August 7, 2025 • 39 mins
We often hear about heart disease prevention, but stroke—a condition nearly as common and often more disabling—gets far less attention. In this episode, Dr. Bobby is joined by cardiologist Dr. Anthony Pearson to uncover what science really says about stroke prevention, the distinct types of strokes, and what practical steps you can take today to lower your risk.
Together, they explore the two major types of stroke—ischemic and hemorrhagic—and explain why strokes caused by clots or vessel rupture can have very different causes and consequences. The data shows nearly 800,000 Americans experience strokes annually, and about half of survivors live with long-term disability (CDC; NIH). Yet most of us are unaware of the modifiable risk factors that account for up to 90% of stroke risk (INTERSTROKE Study).
Dr. Pearson emphasizes the number one culprit: high blood pressure. It triples individual risk and contributes to half of all strokes, with randomized trials like SPRINT showing that aggressive control reduces both stroke and mortality (SPRINT Study). Both doctors also discuss physical activity—while Dr. Bobby cites strong associations between exercise and reduced stroke risk (BMJ Review), Dr. Pearson cautions that current evidence is largely observational and inconclusive.
They also explore the role of lipid levels, citing that high ApoB or LDL may increase risk in strokes caused by carotid atherosclerosis, but not necessarily in cardioembolic strokes. Dietary improvements, particularly following a Mediterranean-style diet, have shown benefits, including reduced stroke risk in randomized trials like PREDIMED.
Beyond traditional risk factors, they also explore loneliness as a newer area of concern. A recent study linked persistent loneliness in adults over 50 to a 50% increased stroke risk (Lancet eClinicalMedicine), highlighting the complex social and behavioral factors at play.
Dr. Pearson discusses atrial fibrillation (AFib) and why it’s a key cause of cardioembolic strokes—especially relevant given that wearables like Apple Watch now help detect AFib early. They also touch on controversial screening approaches, warning against routine carotid ultrasounds and unwarranted treatment of asymptomatic brain aneurysms.
Importantly, Dr. Bobby highlights the signs of stroke—sudden weakness, numbness, speech difficulties, or confusion—and urges immediate ER visits to enable timely treatment like thrombolysis, ideally within four hours of symptom onset.
As always, they wrap by challenging popular myths. Dr. Pearson explains why aspirin, once widely promoted for primary prevention, is no longer recommended due to increased bleeding risk, especially into the brain. He also debunks the idea that supplements like fish oil or B vitamins help prevent strokes, noting no benefit in recent large trials.
Takeaways:
- Know your blood pressure and cholesterol levels—and treat them if needed. These remain the top modifiable risks for stroke.
- Prioritize physical activity, even if trial data is imperfect—it benefits vascular health broadly and may reduce stroke risk.
- Stay socially connected: chronic loneliness has emerging links to stroke risk, highlighting that prevention isn't just physical—it's relational.
To continue learning how to live long and well, visit drbobbylivelongandwell.com.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
We hear so much about heart disease, its causes and
how to reduce our risk, but wedon't hear as much about stroke
and stroke prevention.
Can we reduce our risk?
What specifically can we do?
Let's see where the evidencetakes us.
Hi, I'm Dr Bobby DuBois andwelcome to Live Long and Well a
(00:36):
podcast where we will talk aboutwhat you can do to live as long
as possible and with as muchenergy and vigor that you wish.
With as much energy and vigorthat you wish.
Together, we will explore whatpractical and evidence-supported
steps you can take.
Come join me on this veryimportant journey and I hope
that you feel empowered alongthe way.
(00:56):
I'm a physician, ironman,triathlete and have published
several hundred scientificstudies.
I'm honored to be your guide.
Welcome, my dear listeners, toepisode number 46.
Can we reduce our risk of astroke?
(01:19):
Now?
In prior episodes, we talkedabout reducing our risk of heart
disease.
Now, that was episode 18.
We also talked about how toreduce your risk of cognitive
decline.
That was episode 13.
Now let's look at stroke in thevery same way what we might be
(01:39):
able to do to reduce that risk.
Once again, we are joined by DrAnthony Pearson, who was with
us on episode 37, reducing ourrisk of heart disease and, as I
shared before, we are kindredspirits that focus on evidence
and we're both a bit skepticaluntil proven otherwise.
(02:00):
So Dr Pearson is a boardcertified cardiologist.
He's on faculty at severalacademic medical centers.
He's published 100peer-reviewed papers and he's
been in private practice for 20years.
He takes a very holistic viewdiet, lifestyle, exercise and,
of course, medications.
He's a columnist for MedPageToday and the author of the
(02:25):
Skeptical Cardiologist, anexcellent blog I recommend to
you all, which is now a substack.
Dr Pearson, welcome back onceagain.
Speaker 2 (02:36):
Good to be here, Bobby, and looking forward to a
good discussion.
Speaker 1 (02:41):
Excellent, excellent, and to give our listeners a
preview we are not always goingto agree on everything today and
when anthony raised this likeI'm gonna have to push back on
this I said I love it absolutely.
Well, where we see the worlddifferently, uh, we'll talk
(03:01):
about that and maybe we'll cometo some middle ground, or at
least the listeners will havetwo different viewpoints.
They can try to decide amongstOkay, let's dive right on in.
So part one we're talking todayabout a stroke.
Well, what is a stroke and howcommon are they?
And we're going to do a bit ofpoint counterpoint.
(03:22):
I'm going to raise some issues,dr Pearson will then chime in,
I'll ask some questions, he'llanswer and we'll play ping pong
back and forth.
In a very simple way, a strokeis a blockage of blood flow to
an area of the brain and itpresents as a sudden loss,
(03:44):
typically of function.
It could be your arm is weak orparalyzed, or your leg, or you
can't speak.
All of a sudden, you might loseconsciousness or you might have
an altered sense ofconsciousness.
Typically it's a sudden onset.
Now it can be silent, it can befatal and it can be everything
(04:07):
in between.
And as we'll talk about in justa couple of minutes.
It often leaves the patientwith a significant disability
again weakness or difficultywith speaking or the like and
that's a bit unlike a heartattack, whereas if you survive
the heart attack, typically youfeel reasonably good afterwards.
(04:30):
Often often with the strokeyou're going to have a residual
problem, and that's why so manypeople fear it.
Now there are an awful lot ofstrokes that happen.
In fact it's almost as manystrokes as heart attacks.
There's about 600,000 to800,000 strokes a year, or, if
you do the math, about one every40 seconds and every three
(04:55):
minutes somebody dies of astroke.
Now, in comparison, there'sabout 800,000 heart attacks a
year, so it's in a similarballpark heart attacks a year,
so it's in the similar ballpark.
Strokes typically happen inpeople that are 65 and older not
always, but typically that'stheir age group.
It is the fourth leading causeof death in the United States,
(05:16):
after heart disease, aftercancer and after accidents.
And, as I mentioned earlier,about 50% of patients who had a
stroke become chronicallydisabled in some fashion.
So there's neurologic deficitsthat sometimes go away fairly
(05:39):
quickly, but oftentimes doesn't.
Actually it's not in our notes,but I'm going to ask you
anyways, dr Pearson why do youthink there's so much more
attention on heart disease andheart attacks than stroke.
Speaker 2 (05:56):
That's a good question.
