Stroke after a heart attack: What’s the risk?

Here’s what heart attack survivors need to know to lower their chance of a future stroke.

First, the good news: The rate of first-time heart attacks has dropped by nearly half in the past 25 years. And heart attack survival rates have surged, thanks to improved treatments. The bad news? Compared to people without such a history, heart attack survivors not only face a higher risk of a second heart attack, they’re also more likely to have a stroke.

The risk of stroke is higher in the first year following a heart attack, especially during the first month. After a year, however, only the risk of ischemic stroke remains elevated, according to study in the July 2016 Stroke that tracked more than a quarter-million heart attack survivors over a 30-year period. (See “Types of stroke: Blockage vs. bleeding” for a primer on the different types.)

The heightened stroke risk isn’t surprising, given that heart attacks and ischemic strokes have nearly identical risk factors—namely, high blood pressure, diabetes, unhealthy cholesterol levels, lack of exercise, obesity, and cigarette smoking. But other factors can also come into play.

Traveling clots

A particularly bad type of heart attack happens when a clot forms and completely blocks blood flow to part of the heart muscle. This can damage or scar the left ventricle, the heart’s main pumping chamber. “As a result, the heart may not contract normally, which can cause a blood clot to form,” explains Dr. Louis Caplan, professor of neurology at Harvard-affiliated Beth Israel Deaconess Medical Center. That new clot can then travel through the bloodstream and lodge in an artery that supplies a part of the brain. These so-called cardioembolic strokes are not common in this setting, occurring in about 3% to 4% of heart attack survivors, usually within 30 days of the heart attack. But the possibility is a reminder of why people need a comprehensive assessment to uncover and treat all their contributing factors to prevent cardiovascular problems in the future, says Dr. Caplan.

Rare but risky bleeding

During or after a heart attack, many people have a procedure to reopen the blocked artery (angioplasty), and to insert a tiny wire-mesh tube (stent) to prop the artery open. Then, they take one or more drugs to prevent clots from forming inside the stent, usually aspirin and clopidogrel (Plavix) or more powerful options, for up to a year and sometimes longer.

However, these drugs increase the risk of bleeding—including hemorrhagic strokes. This likely explains why, as the recent Stroke study showed, people face twice the risk of an intracerebral hemorrhage during the first year after a heart attack. But keep in mind that these events are very rare. Even when doubled, the risk is still low. Meanwhile, the drugs’ anti-clotting actions help to prevent another heart attack, which is far more likely than a bleeding stroke.

For heart attack survivors, the main message is to make sure you’re aware of all your personal risks and address them (see “Top 5 ways to prevent stroke”). And make sure you know the warning signs of a stroke; see

Types of stroke: Blockage vs. Bleeding

All strokes result from an injury to a blood vessel that limits blood flow to part of the brain. Without a constant supply of oxygen and nutrients provided by the blood, brain cells start to die. The resulting damage can leave a person unable to move, speak, feel, think, see, or even recognize other people. Ischemic strokes account for about 80% of all strokes; the other 20% are hemorrhagic strokes.

  • Ischemic strokes occur when an artery supplying the brain is blocked by a blood clot. If the clot forms in the heart and travels to the brain, it’s called a cardioembolic stroke. In a thrombotic stroke, a clot forms in an artery supplying blood to the brain, typically after that artery has already been narrowed by plaque—the fat-laden substance that accumulates in artery walls.
  • Hemorrhagic strokes, also known as bleeding strokes, occur when a blood vessel just outside or within the brain leaks or ruptures. Most are intracerebral hemorrhages, which mean the bleeding occurs inside the brain. Others are subarachnoid hemorrhages, which occur between the skull and the brain. Some of these result from an aneurysm—a weak, bulging area of a blood vessel.



New oral anticoagulants provide same stroke prevention as warfarin but cause less bleeding

The new oral anticoagulants provide the same stroke prevention as warfarin but cause less intracranial bleeding, reports an observational study in more than 43,000 patients presented at ESC Congress 2016 today by Dr Laila Staerk, a research fellow at Herlev and Gentofte University Hospital, Denmark.

