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Stroke

Claudia Fortunato-Napolitano at her 'I Am Alive!' party.

By Stephanie Giunta

In honor of National Stroke Awareness Month, we would like to honor a local survivor, Claudia Fortunato-Napolitano, who is beyond inspirational. Here is her story.

On January 11, 2017, 34-year-old Huntington Village resident Claudia Fortunato-Napolitano, went to work like it was any other day, although she remembers having a bad headache. The passionate history buff and Executive Director at the Huntington Historical Society was making some personal calls during her lunch break. As she sat down to eat her lunch, she suddenly felt dizzy; her coworker asked if she was okay, and she couldn’t speak. Out of nowhere, a simple Wednesday became the day that forever-altered Napolitano’s future: the day she unexpectedly suffered a stroke. 

Once the stroke had occurred, Fortunato-Napolitano couldn’t remember what happened next, though she recounted her story by way of others at the scene. She was rushed to Huntington Hospital, and was then airlifted to North Shore University Hospital, where she resided for two weeks. When she woke up, she still couldn’t speak, had weakness in her right arm and couldn’t walk.

After a stint at the hospital, she was released into a rehab facility, but at the end of her week-long tenure, needed to move back into her parents’ house. Though the mobility in her arm was very low, she was slowly regaining the ability to walk, but couldn’t tackle the stairs up to her front door. She lived with her parents for three weeks, while simultaneously beginning outpatient rehab, seeing a handful of therapists to attempt to win her life back as her own through physical and cognitive recovery.

Claudia Fortunato-Napolitano at her ‘I Am Alive!’ party.

No warning signs 

Doctors were puzzled that a healthy 34-year-old, who had nothing more than a routine headache on the day of her stroke, could suffer something so unexpected and traumatic. At six months post-stroke, Fortunato-Napolitano began seeing a neurologist and underwent in-depth testing to reveal underlying notions of root cause.  She tested negative for everything doctors had assumed she would test positive for. Though they could confirm that the stroke was caused by a clogged blood vessel in her brain, the actual diagnosis remains inconclusive. 

A determined patient

After routinely attending speech therapy for six months, Fortunato-Napolitano still fought to talk. In our interview, she mentioned that she struggled with aphasia for the first two years during her recovery. Her therapist alluded to the fact that her speech would not improve — that she should simply get used to this new way of life. This led her down a dark path of depression, afraid that she would never regain her full ability to communicate with others. 

After 4-5 months, her parents encouraged her to seek a second opinion from another therapist who would work with her past the “6 month window.” As Fortunato-Napolitano stated during our interview, her mother “God bless her soul!” put her in touch with her current speech therapist, Judy Cavallo, who she still sees to this day. Cavallo even provides Fortunato-Napolitano with homework because she asks for it!

In addition to speech therapy, Fortunato-Napolitano continues to see an occupational therapist, Ian MacManus, to aid in her physical disabilities. Seven of her fingers work, but three fingers on her right hand are bent in a fixed manner. She dreams of the ability to wear high heels again, but walking is too difficult in any shoe aside from her signature Doc Martens and Birkenstocks — which she has in a wide variety of colors.  Her right foot cannot be fully-placed on the floor, and only the outside edge can go flat completely. 

To this day, Napolitano still goes to outpatient rehab twice per week (once to her speech therapist and once to her occupational therapist) to improve her skills and continually progress.

New realities 

Prior to the stroke, Fortunato-Napolitano was a writer. She wrote a historic Half Hollow Hills column for Patch Media on a weekly basis, as well as many articles for the Huntington Historical Society. Now, on average, it will take her about three hours to write three paragraphs. She mentioned that this has been the hardest thing for her to overcome from a professional perspective. But Siri is her best friend. She is so grateful for technology, which helps her text, post on social media, and write emails.  

Claudia Fortunato-Napolitano at her ‘I Am Alive!’ party.

A major milestone

Within the first five years of having a stroke, an individual is 50% more likely to suffer from a second stroke in comparison to a person of the same age. So, in January 2022, Fortunato-Napolitano threw herself an “I Am Alive!” party to celebrate meeting this critical milestone. There were over 85 people in attendance, including her neurologist and speech therapist, and she donned a stylish, sparkly green jumpsuit. Not only was this a celebration of how far she had come, but also that statistically, her chances of having another stroke or stroke-like episode would start to significantly decrease.  

Pivotal life lessons

Fortunato-Napolitano is so grateful to be alive. She could have been paralyzed and in a wheelchair; she may not have survived. But now, she makes sure that she lives every day to the fullest. She voluntarily chooses happiness.

Prior to the stroke, she was unhappy about stupid, inconsequential things. Now, Fortunato-Napolitano uses a “whatever!” mentality. She believes that life is worth living and she intends to make the most of the hand that she has been dealt. The biggest lesson she learned from her stroke, she mentioned, was, “I can be unhappy [about that] or I can just be happy. And I choose to be happy all of the time.” 

Fortunato-Napolitano fuels her happiness with her work. This February, she was newly-appointed as the Executive Director of the Greenlawn-Centerport Historical Association. She loves her job and the challenges it provides.

She is also a travel connoisseur — something she has been passionate about from a very young age. Her next destination includes heading to Cleveland on a baseball stadium tour for her husband’s birthday, but the top future spots on her international travel list include Africa, Argentina, Australia, and Turkey.

A message to all stroke survivors 

Fortunato-Napolitano’s hope is that someone in similar shoes reads this article, her story, and becomes happy due to reading it.  She can’t stress enough that you can and will get better — you just can’t stop believing in yourself. At six months post-stroke, her original speech therapist told her she would never speak again. Six years later, Fortunato-Napolitano is carrying on conversations beautifully. Each year, she sees subsequent progression and truly believes that she will continue to improve for the rest of her life.

There is a light at the end of the tunnel even during the darkest and most depressing of times. Her outlook on life has drastically changed from Year 2 to Year 6. She stressed the importance of self-dedication, while also surrounding yourself with a great support system.

Above all, Fortunato-Napolitano is a true inspiration.  She epitomizes optimism, and is dedicated, admirable, and determined. Her new dream is to become a life coach, as she hopes to help others through similar dark and unexpected times. She would love a platform in which to tell her story publicly. Fortunato-Napolitano is a happiness evangelist, a survivor to the nth degree, and only hopes she can inspire others, stroke conquerors or not, to live life to the fullest. 