I think we know that with heartattacks the initial
presentation can just be suddendeath and obviously if you died
you don't get any second chances.
So with strokes you may becomedisabled, but you're not going
(06:17):
to necessarily die right awaywith most strokes.
Speaker 1 (06:23):
Well, we'll have to explore I'll have to do a little
more of a deep dive why thepublic health folks and why
people tend to know about heartattacks.
They know of strokes but theydon't seem to worry about them
as much as heart attacks.
I'll have to dig into that.
It's an interesting question.
So not all strokes are the same.
(06:43):
So maybe walk us through thetypes of strokes and what can
cause them, because that willnaturally lead us into risk
factors and what our listenerscan do to prevent a stroke.
Speaker 2 (06:57):
Sure, there's multiple ways of kind of
breaking down the different kindof strokes.
The first way that you and Ihad discussed was whether it's
ischemic or hemorrhagic, whichmostly comes from CT imaging of
the head after a stroke.
(07:17):
With ischemic strokes, wherethere's a block in the blood
flow in an artery to a certainarea of the brain, there is not
necessarily blood that pours outinto the brain.
But with hemorrhagic strokes,when we look on a CT scan we see
blood and that can have someimportant information to give us
(07:39):
about the causes of the strokeand what the prognosis and what
the best treatment is of thestroke and what the prognosis
and what the best treatment is.
So the vast majority of strokesare the ischemic type, where
there isn't blood in the brain.
Probably 90% of strokes in theUnited States are ischemic and
of those ischemic strokesthere's about 30% of them come
(08:06):
from and are related toatherosclerosis in the large
arteries supplying blood to thebrain, the carotid arteries, the
internal carotid in particular,and that atherosclerosis, the
plaque buildup, is the samething that happens in the
coronary arteries Generally.
If it's happening in thecoronary arteries Generally, if
it's happening in the coronaryarteries, it's also going to be
(08:27):
in the carotid arteries and viceversa.
Another group in the ischemicstroke are the strokes that are
related to what we callcardioembolism, and cardio means
it's coming from the heartessentially, but an embolism
means that it left the heart aclot.
(08:48):
Usually a clot comes out of theheart and then goes up the
aorta and then branches off intoone of the internal carotids or
the arteries in the back of thehead and blocks off an artery
and causes a stroke that way, anartery and causes a stroke that
(09:10):
way.
So cardioembolism is about 20to 30 percent of ischemic
strokes and of thosecardioembolic things where a
clot comes out of the heart,maybe 50 percent are related to
atrial fibrillation, where theclot forms in the left atrium of
the heart.
Back in the late 80s we didn'tknow the cause of the majority
of the strokes that we sawunless they were clearly related
(09:34):
to a blockage in the carotidarteries.
And I became interested backthen in a new ultrasound
technology calledtransesophageal echocardiography
.
We'd done the standard echo,which is done from the chest
surface, but that echo thestandard echo or echocardiogram
could not identify, did not seeareas of the heart like the left
(09:58):
atrial appendage where clotsform, the atrial septum where
you can have a hole and haveclots going across that to cause
a stroke.
And it didn't see the valvesthat well and on the valves
clots can form.
So we used the transesophagealecho and it really was vastly
superior at identifying thesekinds of things that cause
(10:22):
stroke that we weren'tidentifying before.
So the number of cases thatturn out to be cardioembolic has
gone up because of thattechnology and it's still
important today, if you don'tknow the cause of your stroke,
to get a transesophageal echo.
Speaker 1 (10:39):
Well, that's great.
So a variety of different typesof strokes and we'll come back
to this because the risk factorsand how you can avoid them will
differ amongst the differentcauses of stroke.
But I know our listeners wantus to dive in and say, okay,
what puts me at risk?
And please, please, doctors,tell me how I might be able to
(11:02):
reduce that risk.
So there are many differentrisk factors, and there's 10,
and we're not going to walkthrough all of them, but I'll
just give you the list now andwe're going to then take a few
of them and dive in a little bitin more depth.
So, in order of most importancehigh blood pressure that's
(11:25):
number one.
Physical activity, where DrPearson and I may differ a
little bit on this, is numbertwo.
Your cholesterol lipids arenumber three.
Diet and weight and beingoverweight are numbers four and
five, psychosocial smoking,cardiac causes, as we've alluded
(11:48):
to.
Too much alcohol and diabetes.
Now, when you look at this longlist and it is a long list you
might say, okay, do I have toworry about all of these?
Well, there's something calledpopulation attributable risk and
then there's something calledrelative risk, and so I don't
want to get too, too, too nerdywith folks, but population
(12:09):
attributable risk means of allthe people in the population
that get a stroke.
How much of that number is dueto hypertension?
That's called populationattributable risk and it turns
out for high blood pressure, 50%of the strokes can tie back to
high blood pressure.
So if you have individuallyhigh blood pressure, it triples
(12:34):
your risk of the stroke.
But on a population level it'sthe number one risk factor and
number one thing we can try tofocus on.
The next and this is wherewe're going to differ a little
bit is on physical activity.
In a meta-analysis that lookedat a whole bunch of different
studies, they identifiedphysical activity as having
(12:58):
about a third of all strokescould be tied back to lack of
physical activity.
So now the question is DrPearson, you feel that the data
on physical activity and strokeare not as strong or convincing?
Speaker 2 (13:17):
No, I think I'm a huge advocate of getting my
patients moving, exercising, andI've written quite a bit about
how to measure your cardiofitness and how you should be
striving to improve it.
(13:37):
I think quoting 36% of strokesare due to inadequate physical
activity are highly suspect.
It's all coming fromobservational studies and this
looks at people who have people.
(13:57):
These are associations thatdon't indicate causation.
Don't indicate causation andwhat you really would want to
know to prove causation is thatwe did this trial and we did
this amount of exercise on onegroup and or did not give
activity recommendations to theother group and we followed them
(14:18):
for a long period of time andwe found some effect on stroke
or heart attack.
And those studies, when they'vebeen done, haven't really shown
that and we don't have any goodlong-term studies that I can
say to a patient you're going toreduce your risk of stroke by
36% if you double your activitylevel.
(14:44):
I'm still going to advise it fora lot of other reasons, but I'm
not going to tell themspecifically that their stroke
or MI risk is reduced.
Speaker 1 (14:52):
So you're also not just questioning the
relationship between physicalactivity and stroke.
You're saying there isn't thattype of randomized trial proof,
even for preventing heartattacks.
Speaker 2 (15:06):
That type of randomized trial proof, even for
preventing heart attacks, it'sextremely weak to non-existence
I would say.
Speaker 1 (15:19):
Well, we can definitely agree on one thing,
which is whether the data isstrong or weak, we still believe
exercise is a wonderful thingto do.
I totally agree.
Yeah, well, and you're right,we may not get the ultimate
study proof that we would like,but I'm sticking with my
recommendation on exercise.
Speaker 2 (15:35):
I would just add on what you said about hypertension
.
I really I think that is numberone and it may be 50%.
I'm not really sure how theycome up with this attributable
risk and how accurate it is,especially given what they're
saying about physical activity,but the SPRINT study was a
(15:58):
randomized trial of loweringblood pressure to 120 systolic
versus 140, and that showed asignificant risk in mortality a
27% reduction in mortality andsignificant reductions in stroke
, heart attack, heart failure.