“Atrial fibrillation is the most common cardiac rhythm disorder and currently affects more than 10 million Europeans,” said Dr Staerk.

“Atrial fibrillation is associated with a five-fold risk of stroke, potentially leading to disability and death,” continued Dr Staerk. “In the next four decades, the number of patients with atrial fibrillation is expected to triple so the number of Europeans diagnosed could rise to a staggering 25 to 30 million.”

Patients with atrial fibrillation are treated life-long with oral anticoagulation to reduce their risk of stroke. But treatment with non-vitamin K antagonist oral anticoagulants (NOACs) and vitamin K antagonists (warfarin) is a double-edged sword, because it lowers the risk of stroke at the cost of increased bleeding risk. Intracranial bleeding is a particular fear.

With several treatment options available the clinical question of which one to use has often been asked. Dr Staerk said: “There has been a need to investigate safety and effectiveness of NOACs versus warfarin in a ‘real world’ population and our Danish registries provide this opportunity.”

The current study compared the risk of stroke and intracranial bleeding with NOACs (dabigatran, rivaroxaban and apixaban) versus warfarin in a ‘real world’ setting. The study was conducted at The Cardiovascular Research Centre at Herlev and Gentofte University Hospital in Denmark. It included 43 299 patients with atrial fibrillation who were recruited from Danish nationwide administrative registries.

Some 42% of patients were taking warfarin, while 29%, 16% and 13% were taking dabigatran, apixaban and rivaroxaban, respectively. During follow up, stroke occurred in 1054 patients and there were 261 intracranial bleedings.

The researchers found that the risk of having a stroke within one year was similar between the NOAC and warfarin groups, and ranged from 2.0 to 2.5%. At one year the risk of intracranial bleeding was significantly lower in patients treated with dabigatran and apixaban (0.3 to 0.4%) compared to those treated with warfarin (0.6%) .

Dr Staerk said: “The inclusion and exclusion criteria in our study were broadly similar for patients initiating NOACs or warfarin, and this gave a straightforward opportunity to directly compare the treatment regimens, which is in contrast to the randomised trials. The results suggest that although they have similar effects in preventing stroke, dabigatran and apixaban were associated with a safer use regarding the absolute one-year risk of intracranial bleeding.”

She added: “Our results complement the large randomised phase III trials by providing ‘real world’ data on stroke and intracranial bleeding with NOACs versus warfarin since fragile patients were not excluded from our nationwide cohort. For example, patients with increased risk of bleeding, liver disease, and chronic kidney disease are less represented in trials.

Image result for New oral anticoagulants provide same stroke prevention as warfarin but cause less bleeding

Dr Staerk concluded: “Registry studies have some limitations such as the observational design, residual confounding, and confounding by drug indication. In the future it would be exciting to see a head-to-head randomised trial performed to compare the different NOAC treatments in patients with atrial fibrillation.”

Facts about atrial fibrillation and oral anticoagulants:

  • Atrial fibrillation is the most common cardiac arrhythmia with an increasing prevalence.
  • In the next four decades, the number of patients with atrial fibrillation is expected to triple.
  • Atrial fibrillation is associated with a five-fold risk of stroke, potentially leading to disability and death.
  • Patients with atrial fibrillation are treated life-long with oral anticoagulation to prevent stroke and death, but oral anticoagulation treatment imposes an increased risk of bleeding.


The above post is reprinted from materials provided by European Society of Cardiology.

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Stroke survivors need better longterm rehabilitation

Ray Powell is working hard HealthSouth Rehabilitation Hospital in Newnan to come back from a stroke that seemed to come out of nowhere early on the morning of July 31, 2016.

“I was lying in bed in about four in the morning, and I woke up and it felt like I was going to get tipped out of bed,” he says.

At first, Powell thought he was having a dizzy spell

But it didn’t pass, and then I broke out into a profuse sweat,” he remembers.

Powell was able to drop to the floor and crawl to his phone, dialing 911.  He was taken to  a stroke treatment center quickly. But, the stroke caused some damage.