Follow along with Claudia Fortunato-Napolitano’s journey on Instagram: @ayoungstrokerecovery.

This article first appeared in TBR News Media’s supplement Focus on Health on May 25, 2023.

From left to right, physician assistants Michelle Rosa and Katherine Malloy, Dr. David Fiorella and Dr. Jason Mathew visit Joseph Annunziata in his hospital bed. Photo from Stony Brook Medicine

By Daniel Dunaief

Joseph “Bob” Annunziata, a resident of Kings Park, wants you not to be like him.

An army veteran, Annunziata urges residents and, in particular, other veterans, to pay attention to their medical needs and to take action when they find out they have a problem. 

A self-described “tough guy” who grew up in Bay Ridge, Brooklyn, Annunziata put off medical care for a partially blocked left carotid artery and it caused a medical crisis.

“My brother and sister vets, if you got a pain or the doctor tells you to do something, do it,” he said. “It almost cost me my life. I don’t want that to happen to anyone else.”

Joseph Annunziata at his 80th birthday party

Annunziata, 80, was driving to the supermarket on Veterans Day when his right hand became limp and he was slurring his speech. Knowing he was in trouble, he turned the car around and drove 10 minutes to the Northport VA Medical Center.

The doctors evaluated him and rushed him to Stony Brook University Hospital, which is well equipped to handle stroke-related emergencies and is the only hospital in the state named one of America’s 100 Best Hospitals for Stroke Care for eight years in a row. 

Several doctors evaluated Annunziata, including by Dr. David Fiorella, Director of the Stony Brook Cerebrovascular Center and Co-Director of the Stony Brook Cerebrovascular and Comprehensive Stroke Center, and Jason Mathew, stroke neurologist.

“We identified that there was a severe blockage in the left side of his brain,” said Dr. Mathew. “If blood flow is not returned to this area, the patient is at risk for a larger area of stroke.”

Indeed, a larger stroke could have caused right side paralysis and could have robbed Annunziata of his ability to speak or worse.

Performing emergency surgery could protect endangered brain cells, but also presented some risk. If not removed carefully and completely, the clot in the carotid artery could travel into the brain or the stroke could expand over time due to a lack of sufficient blood flow to the left side of the brain.

Time pressure

Stony Brook doctors discussed the particulars of the case together and explained the situation to Annunziata, who could understand what they were describing and respond despite symptoms that threatened to deteriorate.

The hospital, which does between 200 and 250 interventional stroke treatments per year and handles many more strokes than that annually, has a group of health care specialists who can provide accessible information to patients who are not experts in the field and who need to make an informed decision under time pressure.

Stony Brook has become adept at “conveying this complex information in a time-sensitive way,” Dr. Fiorella said. In those cases for which surgery is the best option, each minute that the doctors don’t open up a blood vessel reduces the benefits and increases the risk of longer-term damage.

Stony Brook sees about one to two of these kinds of cases per month. As a whole, the hospital, which is a large referral center, sees numerous complex and unusual cerebrovascular cases of all types, Dr. Fiorella said.

Annunziata and the doctors decided to have the emergency surgery.

Dr. Fiorella used a balloon guiding catheter, which is a long tube with a working inner lumen that has a soft balloon on the outside of it that is designed to temporarily block flow. He deploys these occlusion balloons in most all stroke cases. 

The particular way he used it in these complete carotid occlusions is unique. The balloon guiding catheter makes interventional stroke procedures more efficient, safer, and the outcomes better, according to data for thrombectomy, Dr. Fiorella said. 

The occlusion balloon enabled Dr. Fiorella to control blow flow the entire time, which makes the procedure safer. The surgery took under an hour and involved a small incision in Annunziata’s right wrist.

Joseph Annunziata with his girlfriend Rosemarie Madrose

After the surgery, Annunziata was able to speak to doctors and call Rosemarie Madrose, his girlfriend of five and a half years. “He came out talking,” said Madrose. “I could understand him. I was relieved.” Four days after the emergency operation, Annunziata, who also received post operative care from Dr. Yuehjien Gu, Neurocritical Care Unit Director, left the hospital and returned to his home, where he spent the next morning preparing a welcome meal of a scrambled egg and two slices of toast.

The doctors attribute Annunziata’s quick recovery to a host of factors. Getting himself to the hospital as soon as symptoms started saved precious minutes, Dr. Fiorella said, as “time is brain.” He also advised against driving for people having stroke-like symptoms, which can include slurred speech, numbness, weakening of the arm or leg and loss of vision in one eye.

Dr. Fiorella urged people to call for help or to get a ride in an ambulance. Stony Brook has two mobile stroke unit ambulances, which are equipped with technology to assess patients while en route, saving time and alerting doctors in the hospital to patients who might need immediate attention and intervention.

These mobile units, which are available from 8 a.m. to 8 p.m., have helped reduce death and disability for stroke and have cut down the length of stays in the hospital.

People or family and friends who are observing someone who might be having a stroke can call 911 and indicate that the patient is having stroke-like symptoms. The emergency operator will alert the mobile stroke unit of a possible case if the unit is available and the patient is in range.

Helping a veteran

The doctors involved in Annunziata’s care were well aware of the fact that they were treating a veteran on Veterans Day.

“Oftentimes, we think about how we can give back more than just a thank you” to people like Annunziata, who “risked his life and helped his country the way he could,” said Dr. Mathew. “I’m helping him the way I can help.”

Dr. Fiorella added that he thought it was “wonderful” to “help someone who’s given so much to our country on Veterans Day.”

Army origin

Annunziata explained that he wound up in the Army through a circuitous route.  “We watched all the war movies” when he was young and wanted to join the Marines, he said.

When he went to enlist in 1962, he was told there was a two and a half year wait. He and his young friends got the same reception at the Air Force, Navy and the Army. As they were leaving the Army building on Whitehall Street, he and his friends ran into a sergeant with numerous medals on his uniform. The sergeant urged them to go back up the hallway and enter the first door on the right and indicate that they wanted to expedite the draft. About a week later, Annunziata was drafted and got a 15 cent token in the mail for a train trip to Wall Street.