So I do think that aggressiveblood pressure control is
(16:22):
something that can definitelyreduce the risk of stroke.
So we should all be trying toidentify and treat adequately
hypertension.
Speaker 1 (16:31):
So Dr Pearson has raised action item number one,
which is make sure you know whatyour blood pressure is and, if
it's elevated, see your doctor,get it under control.
And if you say to yourself, ohwell, I feel fine, remember
hypertension is a very silentand progressive problem, even if
(16:55):
you feel good, please, pleaseget it taken care of.
And action item number twowhether the data is perfect or
not, please continue with yourexercise.
It's wonderful on so, so manylevels, so please do Okay.
So let's turn to the next one,which is cholesterol.
(17:17):
We know that your lipid levels,your ApoB levels, your LDL
levels, relate to your risk ofheart attack.
In the studies, it wouldsuggest that about one in four
strokes has an importantcomponent related to cholesterol
.
What do you think about that?
(17:37):
Does that ring true for you andyour practice?
Speaker 2 (17:41):
Yeah, I think it's a reasonable estimate of the
effects of hypercholesterolemiaand that is only within a
certain subset of patients.
The patients again who havebuilt up atherosclerotic plaque
either prematurely or moreadvanced than expected, both in
(18:02):
the carotid, and they will havebuilt it up in their carotid
arteries and their coronaryarteries.
So the high ApoB, the high LDL,is going to put them at higher
risk for stroke and getting itdown there is evidence that it
reduces that risk.
Speaker 1 (18:20):
Okay, so we've got another action item Do make sure
you know what your cholesterollevels are, and, if they are
elevated, please talk with yourdoctor about addressing it.
Well, let me just sort of askthis question a little bit
differently.
So we've talked in priorepisodes about reducing your
(18:43):
risk of heart disease, and somany of these factors that we
are already talking about hereseem a whole lot like the ones
we worried about to reduce yourrisk of heart attacks, for our
listeners, to reduce the risk ofstroke, isn't it just worrying
about the same things for yourheart?
Speaker 2 (19:14):
Or is there something above and beyond or different
important things that peopleshould pay attention to who are
trying to minimize their risk ofstroke, which I assume is
pretty much everybody?
Perhaps people with a familyhistory are more interested in
that than those without.
There are some things that arerelevant to the
(19:41):
non-atherosclerotic causes ofstroke that don't fall under the
standard risk factors atrialfibrillation, which we know is
associated with stroke and is acommon cause of this
(20:03):
cardioembolic stroke.
Alcohol consumption increasesyour risk of atrial fibrillation
, and so that's something youprobably would want to pay
particular attention to.
And then the other thing isobesity, which both of these
(20:24):
alcohol and obesity we know fromrandomized trials.
If we lower obesity, we lowerthe risk of atrial fibrillation.
If we reduce alcohol oreliminate it, we lower the risk
of atrial fibrillation.
So those are a couple of thingsthat might be a little bit more
(20:45):
specific to stroke.
Speaker 1 (20:47):
Sounds good.
Well, before we leave thistopic of risk factors, I want to
throw out another one.
Now this is based onobservational data.
It's not the highest qualityevidence, but there's a
suggestion that loneliness isassociated with an increased
risk of stroke.
There was an observationalstudy of about 12,000 folks who
(21:12):
were 50 and above, and atbaseline meaning the beginning
of the study, those people whowere persistently feeling lonely
so it wasn't just an occasionalone, they regularly felt lonely
had a 50% increased risk ofstroke in the ensuing years.
Interesting finding.
(21:32):
Of course, they had to sort ofexplain now how could loneliness
lead to a stroke?
And it may be in ways that wemay not have anticipated.
It could be the people that arelonely or depressed.
Maybe they don't take theirmedicines for high blood
pressure as well as they should.
They're lonely and so they endup smoking or drinking more, or
they're under, you know, morepersonal stress, which could
(21:55):
lead to inflammation or anynumber of things.
So this is all hypothesisgenerating, meaning when you do
an observational study and youfind something of interest, this
isn't the definitive answer.
But if you are focused onloneliness and we have a whole
episode on that socialconnections do take another
listen if you're interested.
(22:16):
The Harvard study of adultdevelopment really showed it was
an extraordinarily importantfactor to live long and to be
very functional as you get older.
Okay, let's turn to some otherthings that maybe listeners
should do or not do.
So you mentioned earlier thatatherosclerosis in your carotid
(22:42):
arteries the vessels that go toyour brain is a really important
cause of stroke, and when youwere on our episode together, we
talked about the calcium scanof the heart and how that really
adds some important informationand gives you a sense of
whether you're at increased riskof a heart attack.
(23:02):
Should folks get their carotidarteries screened, just like we
screen their coronary arteriesat some level?
Should we look at the carotids?
Speaker 2 (23:14):
Yeah, it's a great question, and you would think if
I'm so passionate aboutscreening the coronary arteries
for plaque, I should be the sameabout the carotid arteries, and
I used to be.
I was trained in carotidultrasound during my cardiology
(23:35):
fellowship and I haveestablished vascular ultrasound
labs in several of my practices.
The primary goal of thescreening that I set up in these
labs was identifying earlyplaque in the carotid arteries.
I was looking for small plaquethat would be kind of a warning
(23:58):
that plaque was already buildingup in a young or middle-aged
patient.
That shouldn't be there, and wewould also measure something
called carotid IMT,intramomedial thickness, which
is a measure that is stronglycorrelated with atherosclerosis
and was something else I wasusing in younger individuals too
(24:20):
young to use coronary calcium,because that's generally not
going to be helpful until you're40 years or older.
But for the most part, coronaryartery calcium and coronary
artery CT angiography havereplaced carotid in my
evaluation for earlyatherosclerosis.
(24:41):
That's one way of using carotidvascular ultrasound.
Now I'd say that there are somefly-by-night companies out there
that like Lifeline.
I don't want to finger them inparticular, but I have definite
experience and I've writtenabout this on my blog with the
(25:02):
kind of shoddy screening thatthey do, where they're only
looking for high-grade stenosis,they're not trying to look for
early plaque, and they may tellyou that your artery is normal
even though it's got a plaque init, as long as it doesn't have
evidence for a blockage over 50%.
So there's a lot of poorly donecarotid screening in that manner
(25:24):
, so I recommend staying awayfrom that.
The second way to use carotidscreening is to say we're
looking for blockages that aresevere enough that you would
benefit from having a carotidsurgical procedure, like a
carotid endarterectomy, which isdone by vascular surgeons, or
(25:47):
carotid stenting, which issometimes done by cardiologists,
and the evidence for that kindof screening is non-existent and
I would recommend against it,primarily because, even if we
identify a severe stenosis insomebody who has no symptoms, we
(26:08):
have no idea that.
We don't know that operating onthat is going to be better than
treating that plaqueaggressively with our standard
lipid-lowering therapy and ourchanges in lifestyle and diet.
And so you end up identifyingdisease that probably does not
(26:29):
need to be operated on.
You end up getting operationsand procedures that you didn't
need and the result of that canbe really bad side effects like
strokes caused by the surgery orthe stenting and even death
even a young person whocollapses and they have bleeding
(26:50):
in their brain from an aneurysm.
