about how strokes are more common in Southern states. To quote the article:

States with the highest rates of stroke include South Carolina, Alabama, Mississippi, Louisiana, Arkansas, Oklahoma, Tennessee, Kentucky, Missouri and Nevada.

Those with the lowest rates include New York, Michigan, Colorado, Minnesota, Wisconsin, Wyoming and the New England states.

Older people, American Indians/Alaska Natives, blacks and people with lower levels of education had more strokes than younger people, whites and those with higher levels of education, the researchers found.

The disparities in stroke, a leading cause of long-term disability, are largely due to lifestyle factors including obesity, high blood pressure and smoking, Fang said.

"Southern states have higher rates of obesity, smoking and hypertension, which are all risk factors for stroke," she said.

What is especially said is that many of the risk factors mentioned in the excerpt are preventable or at least (in the case of hypertension) addressable. Stroke prevention has a long way to go in Southern United States. It's past time to start!

Age-adjusted prevalence of stroke among noninstitutionalized adults (18 or older), by state.

(Image from Centers for Disease Control and Prevention)

Strokes don’t just threaten the old

Mine happened at the "young" age of 39 to a longtime distance runner, non-smoker - everyone needs to know about the signs and symptoms and know what to do.

A recent Washington Post story about how strokes don’t just threaten the old; strokes among younger people are on the rise

"Nobody’s invincible,” warns Dr. Ralph Sacco, a University of Miami neurologist and past president of the American Heart Association.

Every year, about 795,000 people in the U.S. have a stroke. While some strokes are caused by bleeding in the brain, most are like a clogged pipe. Called ischemic strokes, a clot blocks blood flow, starving brain cells to death unless that circulation is restored fast.

Make no mistake, the vast majority of strokes do occur in older adults. But up to a quarter of them strike people younger than 65, Sacco says.

In the so-called stroke belt in the Southeast, that figure can be markedly worse. At Wake Forest Baptist Medical Center in North Carolina, a stunning 45 percent of stroke patients are young or middle-aged, says stroke center director Dr. Cheryl Bushnell."

Challenges in the Southern states

Cognitive decline is higher in Southern Stroke Belt:

People who live in the Stroke Belt are more likely to develop cognitive decline, according to new data from a long-running University of Alabama at Birmingham study. It’s hoped that linking cognitive decline to stroke-risk factors could lead to stroke prevention.

People living in this eight-state region, defined by a risk of stroke death higher than in the rest of the nation, are at 18 percent higher risk of developing incident cognitive impairment, which includes failing memory and processing thoughts more slowly, says the study author in the May 27, 2011, online issue of the Annals of Neurology, the official journal of the American Neurological Association.

For fried fish, go for moderation

This is sad news to me, even though it's not a big shocker. My favorite food: fried catfish. Part of my Southern upbringing.

However, it's inarguable that eating a lot of fried fish is not a good healthy choice and for many, many people, it leads to a higher stroke risk. No question.

If, like me, you can't live without it, go with moderation. Here's one of the stories, from USA Today, about a study showing how stroke deaths are higher where fried fish aplenty:

A study published in today's Neurology shows people living in the stroke belt — which comprises North Carolina, South Carolina, Georgia, Alabama, Mississippi, Tennessee, Arkansas and Louisiana — eat more fried fish and less non-fried fish than people living in the rest of the country, and African-Americans eat more fried fish than Caucasians.

"Differences in dietary fish consumption, specifically in cooking methods, may be contributing to higher rates of stroke in the stroke belt and also among African Americans," says study author Fadi Nahab, medical director for the Stroke Program at Emory University Hospital in Atlanta.