After basic training at Fort Dix, he was stationed in Greenland, where Annunziata operated a radar at the top of a mountain for two years. He participated in drills in which he had to catch American planes flying overhead.

Fortunately, he said, even during the height of the Cold War and just months after the Cuban Missile Crisis, Annunziata never spotted a Russian threat, even though the base was just 20 minutes from Russian air space.

Having gone through emergency surgery that likely saved his life, Annunziata urges residents to pay attention to any medical needs on their radar.

Dr. Fiorella was amazed at how quickly Annunziata expressed concern for his fellow veterans during his recovery.

“One of the first things he talked about was, ‘How can I use what happened to me to help other vets?’” Dr. Fiorella said.

Annunziata’s girlfriend Madrose, who is grateful that the procedure saved his life, said he “didn’t listen to me. He knew he had to do this. I kept saying, ‘When are you going to do it?’ He said, ‘I will, I will, I will.’ He learned the hard way.” She added that they both know he is “extremely lucky.”

Ke Jian Liu

By Daniel Dunaief

Ke Jian “Jim” Liu, who arrived at Stony Brook University in late July, plans to help build effective, interdisciplinary research teams.

Ke Jian Liu

Most recently at the University of New Mexico, Liu joins Stony Brook as a Professor in the Renaissance School of Medicine’s Department of Pathology and Associate Director of Basic Science at the Stony Brook Cancer Center.

“In my mind, Stony Brook, research wise, is outstanding,” Liu said in an interview. “The quality of the faculty is excellent.”

Liu will rely on the team building experience he honed while serving as Distinguished Professor in the Department of Pharmaceutical Sciences and Associate Dean for Research in the College of Pharmacy at the University of New Mexico. He also worked for eight years at Dartmouth Medical School, where he focused on developing larger collaborations.

“I really enjoy working with people and building teams,” Liu said.

In a note announcing Liu’s arrival, Kenneth Shroyer, chair in the Department of Pathology, recognized Liu’s multidisciplinary approaches in his research. Shroyer explained that Liu has used techniques ranging from chemical to biochemical to biophysical, and from the molecular and cellular level to animal models, to answer specific biological questions.

Shroyer wrote that Liu would focus on opportunities for grant development within several programs. 

At the Cancer Center, Liu said he plans to continue the effort to help Stony Brook earn National Cancer Institute designation.

To achieve that designation, Stony Brook will need to continue to provide outstanding medical care, demonstrate community engagement and highlight what makes Stony Brook different from everyone else, he said.

“It takes a village to do that,” Liu said.

He praised the efforts of current Cancer Center Director Yusuf Hannun, who recently announced his plans to step down as head of the center, triggering a nationwide search for a replacement.

Liu said an ideal candidate for that position would have clinical experience.

Player coach

With a busy research effort and lofty leadership goals, Liu explained that he’s able to tackle numerous challenges at once.

“I consider myself a player coach,” he said. “I enjoy research. I have my own research grant and am working with my students and post docs.”

Liu typically maintains a lab with five to six people at different levels. His research has two branches, cancer and stroke, that most people likely consider unrelated, but for which he has found connections.

“People always think, ‘Cancer is cancer and stroke is stroke and they are two entirely different diseases,” Liu  said. As a basic researcher, however, he looks at the cells and the molecules involved in both conditions.

“At a molecular level, a molecule doesn’t care where it is,” he said. “When a disease develops, the biological fundamental process is the same. For me, it’s interesting to look at [whether] certain processes that occur in the brain also occur in cancer.”

Liu’s cancer research focuses specifically on the molecular processes that become carcinogenic when metals like arsenic enter people’s bodies. A well-described poison in numerous murder mysteries, arsenic can contaminate drinking water, get incorporated into crops like rice, or can appear in fruit juices.

When metal enters the body, it doesn’t just cause damage everywhere. It has to find a certain molecular target with which to interact.

What Liu and researchers in his lab have discovered is that the target for arsenic is often the same pathways the body uses in zinc. A transition metal, zinc provides an important element as a part of transcription factors that are critical in biological processes.

Arsenic, however, replaces zinc, which is “one of the major mechanisms for carcinogenesis,” Liu said.

Fortunately for residents of Long Island, arsenic isn’t as prevalent as it is in the midwest and the southwest.

“Long Island doesn’t have too much arsenic in drinking water,” Liu said, although people are still exposed to it through fruit juices, rice and other products.

Arsenic also causes vascular disease issues and anemia. People who develop these other conditions in response to arsenic are also at higher risk to develop cancer. The specific types of cancers arsenic causes are lung, skin and bladder cancer.

“Arsenic is the dirty bomb” in the body as it creates multiple problems, Liu said. “Arsenic interacts with those key zinc molecules.” 

Overlap between stroke and cancer

In highlighting the overlaps between the two fields of research, Liu related how the brain has one of the highest concentrations of zinc in the body.

When people have strokes, their brain cells have oxidative stress, which causes a flood of zinc into the brain tissue that also damages cells.

“We are trying to understand how zinc is released and how zinc causes damage to the brain,” Liu said.

Stroke and cancer also have molecular overlaps regarding oxygen. In a stroke, a blood clot causes a blockage of blood flow. Without oxygen, a situation called hypoxia, neurons start to die.

By contrast, a tumor grows in a hypoxic environment, using energy from sugars like glucose, rather than relying on oxygen for its growth.

Liu emphasized the importance of continuing to provide oxygen to brain regions around a clot even before trying to remove the clot or restore blood flow.

A goal for his 100th year

Originally from Beijing, China, Liu and his wife Jiao Ding enjoy traveling. Their daughter Sarah Liu is a resident at Vermont Medical Center and their son Evan Liu is a PhD student at Stanford.

An avid tennis player who plays the sport at least twice a week, Liu is looking forward to attending his first U.S. Open next year.

He and his former tennis partner in New Mexico joked that their goal is to be in the top 20 in the United States when they are 100 years old.

Liu chose the American name “Jim” because it sounds similar to the second syllable of his given name, Ke Jian.

“If people can’t pronounce your name, they shy away,” he said. He believes it’s important to “make yourself adaptable.”