Speaker 1 (27:02):
Somebody has to.
You know this is television, ofcourse.
You know they got to put aneedle in there and reduce the
pressure and get rid of some ofthat blood.
As we mentioned earlier,hemorrhagic strokes, which are a
bleed in the brain as opposedto blockage of the blood to the
brain, are relatively uncommon.
(27:24):
It's about 30,000 a year.
It's about three to fivepercent of all strokes, and
these are often fatal and a lotof people are walking around
with an aneurysm that isn'truptured and is likely never to
rupture.
So for our listeners, should wehave a brain aneurysm screened
(27:47):
for and if we find something,should we do something about it?
Speaker 2 (27:52):
Yeah, that isn't a question that comes up a lot but
after thinking about it whenyou brought it up it does seem
like a very relevant questionand looking at the kind of
guideline recommendations fromvarious societies.
Even though intracranialaneurysms, which are basically
(28:18):
little bulging areas in thearteries, can occur in 2% to 6%
of the population and they haveno symptoms whatsoever, it is
not recommended that we screenthe general population because
of the downsides of identifyingof these, the anxiety that's
(28:42):
created, the downstream testing,and because the yield is so low
that most of the ones that weidentify are not going to go on
to have a problem.
So the guidelines wouldrecommend that if you have two
or more first-degree relativeswith an aneurysm or a
(29:03):
subarachnoid hemorrhage, whichis the kind of bleed that you
get from an aneurysm, that youshould be offered screening.
So if your mother and one ofyour sisters had one, then they
say that you should get it.
If you have one, I thinkPersonally I would want to get
(29:23):
screening, even if I just hadone first degree relative.
I would want to know, andscreening is going to involve a
CTA or an MRI exam.
But for the most of us, eventhough a bleed into the head is
an extremely serious kind ofstroke and potentially
life-threatening.
The risk is so so low that it'snot recommended that we get
(29:48):
screening.
Speaker 1 (29:50):
Okay, good, thank you for that reassurance.
Okay, so we now know what aresome of the causes of stroke,
some of the things that we cando to reduce that risk.
So we now come to the segmentabout get yourself to the
emergency room as fast aspossible.
(30:10):
Now, with heart attacks, folksare aware of sort of the classic
symptoms of an elephant sittingon your chest tightness in your
chest, shortness of breath,pain in your left arm in your
chest, shortness of breath, painin your left arm, sweating,
nausea, various things like that.
And folks have encounteredenough discussions around this
(30:32):
that they know they need to getto the hospital where you can
give clot busters and open upthe blood vessels.
And nowadays people do a lot,lot better both surviving the
heart attack and beingfunctional afterwards.
But that concept of an absoluteacute emergency has not been
(30:54):
brought to bear to stroke untilrelatively recently, because
historically there wasn't muchwe could do, or at least not
much we could do acutely.
But now, the same treatmentsthat we use to make a heart
attack get less severe, we cando the same things with the
(31:15):
stroke, not so much if it's ableed, but definitely if it's a
clot or something like that.
So you should rush to theemergency room just like if
there was any evidence of aheart attack and remember what
were those symptoms.
It might be sudden onset ofweakness.
When I say weakness, I'm notmeaning you're generally tired,
(31:39):
but your arm on one side doesn'twork, or your leg on the other
side doesn't work, or your lovedone isn't able to talk, or
they're just acutely confused,or a severe headache.
These are all things that youshould get to the hospital
quickly, because there is a lotmore that we can do and reduce
(32:04):
that disability that so oftenhappens.
Any other sort of words ofthought for getting folks aware
of what to do?
Speaker 2 (32:15):
I think it was a great summary, bobby.
I would emphasize the speechabnormality, which can be quite
subtle, but I've had a number ofpatients tell me that they
really didn't know anything waswrong until their spouse told
them they they were kind ofgarbling their words or speaking
(32:37):
strangely, so that tends to befairly specific, uh, for a TIA
or a stroke, tia being a smaller, transient kind of stroke
episode.
And then, as you said, theearly treatment is something
(32:57):
that the neurologists and theneuroradiologists have kind of
lagged behind cardiology bydecades in terms of how
aggressive they're treatingstrokes.
But we're now seeing earlytreatment and I think, as you
may have said, like four hours,it has to be very early.
The problem is that if you'regetting something like a
(33:21):
clot-busting drug and you'vealready set up a lot of damage
in the brain artery and then yougive a drug that dissolves clot
, you can create a bleed.
So there's definitely a muchharder cutoff for that than
there is for people going inwith a heart attack.
Speaker 1 (33:41):
Well, on this podcast , we talk about what works and
we have obviously talked aboutthat for the last half hour or
so but we also talk about whatdoesn't work.
So what about supplements thatpeople might take?
Some people take aspirin fortheir heart, but does the
(34:02):
aspirin prevent a stroke?
What about supplements likefolate or B12, or one of your
favorites fish oils?
Can any of these help, or arethey really not going to be of
support to the patient?
Speaker 2 (34:17):
So the aspirin story is an interesting one, I think a
decade ago is an interestingone.
I think a decade ago thecurrent director of Medicare, dr
Mehmet Oz, came to St Louis andhe told 500 women that were at
(34:43):
a luncheon that they should allbe taking baby aspirin and fish
oil, and these were middle-agedwomen who had not had a stroke
or a heart attack.
He just thought they should betaking it for prevention, and so
aspirin kind of had a heydayafter that, just taking it,
thinking that you were stoppingstrokes and heart attacks.
But it's become clear in thelast five to 10 years, based on
some very good hard scalerandomized trials, that aspirin
(35:08):
does not have a role in theprimary prevention of stroke or
heart attack in most people, andthe reason is that it increases
this bleeding into the brain.
And so when we look at thecauses of hemorrhagic stroke,
(35:36):
which is again tends to be amore serious one and a more
life-threatening one, aspirin isat the top of the list Also on
that list, and actually nottaking aspirin is a good way to
prevent that kind of stroke ifyou don't need the aspirin.
And at the top of that list isalso, paradoxically, the drugs
that we give for atrialfibrillation to prevent stroke,
(36:01):
and these drugs are two-edgedswords.
They stop clots from forming inthe left atrium in atrial
fibrillation and then going offto the brain, but they also make
it more likely that you'regoing to bleed either in the GI
tract or sometimes into thebrain if there's a weakened
artery there.
And if you bleed into the brainon one of these drugs, you're
(36:22):
going to much rap more rapidlyand the consequences will be
much more severe.
So aspen is definitely somethingyou don't want to just start.
You need to talk to your doctorabout whether there's a reason
to have it or not.
Um, how about fish oils?
Yeah, fish oils, as I recentlywrote about I mostly I was
(36:45):
writing in the area ofcardiovascular disease but when
we look at the large randomizedstudies in the last decade
multiple large randomized trialsof EPA plus DHA fish oil
supplements the kind thateverybody's taking over the
counter thinking that it'sstopping heart attacks there's
(37:05):
no benefit.
There's no benefit on reducingheart attacks, and what they are
looking at in those trials is acombined endpoint that includes
stroke, and the stroke endpointis not changed either.
So no on fish oils, no onaspirin.
Speaker 1 (37:24):
Okay.
Speaker 2 (37:26):
And you know there are multiple other supplements
that are advocated for that, butthey all lack good evidence
that they're useful.