“He had a stroke in the cerebellum, which is the part of the brain that controls coordination and movement quality, “ says HealthSouth physical therapist Leigh Whitton.  “So, his biggest limitations were stability and balance.”

The emergency, or acute stroke treatment, was just part one.

Stroke rehab, part two, and Powell began therapy on day one at HealthSouth.

“The first day, I got up to try to walk and they took me out in the hallway, it looked like the walls were slanted,” he says.

By the second day, the walls were straight again. Someone came and fixed them up I guess,” he laughs.

Powell feels fortunate that he’s making progress.

And, in newly-released 2016 stroke rehabilitation guidelines, a panel of experts from the American Heart and the American Stroke Association says more stroke survivors need access to this kind of long-term, multi-disciplinary approach to their recovery.

The panel says acute stroke treatment is essential.

But, many stroke survivors also need rehabilitation and support to help them cope with the challenges and disability that can affect them for the rest of their lives.

HealthSouth physical therapist Leigh Whitton says they take a team approach at their hospital, offering around-the-clock care headed up by doctors and nurses who specialize in stroke recovery.

“So you’ve got physical therapists, occupational therapist, speech therapists, case managers,” she says.  “Everybody is working together and communicating.”

This kind of intense in-patient rehabilitation is expensive.

Powell is hopeful Medicare and a supplemental insurance plan he has will cover most, if not all, of the cost of his in-patient hospitalization.

And Leigh Whitton says most patients will only stay here only a couple of weeks.

“Mr. Powell is doing so well, he may not even be here that long,” Whitton says.  “But it will be that bridge to help him get back home safely, back to the activities he wants to do.”

Ray Powell feels he’s getting closer every day to putting this stroke behind him.

“The important thing for me was to get back and be able to live independently,” he says.



Why you should know the risk factors and symptoms of a stroke

One of the first steps in preventing a disease is knowing more about it. While scientists and researchers devote their lives to learning more about conditions like cancer or heart disease, the average U.S. citizen may not know much about a leading cause of death in this country – stroke.

A report released by the Centers for Disease Control and Prevention last year shows that 130,000 U.S. consumers die from stroke each year, or about one out of every 20 deaths. Unfortunately, not knowing more about this fatal condition can make it even more dangerous.

In a recent study, over half of all patients who had suffered a stroke failed to recognize symptoms as they developed. Researchers believe that educating the general public about strokes may help improve overall health outcomes.


Stroke risk factors

The American Heart Association and American Stroke Association define stroke as a disease that affects arteries that carry blood and oxygen to the brain. When these arteries burst, rupture, or become blocked, the brain doesn’t get the resources it needs. This can result in brain cell death, as well as a range of short- and long-term issues, such as paralysis, vision problems, behavioral changes, memory loss, and speech problems.

According to the National Institute of Neurological Disorders and Stroke (NINDS), there are several risk factors associated with stroke. While consumers cannot control some of them – such as age, race, or family history – others can be managed. These include factors like blood pressure, cigarette smoking, heart disease, diabetes, cholesterol imbalance, and obesity.

Symptoms to look out for

But how do you know when you are experiencing a stroke? It’s a problem that many people struggle with. One recent study found that 58.7% of patients in a trial group did not think they were having a stroke when it happened to them.

NINDS states that there are several warning signs that consumers can observe to know if something is wrong. They include:

  • Sudden numbness or weakness of face, arm, or leg, especially on one side of the body;
  • Sudden confusion, or trouble talking or understanding speech;
  • Sudden trouble seeing in one or both eyes;
  • Sudden trouble walking, dizziness, or loss of balance or coordination; and
  • sudden severe headache with no known cause.

Consumers can remember some of these symptoms by remembering the acronym FAST, which stands for Face, Arm, Speech, and Time. However, researchers from the aforementioned study say that many patients in their trial group displayed eye-related symptoms. They suggest that a small modification could help patients identify a greater range of stroke symptoms.

“FASTER – Face, Arm, Speech, Time, Eyes, React – may be a better acronym,” said Professor Ashok Handa, senior author of the study