Moderation is the key. Photo from Pexels
Modest alcohol consumption may decrease stroke risk in women

By David Dunaief

Dr. David Dunaief

Alcohol is one of the most widely used over-the-counter drugs, and there is much confusion over whether it is beneficial or detrimental to your health. The short answer: it depends on your circumstances, including your family history and consideration of diseases you are at high risk of developing. 

Several studies have been published – some touting alcohol’s health benefits, with others warning of its risks. The diseases addressed by these studies include breast cancer, heart disease and stroke. Remember, context is the determining factor for alcohol intake.

Breast Cancer Impact

In a meta-analysis of 113 studies, there was an increased risk of breast cancer with daily consumption of alcohol (1). The increase was a modest, but statistically significant, four percent, and the effect was seen at one drink or less a day. The authors warned that women who are at high risk of breast cancer should not drink alcohol or should drink it only occasionally.

It was also shown in the Nurses’ Health Study that drinking three to six glasses a week increases the risk of breast cancer modestly over a 28-year period (2). This study involved over 100,000 women. Even a half-glass of alcohol was associated with a 15 percent elevated risk of invasive breast cancer. The risk was dose-dependent, with one to two drinks per day increasing risk to 22 percent, while those having three or more drinks per day had a 51 percent increased risk.

Alcohol’s impact on breast cancer risk is being actively studied, considering types of alcohol, as well as other mitigating factors that may increase or decrease risk. We still have much to learn.

Based on what we think we know, if you are going to drink, a drink several times a week may have the least impact on breast cancer. According to an accompanying editorial, alcohol may work by increasing the levels of sex hormones, including estrogen, and we don’t know if stopping diminishes the effect, although it might (3).

Stroke Effects

On the positive side, the Nurses’ Health Study demonstrated a decrease in the risk of both ischemic (caused by clots) and hemorrhagic (caused by bleeding) strokes with low to moderate amounts of alcohol (4). This analysis involved over 83,000 women. Those who drank less than a half-glass of alcohol daily were 17 percent less likely than nondrinkers to experience a stroke. Those who consumed one-half to one-and-a-half glasses a day had a 23 percent decreased risk of stroke, compared to nondrinkers. 

However, women who consumed more experienced a decline in benefit, and drinking three or more glasses daily resulted in a non-significant increased risk of stroke. The reasons for alcohol’s benefits in stroke have been postulated to involve an anti-platelet effect (preventing clots) and increasing HDL (“good”) cholesterol. Patients shouldn’t drink alcohol solely to get stroke protection benefits. 

Moderation is the key.
METRO photo

Heart effects

In the Health Professionals follow-up study, there was a substantial decrease in the risk of death after a heart attack from any cause, including heart disease, in men who drank moderate amounts of alcohol compared to those who drank more or were non-drinkers (5). Those who drank less than one glass daily experienced a 22 percent risk reduction, while those who drank one-to-two glasses saw a 34 percent risk reduction. The authors mention that binge drinking negates any benefits. This study has a high durability spanning 20 years.

Citrus benefits rival alcohol benefits for stroke risk

An analysis of the Nurses’ Health Study recently showed that those who consumed more citrus fruits had approximately a 19 percent reduction in stroke risk (6). These results were similar to the reduction seen in the Nurses’ Health Study with modest amounts of alcohol.

The citrus fruits used most often in this study were oranges and grapefruits. Of note, grapefruit may interfere with medications such as Plavix (clopidogrel), a commonly used antiplatelet medication used to prevent strokes (7). Grapefruit inhibits the CYP3A4 system in the liver, thus increasing the levels of certain medications.

Alcohol in Moderation

Moderation is the key. It is very important to remember that alcohol is a drug that does have side effects, including insomnia. The American Heart Association recommends that women drink up to one glass a day of alcohol. I would say that less is more. To get the stroke benefits and avoid the increased breast cancer risk, half a glass of alcohol per day may be the ideal amount for women. Moderate amounts of alcohol for men are up to two glasses daily, though one glass showed significant benefits. 

Remember, there are other ways of reducing your risk of these maladies that don’t require alcohol. However, if you enjoy alcohol, moderate amounts may reap some health benefits.

References:

(1) Alc and Alcoholism. 2012;47(3)3:204–212. (2) JAMA. 2011;306:1884-1890. (3) JAMA. 2011;306(17):1920-1921. (4) Stroke. 2012;43:939–945. (5) Eur Heart J. Published online March 28, 2012. (6) Stroke. 2012;43:946–951. (7) Medscape.com.

Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com. 

White fleshy fruits like apples, pears and bananas have shown to decrease ischemic stroke risk. Stock photo
Medications and lifestyle play important roles

By David Dunaief

Dr. David Dunaief

Stroke remains one of the top five causes of mortality and morbidity in the United States (1). While some risk factors are out of our control, like family history and age, many of our risks can be altered by making lifestyle changes and managing contributing diseases, like hypertension and diabetes.

We have a wealth of studies that inform us on the roles of medications and lifestyle in managing risk. Of particular importance are medication guidelines that balance the risks and benefits of different stroke prevention regimens.

Medications can be protective

Two medications have shown positive impacts on reducing stroke risk: statins and valsartan. Statins are used to lower cholesterol and inflammation, and valsartan is used to treat high blood pressure. Statins do have side effects, such as increased risks of diabetes, cognitive impairment and myopathy (muscle pain). However, used in the right setting, statins are very effective. Some studies have shown reduced mortality from stroke in patients who were on statins at the time of the event (2). Patients who were on a statin to treat high cholesterol had an almost six-fold reduction in mortality, compared to those with high cholesterol who were not on therapy.

There was also significant mortality reduction in those on a statin without high cholesterol, but with diabetes or heart disease. The authors surmise that this result might be from an anti-inflammatory effect of the statins. Of course, if you have side effects, you should contact your physician immediately.

Valsartan is an angiotensin II receptor blocker that works on the kidney to reduce blood pressure. However, in the post-hoc analysis (looking back at a completed trial) of the Kyoto Heart Study data, valsartan used as an add-on to other blood pressure medications showed a significant reduction, 41 percent, in the risk of stroke and other cardiovascular events for patients who have coronary artery disease (3).

It is important to recognize that high blood pressure and high cholesterol are two of the most significant risk factors for stroke. Fortunately, statins can reduce cholesterol, and valsartan may be a valuable add-on to prevent stroke in those patients with coronary artery disease.