Speaker 1 (37:38):
Sounds good.
Thank you.
Well, I think it's time to wrapup this episode.
I'm sure Dr Pearson will joinus in future ones.
So a few points to finish offwith.
Please talk with your doctorabout risk factors like
cholesterol, high blood pressureand doing all the things that
will protect your heart, likeactivity and such.
(38:00):
Talk with your doctor about anyscreening that might be
appropriate for you.
It sounds like the carotidultrasound's not the way to go,
but if you're concerned aboutatherosclerosis, the calcium
scan may be something that'sappropriate.
Again, talk to your doctor, beaware of the stroke symptoms and
if any of them arise in you orin a loved one, get to the
(38:25):
emergency room right away.
Your outcome will be a wholelot better and the good news is,
if you're focused on helpingyour heart, you're likely doing
most of what's possible toreduce your risk of stroke as
well.
So, dr Pearson, thank you toall our listeners.
I hope you live long and well.
Speaker 2 (38:46):
Thank you, thank you.
Speaker 1 (38:49):
Thanks so much for listening to Live Long and Well
with Dr Bobby.
If you like this episode,please provide a review on Apple
or Spotify or wherever youlisten.
If you want to continue thisjourney or want to receive my
newsletter on practical andscientific ways to improve your
health and longevity, pleasevisit me at
(39:12):
drbobblivelongandwellcom.
That's Dr.
As in D-R Bobby.
Live long and wellcom.
We hear so much about heart disease, its causes and
how to reduce our risk, but wedon't hear as much about stroke
and stroke prevention.
Can we reduce our risk?
What specifically can we do?
Let's see where the evidencetakes us.
Hi, I'm Dr Bobby DuBois andwelcome to Live Long and Well a
(00:36):
podcast where we will talk aboutwhat you can do to live as long
as possible and with as muchenergy and vigor that you wish.
With as much energy and vigorthat you wish.
Together, we will explore whatpractical and evidence-supported
steps you can take.
Come join me on this veryimportant journey and I hope
that you feel empowered alongthe way.
(00:56):
I'm a physician, ironman,triathlete and have published
several hundred scientificstudies.
I'm honored to be your guide.
Welcome, my dear listeners, toepisode number 46.
Can we reduce our risk of astroke?
(01:19):
Now?
In prior episodes, we talkedabout reducing our risk of heart
disease.
Now, that was episode 18.
We also talked about how toreduce your risk of cognitive
decline.
That was episode 13.
Now let's look at stroke in thevery same way what we might be
(01:39):
able to do to reduce that risk.
Once again, we are joined by DrAnthony Pearson, who was with
us on episode 37, reducing ourrisk of heart disease and, as I
shared before, we are kindredspirits that focus on evidence
and we're both a bit skepticaluntil proven otherwise.
(02:00):
So Dr Pearson is a boardcertified cardiologist.
He's on faculty at severalacademic medical centers.
He's published 100peer-reviewed papers and he's
been in private practice for 20years.
He takes a very holistic viewdiet, lifestyle, exercise and,
of course, medications.
He's a columnist for MedPageToday and the author of the
(02:25):
Skeptical Cardiologist, anexcellent blog I recommend to
you all, which is now a substack.
Dr Pearson, welcome back onceagain.
Speaker 2 (02:36):
Good to be here, Bobby, and looking forward to a
good discussion.
Speaker 1 (02:41):
Excellent, excellent, and to give our listeners a
preview we are not always goingto agree on everything today and
when anthony raised this likeI'm gonna have to push back on
this I said I love it absolutely.
Well, where we see the worlddifferently, uh, we'll talk
(03:01):
about that and maybe we'll cometo some middle ground, or at
least the listeners will havetwo different viewpoints.
They can try to decide amongstOkay, let's dive right on in.
So part one we're talking todayabout a stroke.
Well, what is a stroke and howcommon are they?
And we're going to do a bit ofpoint counterpoint.
(03:22):
I'm going to raise some issues,dr Pearson will then chime in,
I'll ask some questions, he'llanswer and we'll play ping pong
back and forth.
In a very simple way, a strokeis a blockage of blood flow to
an area of the brain and itpresents as a sudden loss,
(03:44):
typically of function.
It could be your arm is weak orparalyzed, or your leg, or you
can't speak.
All of a sudden, you might loseconsciousness or you might have
an altered sense ofconsciousness.
Typically it's a sudden onset.
Now it can be silent, it can befatal and it can be everything
(04:07):
in between.
And as we'll talk about in justa couple of minutes.
It often leaves the patientwith a significant disability
again weakness or difficultywith speaking or the like and
that's a bit unlike a heartattack, whereas if you survive
the heart attack, typically youfeel reasonably good afterwards.
(04:30):
Often often with the strokeyou're going to have a residual
problem, and that's why so manypeople fear it.
Now there are an awful lot ofstrokes that happen.
In fact it's almost as manystrokes as heart attacks.
There's about 600,000 to800,000 strokes a year, or, if
you do the math, about one every40 seconds and every three
(04:55):
minutes somebody dies of astroke.
Now, in comparison, there'sabout 800,000 heart attacks a
year, so it's in a similarballpark heart attacks a year,
so it's in the similar ballpark.
Strokes typically happen inpeople that are 65 and older not
always, but typically that'stheir age group.
It is the fourth leading causeof death in the United States,
(05:16):
after heart disease, aftercancer and after accidents.
And, as I mentioned earlier,about 50% of patients who had a
stroke become chronicallydisabled in some fashion.
So there's neurologic deficitsthat sometimes go away fairly
(05:39):
quickly, but oftentimes doesn't.
Actually it's not in our notes,but I'm going to ask you
anyways, dr Pearson why do youthink there's so much more
attention on heart disease andheart attacks than stroke.
Speaker 2 (05:56):
That's a good question.
I think we know that with heartattacks the initial
presentation can just be suddendeath and obviously if you died
you don't get any second chances.
So with strokes you may becomedisabled, but you're not going
(06:17):
to necessarily die right awaywith most strokes.
Speaker 1 (06:23):
Well, we'll have to explore I'll have to do a little
more of a deep dive why thepublic health folks and why
people tend to know about heartattacks.
They know of strokes but theydon't seem to worry about them
as much as heart attacks.
I'll have to dig into that.
It's an interesting question.
So not all strokes are the same.
(06:43):
So maybe walk us through thetypes of strokes and what can
cause them, because that willnaturally lead us into risk
factors and what our listenerscan do to prevent a stroke.
Speaker 2 (06:57):
Sure, there's multiple ways of kind of
breaking down the different kindof strokes.
The first way that you and Ihad discussed was whether it's
ischemic or hemorrhagic, whichmostly comes from CT imaging of
the head after a stroke.
(07:17):
With ischemic strokes, wherethere's a block in the blood
flow in an artery to a certainarea of the brain, there is not
necessarily blood that pours outinto the brain.
But with hemorrhagic strokes,when we look on a CT scan we see
blood and that can have someimportant information to give us
(07:39):
about the causes of the strokeand what the prognosis and what
the best treatment is of thestroke and what the prognosis
and what the best treatment is.
So the vast majority of strokesare the ischemic type, where
there isn't blood in the brain.
Probably 90% of strokes in theUnited States are ischemic and
of those ischemic strokesthere's about 30% of them come
(08:06):
from and are related toatherosclerosis in the large
arteries supplying blood to thebrain, the carotid arteries, the
internal carotid in particular,and that atherosclerosis, the
plaque buildup, is the samething that happens in the
coronary arteries Generally.
If it's happening in thecoronary arteries Generally, if
it's happening in the coronaryarteries, it's also going to be
(08:27):
in the carotid arteries and viceversa.
Another group in the ischemicstroke are the strokes that are
related to what we callcardioembolism, and cardio means
it's coming from the heartessentially, but an embolism
means that it left the heart aclot.
(08:48):
Usually a clot comes out of theheart and then goes up the
aorta and then branches off intoone of the internal carotids or
the arteries in the back of thehead and blocks off an artery
and causes a stroke that way, anartery and causes a stroke that
(09:10):
way.
So cardioembolism is about 20to 30 percent of ischemic
strokes and of thosecardioembolic things where a
clot comes out of the heart,maybe 50 percent are related to
atrial fibrillation, where theclot forms in the left atrium of
the heart.
Back in the late 80s we didn'tknow the cause of the majority
of the strokes that we sawunless they were clearly related
(09:34):
to a blockage in the carotidarteries.
And I became interested backthen in a new ultrasound
technology calledtransesophageal echocardiography
.
We'd done the standard echo,which is done from the chest
surface, but that echo thestandard echo or echocardiogram
could not identify, did not seeareas of the heart like the left
(09:58):
atrial appendage where clotsform, the atrial septum where
you can have a hole and haveclots going across that to cause
a stroke.
And it didn't see the valvesthat well and on the valves
clots can form.
So we used the transesophagealecho and it really was vastly
superior at identifying thesekinds of things that cause
(10:22):
stroke that we weren'tidentifying before.
So the number of cases thatturn out to be cardioembolic has
gone up because of thattechnology and it's still
important today, if you don'tknow the cause of your stroke,
to get a transesophageal echo.
Speaker 1 (10:39):
Well, that's great.
So a variety of different typesof strokes and we'll come back
to this because the risk factorsand how you can avoid them will
differ amongst the differentcauses of stroke.
But I know our listeners wantus to dive in and say, okay,
what puts me at risk?
And please, please, doctors,tell me how I might be able to
(11:02):
reduce that risk.
So there are many differentrisk factors, and there's 10,
and we're not going to walkthrough all of them, but I'll
just give you the list now andwe're going to then take a few
of them and dive in a little bitin more depth.
So, in order of most importancehigh blood pressure that's
(11:25):
number one.
Physical activity, where DrPearson and I may differ a
little bit on this, is numbertwo.
Your cholesterol lipids arenumber three.
Diet and weight and beingoverweight are numbers four and
five, psychosocial smoking,cardiac causes, as we've alluded
(11:48):
to.
Too much alcohol and diabetes.
Now, when you look at this longlist and it is a long list you
might say, okay, do I have toworry about all of these?
Well, there's something calledpopulation attributable risk and
then there's something calledrelative risk, and so I don't
want to get too, too, too nerdywith folks, but population
(12:09):
attributable risk means of allthe people in the population
that get a stroke.
How much of that number is dueto hypertension?
That's called populationattributable risk and it turns
out for high blood pressure, 50%of the strokes can tie back to
high blood pressure.
So if you have individuallyhigh blood pressure, it triples
(12:34):
your risk of the stroke.
But on a population level it'sthe number one risk factor and
number one thing we can try tofocus on.
The next and this is wherewe're going to differ a little
bit is on physical activity.
In a meta-analysis that lookedat a whole bunch of different
studies, they identifiedphysical activity as having
(12:58):
about a third of all strokescould be tied back to lack of
physical activity.
So now the question is DrPearson, you feel that the data
on physical activity and strokeare not as strong or convincing?
Speaker 2 (13:17):
No, I think I'm a huge advocate of getting my
patients moving, exercising, andI've written quite a bit about
how to measure your cardiofitness and how you should be
striving to improve it.
(13:37):
I think quoting 36% of strokesare due to inadequate physical
activity are highly suspect.
It's all coming fromobservational studies and this
looks at people who have people.
(13:57):
These are associations thatdon't indicate causation.
Don't indicate causation andwhat you really would want to
know to prove causation is thatwe did this trial and we did
this amount of exercise on onegroup and or did not give
activity recommendations to theother group and we followed them
(14:18):
for a long period of time andwe found some effect on stroke
or heart attack.
And those studies, when they'vebeen done, haven't really shown
that and we don't have any goodlong-term studies that I can
say to a patient you're going toreduce your risk of stroke by
36% if you double your activitylevel.
(14:44):
I'm still going to advise it fora lot of other reasons, but I'm
not going to tell themspecifically that their stroke
or MI risk is reduced.
Speaker 1 (14:52):
So you're also not just questioning the
relationship between physicalactivity and stroke.
You're saying there isn't thattype of randomized trial proof,
even for preventing heartattacks.
Speaker 2 (15:06):
That type of randomized trial proof, even for
preventing heart attacks, it'sextremely weak to non-existence
I would say.
Speaker 1 (15:19):
Well, we can definitely agree on one thing,
which is whether the data isstrong or weak, we still believe
exercise is a wonderful thingto do.
I totally agree.
Yeah, well, and you're right,we may not get the ultimate
study proof that we would like,but I'm sticking with my
recommendation on exercise.
Speaker 2 (15:35):
I would just add on what you said about hypertension
.
I really I think that is numberone and it may be 50%.
I'm not really sure how theycome up with this attributable
risk and how accurate it is,especially given what they're
saying about physical activity,but the SPRINT study was a
(15:58):
randomized trial of loweringblood pressure to 120 systolic
versus 140, and that showed asignificant risk in mortality a
27% reduction in mortality andsignificant reductions in stroke
, heart attack, heart failure.
So I do think that aggressiveblood pressure control is
(16:22):
something that can definitelyreduce the risk of stroke.
So we should all be trying toidentify and treat adequately
hypertension.
Speaker 1 (16:31):
So Dr Pearson has raised action item number one,
which is make sure you know whatyour blood pressure is and, if
it's elevated, see your doctor,get it under control.
And if you say to yourself, ohwell, I feel fine, remember
hypertension is a very silentand progressive problem, even if
(16:55):
you feel good, please, pleaseget it taken care of.
And action item number twowhether the data is perfect or
not, please continue with yourexercise.
It's wonderful on so, so manylevels, so please do Okay.
So let's turn to the next one,which is cholesterol.
(17:17):
We know that your lipid levels,your ApoB levels, your LDL
levels, relate to your risk ofheart attack.
In the studies, it wouldsuggest that about one in four
strokes has an importantcomponent related to cholesterol
.
What do you think about that?
(17:37):
Does that ring true for you andyour practice?
Speaker 2 (17:41):
Yeah, I think it's a reasonable estimate of the
effects of hypercholesterolemiaand that is only within a
certain subset of patients.
The patients again who havebuilt up atherosclerotic plaque
either prematurely or moreadvanced than expected, both in
(18:02):
the carotid, and they will havebuilt it up in their carotid
arteries and their coronaryarteries.
So the high ApoB, the high LDL,is going to put them at higher
risk for stroke and getting itdown there is evidence that it
reduces that risk.