Use caution with medication combinations

There are two anti-platelet medications that are sometimes given together in the hopes of reducing stroke recurrence — aspirin and Plavix (clopidogrel). The assumption is that these medications together will work better than either alone. However, in a randomized controlled trial, the gold standard of studies, this combination not only didn’t demonstrate efficacy improvement but significantly increased the risk of major bleed and death (4, 5).

Major bleeding risk was 2.1 percent with the combination versus 1.1 percent with aspirin alone, an almost twofold increase. In addition, there was a 50 percent increased risk of all-cause death with the combination, compared to aspirin alone. Patients were given 325 mg of aspirin and either a placebo or 75 mg of Plavix. The study was halted due to these deleterious effects. The American Heart Association recommends monotherapy for the prevention of recurrent stroke. If you are on this combination of drugs, please consult your physician.

Managing aspirin dosing

Greater hemorrhagic (bleed) risk is also a concern with daily aspirin regimens greater than 81 mg, which is the equivalent of a single baby aspirin. Aspirin’s effects are cumulative; therefore, a lower dose is better over the long term. Even 100 mg taken every other day was shown to be effective in trials. There are about 50 million patients who take aspirin chronically in the United States. If these patients all took 325 mg of aspirin per day, an adult dose, it would result in 900,000 major bleeding events per year (6). Do not take an aspirin regimen — even a low-dose aspirin regimen — for stroke prevention without consulting your physician.

Protection from fruits and vegetables

A prospective study of 20,000 participants showed that consuming white fleshy fruits — apples, pears, bananas, etc. — and vegetables — cauliflower, mushrooms, etc. — decreased ischemic stroke risk by 52 percent (7). Additionally, the Nurses’ Health Study showed that foods with flavanones, found mainly in citrus fruits, decreased the risk of ischemic stroke by 19 percent (8). The authors suggest that the reasons for the reduction may have to do with the ability of flavanones to reduce inflammation and/or improve blood vessel function. I mention both of these trials together because of the importance of fruits in prevention of ischemic (clot-based) stroke.

Fiber’s role

Fiber also plays a key role in reducing the risk of a hemorrhagic stroke. In a study involving over 78,000 women, those who consumed the most fiber had a total stroke risk reduction of 34 percent and a 49 percent risk reduction in hemorrhagic stroke. The type of fiber used in this study was cereal fiber, or fiber from whole grains.

Refined grains, however, increased the risk of hemorrhagic stroke twofold (9). When eating grains, it is important to have whole grains. Read labels carefully, since some products that claim to have whole grains contain unbleached or bleached wheat flour, which is refined.

Fortunately, there are many options to help reduce the risk or the recurrence of a stroke. Ideally, the best option would involve lifestyle modifications. Some patients may need to take statins, even with lifestyle modifications. However, statins’ side effect profile is dose-related. Therefore, if you need to take a statin, lifestyle changes may help lower your dose and avoid harsh side effects. Once you have had a stroke, it is likely that you will remain on at least one medication — typically low-dose aspirin — since the risk of a second stroke is high.

References:

(1) cdc.gov. (2) AAN conference: April 2012. (3) Am J Cardiol 2012; 109(9):1308-1314. (4) ISC 2012; Abstract LB 9-4504; (5) www.clinicaltrials.gov NCT00059306. (6) JAMA 2007;297:2018-2024. (7) Stroke. 2011; 42: 3190-3195. (8) J. Nutr. 2011;141(8):1552-1558. (9) Am J Epidemiol. 2005 Jan 15;161(2):161-169.

Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com.

Stock photo
Medication guidelines have changed with recent studies

By David Dunaief, M.D.

Dr. David Dunaief

May is National Stroke Awareness Month, with a focus on raising awareness of stroke risk factors and prevention. This is valuable, since stroke remains one of the top five causes of mortality and morbidity in the United States (1). As a result, we have a wealth of studies that inform us on the roles of medications and lifestyle in managing risk. Of particular importance are changes in medication guidelines that balance the risks and benefits of different stroke prevention regimens.

Medications with beneficial effects

Two medications have shown positive impacts on reducing stroke risk: statins and valsartan. Statins are used to lower cholesterol and inflammation, and valsartan is used to treat high blood pressure. Statins do have side effects, such as increased risks of diabetes, cognitive impairment and myopathy (muscle pain). However, used in the right setting, statins are very effective. In one study, there was reduced mortality from stroke in patients who were on statins at the time of the event (2). Patients who were on a statin to treat high cholesterol had an almost sixfold reduction in mortality, compared to those with high cholesterol who were not on therapy.

There was also significant mortality reduction in those on a statin without high cholesterol, but with diabetes or heart disease. The authors surmise that this result might be from an anti-inflammatory effect of the statins. Of course, if you have side effects, you should contact your physician immediately.

Valsartan is an angiotensin II receptor blocker that works on the kidney to reduce blood pressure. However, in the post-hoc analysis (looking back at a completed trial) of the Kyoto Heart Study data, valsartan used as an add-on to other blood pressure medications showed a significant reduction, 41 percent, in the risk of stroke and other cardiovascular events for patients who have coronary artery disease (3).

It is important to recognize that high blood pressure and high cholesterol are two of the most significant risk factors for stroke. Fortunately, statins can reduce cholesterol, and valsartan may be a valuable add-on to prevent stroke in those patients with coronary artery disease.

Medication combination: negative impact

There are two anti-platelet medications that are sometimes given together in the hopes of reducing stroke recurrence — aspirin and Plavix (clopidogrel). The assumption is that these medications together will work better than either alone. However, in a randomized controlled trial, the gold standard of studies, this combination not only didn’t demonstrate efficacy improvement but significantly increased the risk of major bleed and death (4, 5).

Major bleeding risk was 2.1 percent with the combination versus 1.1 percent with aspirin alone, an almost twofold increase. In addition, there was a 50 percent increased risk of all-cause death with the combination, compared to aspirin alone. Patients were given 325 mg of aspirin and either a placebo or 75 mg of Plavix. The study was halted due to these deleterious effects. The American Heart Association recommends monotherapy for the prevention of recurrent stroke. If you are on this combination of drugs, please consult your physician.