Speaker 1 (18:20):
Okay, so we've got another action item Do make sure
you know what your cholesterollevels are, and, if they are
elevated, please talk with yourdoctor about addressing it.
Well, let me just sort of askthis question a little bit
differently.
So we've talked in priorepisodes about reducing your
(18:43):
risk of heart disease, and somany of these factors that we
are already talking about hereseem a whole lot like the ones
we worried about to reduce yourrisk of heart attacks, for our
listeners, to reduce the risk ofstroke, isn't it just worrying
about the same things for yourheart?
Speaker 2 (19:14):
Or is there something above and beyond or different
important things that peopleshould pay attention to who are
trying to minimize their risk ofstroke, which I assume is
pretty much everybody?
Perhaps people with a familyhistory are more interested in
that than those without.
There are some things that arerelevant to the
(19:41):
non-atherosclerotic causes ofstroke that don't fall under the
standard risk factors atrialfibrillation, which we know is
associated with stroke and is acommon cause of this
(20:03):
cardioembolic stroke.
Alcohol consumption increasesyour risk of atrial fibrillation
, and so that's something youprobably would want to pay
particular attention to.
And then the other thing isobesity, which both of these
(20:24):
alcohol and obesity we know fromrandomized trials.
If we lower obesity, we lowerthe risk of atrial fibrillation.
If we reduce alcohol oreliminate it, we lower the risk
of atrial fibrillation.
So those are a couple of thingsthat might be a little bit more
(20:45):
specific to stroke.
Speaker 1 (20:47):
Sounds good.
Well, before we leave thistopic of risk factors, I want to
throw out another one.
Now this is based onobservational data.
It's not the highest qualityevidence, but there's a
suggestion that loneliness isassociated with an increased
risk of stroke.
There was an observationalstudy of about 12,000 folks who
(21:12):
were 50 and above, and atbaseline meaning the beginning
of the study, those people whowere persistently feeling lonely
so it wasn't just an occasionalone, they regularly felt lonely
had a 50% increased risk ofstroke in the ensuing years.
Interesting finding.
(21:32):
Of course, they had to sort ofexplain now how could loneliness
lead to a stroke?
And it may be in ways that wemay not have anticipated.
It could be the people that arelonely or depressed.
Maybe they don't take theirmedicines for high blood
pressure as well as they should.
They're lonely and so they endup smoking or drinking more, or
they're under, you know, morepersonal stress, which could
(21:55):
lead to inflammation or anynumber of things.
So this is all hypothesisgenerating, meaning when you do
an observational study and youfind something of interest, this
isn't the definitive answer.
But if you are focused onloneliness and we have a whole
episode on that socialconnections do take another
listen if you're interested.
(22:16):
The Harvard study of adultdevelopment really showed it was
an extraordinarily importantfactor to live long and to be
very functional as you get older.
Okay, let's turn to some otherthings that maybe listeners
should do or not do.
So you mentioned earlier thatatherosclerosis in your carotid
(22:42):
arteries the vessels that go toyour brain is a really important
cause of stroke, and when youwere on our episode together, we
talked about the calcium scanof the heart and how that really
adds some important informationand gives you a sense of
whether you're at increased riskof a heart attack.
(23:02):
Should folks get their carotidarteries screened, just like we
screen their coronary arteriesat some level?
Should we look at the carotids?
Speaker 2 (23:14):
Yeah, it's a great question, and you would think if
I'm so passionate aboutscreening the coronary arteries
for plaque, I should be the sameabout the carotid arteries, and
I used to be.
I was trained in carotidultrasound during my cardiology
(23:35):
fellowship and I haveestablished vascular ultrasound
labs in several of my practices.
The primary goal of thescreening that I set up in these
labs was identifying earlyplaque in the carotid arteries.
I was looking for small plaquethat would be kind of a warning
(23:58):
that plaque was already buildingup in a young or middle-aged
patient.
That shouldn't be there, and wewould also measure something
called carotid IMT,intramomedial thickness, which
is a measure that is stronglycorrelated with atherosclerosis
and was something else I wasusing in younger individuals too
(24:20):
young to use coronary calcium,because that's generally not
going to be helpful until you're40 years or older.
But for the most part, coronaryartery calcium and coronary
artery CT angiography havereplaced carotid in my
evaluation for earlyatherosclerosis.
(24:41):
That's one way of using carotidvascular ultrasound.
Now I'd say that there are somefly-by-night companies out there
that like Lifeline.
I don't want to finger them inparticular, but I have definite
experience and I've writtenabout this on my blog with the
(25:02):
kind of shoddy screening thatthey do, where they're only
looking for high-grade stenosis,they're not trying to look for
early plaque, and they may tellyou that your artery is normal
even though it's got a plaque init, as long as it doesn't have
evidence for a blockage over 50%.
So there's a lot of poorly donecarotid screening in that manner
(25:24):
, so I recommend staying awayfrom that.
The second way to use carotidscreening is to say we're
looking for blockages that aresevere enough that you would
benefit from having a carotidsurgical procedure, like a
carotid endarterectomy, which isdone by vascular surgeons, or
(25:47):
carotid stenting, which issometimes done by cardiologists,
and the evidence for that kindof screening is non-existent and
I would recommend against it,primarily because, even if we
identify a severe stenosis insomebody who has no symptoms, we
(26:08):
have no idea that.
We don't know that operating onthat is going to be better than
treating that plaqueaggressively with our standard
lipid-lowering therapy and ourchanges in lifestyle and diet.
And so you end up identifyingdisease that probably does not
(26:29):
need to be operated on.
You end up getting operationsand procedures that you didn't
need and the result of that canbe really bad side effects like
strokes caused by the surgery orthe stenting and even death
even a young person whocollapses and they have bleeding
(26:50):
in their brain from an aneurysm.
Speaker 1 (27:02):
Somebody has to.
You know this is television, ofcourse.
You know they got to put aneedle in there and reduce the
pressure and get rid of some ofthat blood.
As we mentioned earlier,hemorrhagic strokes, which are a
bleed in the brain as opposedto blockage of the blood to the
brain, are relatively uncommon.
(27:24):
It's about 30,000 a year.
It's about three to fivepercent of all strokes, and
these are often fatal and a lotof people are walking around
with an aneurysm that isn'truptured and is likely never to
rupture.
So for our listeners, should wehave a brain aneurysm screened
(27:47):
for and if we find something,should we do something about it?
Speaker 2 (27:52):
Yeah, that isn't a question that comes up a lot but
after thinking about it whenyou brought it up it does seem
like a very relevant questionand looking at the kind of
guideline recommendations fromvarious societies.
Even though intracranialaneurysms, which are basically
(28:18):
little bulging areas in thearteries, can occur in 2% to 6%
of the population and they haveno symptoms whatsoever, it is
not recommended that we screenthe general population because
of the downsides of identifyingof these, the anxiety that's
(28:42):
created, the downstream testing,and because the yield is so low
that most of the ones that weidentify are not going to go on
to have a problem.
So the guidelines wouldrecommend that if you have two
or more first-degree relativeswith an aneurysm or a
(29:03):
subarachnoid hemorrhage, whichis the kind of bleed that you
get from an aneurysm, that youshould be offered screening.