Aspirin: low dose vs. high dose

Greater hemorrhagic (bleed) risk is also a concern with daily aspirin regimens greater than 81 mg, which is the equivalent of a single baby aspirin. Aspirin’s effects are cumulative; therefore, a lower dose is better over the long term. Even 100 mg taken every other day was shown to be effective in trials. There are about 50 million patients who take aspirin chronically in the United States. If these patients all took 325 mg of aspirin per day, an adult dose, it would result in 900,000 major bleeding events per year (6). Do not take an aspirin regimen – even a low-dose aspirin regimen – for stroke prevention without consulting your physician.

Lifestyle modifications

A prospective study of 20,000 participants showed that consuming white fleshy fruits — apples, pears, bananas, etc. — and vegetables — cauliflower, mushrooms, etc. — decreased ischemic stroke risk by 52 percent (7). Additionally, the Nurses’ Health Study showed that foods with flavanones, found mainly in citrus fruits, decreased the risk of ischemic stroke by 19 percent (8). 

The authors suggest that the reasons for the reduction may have to do with the ability of flavanones to reduce inflammation and/or improve blood vessel function. I mention both of these trials together because of the importance of fruits in prevention of ischemic (clot-based) stroke.

Fiber’s important role

Fiber also plays a key role in reducing the risk of a hemorrhagic stroke. In a study involving over 78,000 women, those who consumed the most fiber had a total stroke risk reduction of 34 percent and a 49 percent risk reduction in hemorrhagic stroke. The type of fiber used in this study was cereal fiber, or fiber from whole grains.

Refined grains, however, increased the risk of hemorrhagic stroke twofold (9). When eating grains, it is important to have whole grains. Read labels carefully, since some products that claim to have whole grains contain unbleached or bleached wheat flour, which is refined.

Fortunately, there are many options to help reduce the risk or the recurrence of a stroke. Ideally, the best option would involve lifestyle modifications. Some patients may need to take statins, even with lifestyle modifications. However, statins’ side effect profile is dose-related. Therefore, if you need to take a statin, lifestyle changes may help lower your dose and avoid harsh side effects. Once you have had a stroke, it is likely that you will remain on at least one medication — typically low-dose aspirin — since the risk of a second stroke is high.

References:

(1) cdc.gov. (2) AAN conference: April 2012. (3) Am J Cardiol 2012; 109(9):1308-1314. (4) ISC 2012; Abstract LB 9-4504. (5) www.clinicaltrials.gov NCT00059306. (6) JAMA 2007;297:2018-2024. (7) Stroke. 2011; 42: 3190-3195. (8) J. Nutr. 2011;141(8):1552-1558. (9) Am J Epidemiol. 2005 Jan 15;161(2):161-169.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.  

Dr. David Fiorella and Eric Niegelberg. Photo from Stony Brook Medicine

As American Heart Month kicks off in February, Stony Brook Medicine is finalizing plans to provide speedy help to stroke victims in Suffolk County.

“When a blood vessel supplying the brain is blocked, it is estimated that nearly two million brain cells are lost for each minute that passes, making stroke the most time sensitive diagnosis we have in medicine.”

— Dr. David Fiorella

The Stony Brook Cerebrovascular and Comprehensive Stroke Center and the Stony Brook Renaissance School of Medicine’s Department of Emergency Medicine will launch Long Island’s first mobile stroke unit program in March. The program will include specially equipped ambulances that will be strategically based along the length of the Long Island Expressway, taking calls within 10 miles of their bases.

The hope is to ensure response times of 20 minutes or less.

“When a blood vessel supplying the brain is blocked, it is estimated that nearly two million brain cells are lost for each minute that passes, making stroke the most time sensitive diagnosis we have in medicine,” said Dr. David Fiorella, director of the stroke center and professor of neurological surgery and radiology at the Renaissance School of Medicine. “The faster we can restore blood flow to the brain the more likely that the patient will have a full recovery.”

The units will be available seven days a week from 8 a.m. to 8 p.m., which is the window of time when most stroke calls are received.

Eric Niegelberg, associate director of Operations for Emergency Services and Internal Medicine, said an evaluation was completed to choose what time frame the mobile units would be available.

“We evaluated 911 ambulance call volume by area in the county and combined that data with what we felt was a reasonable response distance and time.”

— Eric Niegelberg,

“We looked at actual data for five years and historically the highest percentage of stroke calls come in during that time frame,” he said, adding once the program begins Stony Brook Medicine will continue to evaluate data and modify the hours based upon current call volume.

While the first unit will be deployed at Exit 57 on the LIE sometime between mid-to-late March, the second will not be in use until April and will be set up at Exit 68.

“The locations were chosen based upon call volume,” Niegelberg said. “We evaluated 911 ambulance call volume by area in the county and combined that data with what we felt was a reasonable response distance and time. Based upon this analysis the two locations were chosen. We did want locations that would provide easy North-South and East-West access.”

The units will include an in-ambulance care team, telemedicine system that enables emergency physicians and neurologists to see the patient via audio/visual conferencing, CT scanner for a standard scan and CT scan angiogram, which allows doctors to check for bleeding in the brain immediately.

Robert Simpson, district manager of Medford Volunteer Ambulance, said the mobile stroke units would be valuable to emergency response workers.

“As an EMS provider, we are always looking for ways to enhance treatment to patients,” Simpson said. “I think that it will definitely be an asset to us, especially for patients with strokes. As they say, ‘Saving time, saves the brain.’ Minutes count when someone is having a stroke as far as being able to enhance their chances of survival.”

According to Centers for Disease Control and Prevention, Division for Heart Disease and Stroke Prevention, stroke is the fifth leading cause of death in the United States, killing about 140,000 Americans each year.

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It is disconcerting when the medical community reverses course. They seem to do that every decade or so, as with the purported value of vitamin C, estrogen and so forth. The latest about face, in case you haven’t yet heard, is on the matter of taking baby aspirin. For years we have been urged to take a baby aspirin each day to ward off all sorts of ills: heart attacks, strokes, dementia, colorectal cancers and who knows what else. Those tiny pills that can dissolve in seconds against the roof of one’s mouth, or be popped into it, seemed capable of miracles.

Now, with a shot heard truly around the world, an Australian research team at Monash University in Melbourne concluded that not only may aspirin not help, it may in some cases actually harm. The results of their study, which included more than 19,000 people over 4.7 years, were published in three articles this past Sunday in the prestigious New England Journal of Medicine and summarized by The New York Times on Monday, and by just about all other major media.

The study included whites 70 and older, and blacks and Hispanics 65 and older. Each took 100 milligrams — slightly more than the 81 milligrams of a baby aspirin — or a placebo each day. While doing so did not lower their risks of diseases, it did increase “the risk of significant bleeding in the digestive tract, brain or other sites that required transfusions or admission to the hospital,” according to The Times.

So what does all that mean, especially for those already at risk for the conditions aspirin was supposed to protect against?

I am going to quote from The Times very carefully here because this can get confusing due to mixed messages. “Although there is good evidence that aspirin can help people who have already had heart attacks or strokes, or who have a high risk that they will occur, the drug’s value is actually not so clear for people with less risk, especially older ones,” wrote reporter Denise Grady.

So can aspirin prevent cardiovascular events in people with diabetes, for example, or is the benefit outweighed by the risk of major bleeding? Does dose matter in that heavier people might require more aspirin to be prophylactive?

Here’s what the study tells us: Healthy older people should not begin taking aspirin. This will no doubt disappoint Bayer, St. Joseph and others who manufacture the drug. But those who have already been using it regularly should not quit based on these findings, according to Dr. John McNeil, leader of the Australian study. Rather they should talk with their doctors first because the new findings do not apply to those who have already had heart attacks or strokes, which involve blood clots. Aspirin is known to inhibit clotting.

The name of this study is Aspree and it was funded by the National Institute on Aging, along with the National Cancer Institute, Monash University and the Australian government. Bayer supplied the aspirin and placebos but had no other role, according to The Times.

The study focuses on preventive medicine, especially how to keep older people healthy longer. It included 16,703 people from Australia and 2,411 from the United States, starting in 2010. Serious bleeding occurred in 3.8 percent of the aspirin group as opposed to 2.7 percent in the placebo group.

McNeil does suggest the possibility that aspirin’s protective effect against colorectal cancers might still exist but not show up for a longer time span than the study. The Times article does go on to say that the good doctor, who is 71 and specializes in epidemiology and preventive medicine, does not himself take aspirin.

Don’t know what to do? As they say in the commercials, consult your doctor.

The effects of high sodium are insidious

By David Dunaief, M.D.

Dr. David Dunaief

By now, most of us have been hit over the head with the fact that too much salt in our diets is unhealthy. Still, we respond with “I don’t use salt,” “I use very little,” or “I don’t have high blood pressure, so I don’t have to worry.” Unfortunately, these are myths. All of us should be concerned about salt or, more specifically, our sodium intake.

Excessive sodium in the diet does increase the risk of high blood pressure (hypertension); the consequences are stroke or heart disease. Approximately 90 percent of Americans consume too much sodium (1).

Now comes the interesting part. Sodium has a nefarious effect on the kidneys. In the Nurses Health Study, approximately 3,200 women were evaluated in terms of kidney function, looking at the estimated glomerular filtration rate (GFR) as related to sodium intake (2). Over 14 years, those with a sodium intake of 2,300 mg had a much greater chance of an at least 30 percent reduction in kidney function, compared to those who consumed 1,700 mg per day.

Why is this study important? Kidneys are one of our main systems for removing toxins and waste. The kidneys are where many initial high blood pressure medications work, including ACE inhibitors, such as lisinopril; ARBs, such as Diovan or Cozaar; and diuretics (water pills). If the kidney loses function, it may be harder to treat high blood pressure. Worse, it could lead to chronic kidney disease and dialysis. Once someone has reached dialysis, most blood pressure medications are not very effective.

Ironically, the current recommended maximum sodium intake is 2,300 mg per day, or one teaspoon, the same level that led to negative effects in the study. However, Americans’ mean intake is twice that level.

Excessive sodium in one’s diet can increase the risk of high blood pressure, which can lead to a stroke or heart disease. Stock photo

If we reduced our consumption by even a modest 20 percent, we could reduce the incidence of heart disease dramatically. Current recommendations from the American Heart Association indicate an upper limit of 2,300 mg per day, with an “ideal” limit of no more than 1,500 mg per day (3).

If the salt shaker is not the problem, what is? Most of our sodium comes from processed foods, packaged foods and restaurants. There is nothing wrong with eating out on occasion, but you can’t control how much salt goes into your food. My wife is a great barometer of restaurant salt use. If food from the night before was salty, she complains of not being able to get her rings off.

Do you want to lose 5 to 10 pounds quickly? Decreasing your salt intake will allow you to achieve this goal. Excess sodium causes the body to retain fluids. 

One approach is to choose products that have 200 mg or fewer per serving indicated on the label. Foods labeled “low sodium” have fewer than 140 mg of sodium, but foods labeled “reduced sodium” have 25 percent less than the full-sodium version, which doesn’t necessarily mean much. Soy sauce has 1,000 mg of sodium per tablespoon, but low-sodium soy sauce still has about 600 mg per tablespoon. Salad dressings and other condiments, where serving sizes are small, add up very quickly. Mustard has 120 mg per teaspoon. Most of us use far more than one teaspoon of mustard. Caveat emptor: Make sure to read labels on all packaged foods very carefully.

Is sea salt better than table salt? High amounts of salt are harmful, and the type is not as important. The only difference between them is slight taste and texture variation. I recommend not buying either. In addition to the health issues, salt tends to dampen your taste buds, masking the flavors of food.

If you are working to decrease your sodium intake, become an avid label reader. Sodium hides in all kinds of foods that don’t necessarily taste salty, such as breads, soups, cheeses and salad dressings. I also recommend getting all sauces on the side, so you can control how much — if any — you choose to use.

As you reduce your sodium intake, you might be surprised at how quickly your taste buds adjust. In just a few weeks, foods you previously thought didn’t taste salty will seem overwhelmingly salty, and you will notice new flavors in unsalted foods.