So if your mother and one ofyour sisters had one, then they
say that you should get it.
If you have one, I thinkPersonally I would want to get
(29:23):
screening, even if I just hadone first degree relative.
I would want to know, andscreening is going to involve a
CTA or an MRI exam.
But for the most of us, eventhough a bleed into the head is
an extremely serious kind ofstroke and potentially
life-threatening.
The risk is so so low that it'snot recommended that we get
(29:48):
screening.
Speaker 1 (29:50):
Okay, good, thank you for that reassurance.
Okay, so we now know what aresome of the causes of stroke,
some of the things that we cando to reduce that risk.
So we now come to the segmentabout get yourself to the
emergency room as fast aspossible.
(30:10):
Now, with heart attacks, folksare aware of sort of the classic
symptoms of an elephant sittingon your chest tightness in your
chest, shortness of breath,pain in your left arm in your
chest, shortness of breath, painin your left arm, sweating,
nausea, various things like that.
And folks have encounteredenough discussions around this
(30:32):
that they know they need to getto the hospital where you can
give clot busters and open upthe blood vessels.
And nowadays people do a lot,lot better both surviving the
heart attack and beingfunctional afterwards.
But that concept of an absoluteacute emergency has not been
(30:54):
brought to bear to stroke untilrelatively recently, because
historically there wasn't muchwe could do, or at least not
much we could do acutely.
But now, the same treatmentsthat we use to make a heart
attack get less severe, we cando the same things with the
(31:15):
stroke, not so much if it's ableed, but definitely if it's a
clot or something like that.
So you should rush to theemergency room just like if
there was any evidence of aheart attack and remember what
were those symptoms.
It might be sudden onset ofweakness.
When I say weakness, I'm notmeaning you're generally tired,
(31:39):
but your arm on one side doesn'twork, or your leg on the other
side doesn't work, or your lovedone isn't able to talk, or
they're just acutely confused,or a severe headache.
These are all things that youshould get to the hospital
quickly, because there is a lotmore that we can do and reduce
(32:04):
that disability that so oftenhappens.
Any other sort of words ofthought for getting folks aware
of what to do?
Speaker 2 (32:15):
I think it was a great summary, bobby.
I would emphasize the speechabnormality, which can be quite
subtle, but I've had a number ofpatients tell me that they
really didn't know anything waswrong until their spouse told
them they they were kind ofgarbling their words or speaking
(32:37):
strangely, so that tends to befairly specific, uh, for a TIA
or a stroke, tia being a smaller, transient kind of stroke
episode.
And then, as you said, theearly treatment is something
(32:57):
that the neurologists and theneuroradiologists have kind of
lagged behind cardiology bydecades in terms of how
aggressive they're treatingstrokes.
But we're now seeing earlytreatment and I think, as you
may have said, like four hours,it has to be very early.
The problem is that if you'regetting something like a
(33:21):
clot-busting drug and you'vealready set up a lot of damage
in the brain artery and then yougive a drug that dissolves clot
, you can create a bleed.
So there's definitely a muchharder cutoff for that than
there is for people going inwith a heart attack.
Speaker 1 (33:41):
Well, on this podcast , we talk about what works and
we have obviously talked aboutthat for the last half hour or
so but we also talk about whatdoesn't work.
So what about supplements thatpeople might take?
Some people take aspirin fortheir heart, but does the
(34:02):
aspirin prevent a stroke?
What about supplements likefolate or B12, or one of your
favorites fish oils?
Can any of these help, or arethey really not going to be of
support to the patient?
Speaker 2 (34:17):
So the aspirin story is an interesting one, I think a
decade ago is an interestingone.
I think a decade ago thecurrent director of Medicare, dr
Mehmet Oz, came to St Louis andhe told 500 women that were at
(34:43):
a luncheon that they should allbe taking baby aspirin and fish
oil, and these were middle-agedwomen who had not had a stroke
or a heart attack.
He just thought they should betaking it for prevention, and so
aspirin kind of had a heydayafter that, just taking it,
thinking that you were stoppingstrokes and heart attacks.
But it's become clear in thelast five to 10 years, based on
some very good hard scalerandomized trials, that aspirin
(35:08):
does not have a role in theprimary prevention of stroke or
heart attack in most people, andthe reason is that it increases
this bleeding into the brain.
And so when we look at thecauses of hemorrhagic stroke,
(35:36):
which is again tends to be amore serious one and a more
life-threatening one, aspirin isat the top of the list Also on
that list, and actually nottaking aspirin is a good way to
prevent that kind of stroke ifyou don't need the aspirin.
And at the top of that list isalso, paradoxically, the drugs
that we give for atrialfibrillation to prevent stroke,
(36:01):
and these drugs are two-edgedswords.
They stop clots from forming inthe left atrium in atrial
fibrillation and then going offto the brain, but they also make
it more likely that you'regoing to bleed either in the GI
tract or sometimes into thebrain if there's a weakened
artery there.
And if you bleed into the brainon one of these drugs, you're
(36:22):
going to much rap more rapidlyand the consequences will be
much more severe.
So aspen is definitely somethingyou don't want to just start.
You need to talk to your doctorabout whether there's a reason
to have it or not.
Um, how about fish oils?
Yeah, fish oils, as I recentlywrote about I mostly I was
(36:45):
writing in the area ofcardiovascular disease but when
we look at the large randomizedstudies in the last decade
multiple large randomized trialsof EPA plus DHA fish oil
supplements the kind thateverybody's taking over the
counter thinking that it'sstopping heart attacks there's
(37:05):
no benefit.
There's no benefit on reducingheart attacks, and what they are
looking at in those trials is acombined endpoint that includes
stroke, and the stroke endpointis not changed either.
So no on fish oils, no onaspirin.
Speaker 1 (37:24):
Okay.
Speaker 2 (37:26):
And you know there are multiple other supplements
that are advocated for that, butthey all lack good evidence
that they're useful.
Speaker 1 (37:38):
Sounds good.
Thank you.
Well, I think it's time to wrapup this episode.
I'm sure Dr Pearson will joinus in future ones.
So a few points to finish offwith.
Please talk with your doctorabout risk factors like
cholesterol, high blood pressureand doing all the things that
will protect your heart, likeactivity and such.
(38:00):
Talk with your doctor about anyscreening that might be
appropriate for you.
It sounds like the carotidultrasound's not the way to go,
but if you're concerned aboutatherosclerosis, the calcium
scan may be something that'sappropriate.
Again, talk to your doctor, beaware of the stroke symptoms and
if any of them arise in you orin a loved one, get to the
(38:25):
emergency room right away.
Your outcome will be a wholelot better and the good news is,
if you're focused on helpingyour heart, you're likely doing
most of what's possible toreduce your risk of stroke as
well.
So, dr Pearson, thank you toall our listeners.
I hope you live long and well.
Speaker 2 (38:46):
Thank you, thank you.
Speaker 1 (38:49):
Thanks so much for listening to Live Long and Well
with Dr Bobby.
If you like this episode,please provide a review on Apple
or Spotify or wherever youlisten.
If you want to continue thisjourney or want to receive my
newsletter on practical andscientific ways to improve your
health and longevity, pleasevisit me at
(39:12):
drbobblivelongandwellcom.
That's Dr.
As in D-R Bobby.
Live long and wellcom.
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