If you have a salt shaker and don’t know what to do with all the excess salt, don’t despair. There are several uses for salt that are actually beneficial. According to the Mayo Clinic, gargling with ¼ to ½ teaspoon of salt in eight ounces of warm water significantly reduces symptoms of a sore throat from infectious disease, such as mononucleosis, strep throat and the common cold. Having had mono, I can attest that this works.

Remember, if you want to season your food at a meal, you are much better off asking for the pepper than the salt.

References:

(1) cdc.gov. (2) Clin J Am Soc Nephrol. 2010;5:836-843. (3) heart.org.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

Cocoa components reduce cardiovascular risk

By David Dunaief, M.D.

Dr. David Dunaief

Valentine’s Day is one of the wonderful things about winter. For many, it lifts the mood and spirit. A traditional gift is chocolate. But do the benefits of chocolate go beyond Valentine’s Day? The short answer is yes, which is good news for chocolate lovers. However, we are not talking about filled chocolates, but primarily dark chocolate and cocoa powder.

The health benefits of chocolate are derived in large part from its flavonoid content — compounds that are produced by plants. These health benefits are seen in cardiovascular disease, including stroke, heart disease and high blood pressure. This is ironic, since many chocolate boxes are shaped as hearts. Unfortunately, it is not necessarily the chocolates that come in these boxes that are beneficial.

Let’s look at the evidence.

Effect on heart failure

Heart failure is very difficult to reverse. Therefore, the best approach is prevention, and dark chocolate may be one weapon in this crusade. In the Swedish Mammography Cohort study, those women who consumed dark chocolate saw a reduction in heart failure (1). The results were on a dose-response curve, but only to a point. Those women who consumed two to three servings of dark chocolate a month had a 26 percent reduction in the risk of heart failure.

For the dark chocolate lovers, it gets even better. Women who consumed one to two servings per week had an even greater reduction of 32 percent. However, those who ate more than these amounts actually lost the benefit in heart failure reduction and may have increased risk. With a serving (1 ounce) a day, there was actually a 23 percent increased risk.

This study was a prospective (forward-looking) observational study that involved more than 30,000 women over a long duration, nine years. The authors comment that chocolate has a downside of too much fat and calories and, if eaten in large quantities, it may interfere with eating other beneficial foods, such as fruits and vegetables. The positive effects are most likely from the flavonols, a subset of flavonoids, which come from the cocoa solids — the chocolate minus the cocoa butter.

Impact on mortality from heart attacks

In a two-year observational study, results showed that chocolate seemed to reduce the risk of cardiac death after a first heart attack (2). Again, the effects were based on a dose-response curve, but unlike the previous study, there was no increased risk beyond a certain modest frequency.

Those who consumed chocolate up to once a week saw a 44 percent reduction in risk of death, and those who ate the most chocolate — two or more times per week — saw the most effect, with 66 percent reduced risk. And finally, even those who consumed one serving of chocolate less than once per month saw a 27 percent reduction in death, compared to those who consumed no chocolate.

The study did not mention dark or milk chocolate; however, this was another study that took place in Sweden. In Sweden, milk chocolate has substantially more cocoa solids, and thus flavonols, than that manufactured for the U.S. There were over 1,100 patients involved in this study, and none of them had a history of diabetes, which is important to emphasize.

Stroke reduction

I don’t know anyone who does not want to reduce the risk of stroke. We tell patients to avoid sodium in order to control blood pressure and reduce their risk. Initially, sodium reduction is a difficult thing to acclimate to — and one that people fear. However, it turns out that eating chocolate may reduce the risk of stroke, so this is something you can use to balance out the lifestyle changes.

In yet another study, the Cohort of Swedish Men, which involved over 37,000 men, there was an inverse relationship between chocolate consumption in men and the risk of stroke (3). Those who ate at least two servings of chocolate a week benefited the most with a 17 percent reduction in both major types of stroke — ischemic and hemorrhagic — compared to those who consumed the least amount of chocolate. Although the reduction does not sound tremendous, compare this to aspirin, which reduces stroke risk by 20 percent. However, chocolate consumption study was observational, not the gold standard randomized controlled trial, like aspirin studies.

Blood pressure

One of the most common maladies, especially in people over 50, is high blood pressure. So, whatever we can do to lower blood pressure levels is important, including decreasing sodium levels, exercising and even eating flavonoid-rich cocoa.

In a meta-analysis (a group of 20 RCTs), flavonoid-rich cocoa reduced both systolic (top number) and diastolic (bottom number) blood pressure significantly: −2.77 mm Hg and −2.20 mm Hg, respectively (4). These studies involved healthy participants, who are sometimes the most difficult in whom to show a significant reduction, since their blood pressure is not high initially. One of the weaknesses of this meta-analysis is that the trials were short, between two and 18 weeks.

Why chocolate has an effect

Consuming a small amount of dark chocolate twice a week may lower the risk of heart disease.

Chocolate has compounds called flavonoids. The darker the chocolate, the more flavonoids there are. These flavonoids have potential antioxidant, antiplatelet and anti-inflammatory effects.

In a small, randomized controlled trial comparing 22 heart transplant patients, those who received dark flavonoid-rich chocolate, compared to a cocoa-free control group, had greater vasodilation (enlargement) of coronary arteries two hours after consumption (5). There was also a decrease in the aggregation, or adhesion, of platelets, one of the primary substances in forming clots. The authors concluded that dark chocolate may also cause a reduction in oxidative stress.

It’s great that chocolate, mainly dark, and cocoa powder have such substantial effects in cardiovascular disease. However, certain patients should avoid chocolate such as those with reflux disease, allergies to chocolate and diabetes. Be aware that Dutch-processed, or alkalized, cocoa powder may have lower flavonoid levels and is best avoided. Also, the darker the chocolate is, the higher the flavonoid levels. I suggest that the chocolate be at least 60 to 70 percent dark.

Moderation is the key, for all chocolate contains a lot of calories and fat. Based on the studies, two servings a week are probably where you will see the most cardiovascular benefits. Happy Post-Valentine’s Day!

References: (1) Circ Heart Fail. 2010;3(5):612-616. (2) J Intern Med. 2009;266(3):248-257. (3) Neurology. 2012;79:1223-1229. (4) Cochrane Database Syst Rev. 2012:15;8:CD008893. (5) Circulation. 2007 Nov 20;116(21):2376-2382.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.