Cholesterol, Blood Pressure, and Stroke. What You Should Know

Dr. Michael Koren and Dr. Ravi Pande present What You Should Know about Strokes, including how high cholesterol and blood pressure can increase your risk. In this episode, recorded in front of a live audience, the two doctors discuss the BE FAST warning signs of a stroke and the importance of getting to an emergency room as fast as possible. Then they talk about treatment options, including new medications and guidelines that guide how doctors may use medications or rapid surgery to help preserve brain cells. Finally, the doctors emphasize the importance of prevention and how keeping blood pressure and cholesterol under control has measurable, positive impacts on stroke risk and recovery.

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Music: Storyblocks - Corporate Inspired

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Transcript

Welcome And Why Stroke Matters

Announcer 0:00

Welcome to the MedEvidence Podcast. This episode is a rebroadcast from a live MedEvidence! presentation.

Audience Fears And Case Quiz

Dr. Michael Koren 0:06

Ravi, I'm really excited about this program. First of all, you're a good friend, and it's always fun to work with a good friend, so I appreciate that. Thank you. But I am concerned about a couple of things, which I'll get into in a second. One is if you notice on Dr. Pande's slide, you can see his credentials, and that includes an MBA, a master of business association. So he's an expert in neurology, an expert on stroke, but he can also tell us how we can all get the most for our money. So please, when you think about questions, to ask him about that. So I have a few questions about that, probably that I'll share with you after the talk on that particular issue. So that's one thing. The second concern is that I was a little worried when I walked in here and I saw the computer talking on my slides using my voice. So I thought that Sharon was going to come up to me and say, I'm sorry, Dr. Koren, but you've been replaced by AI. Your services are no longer needed today, but uh but your your severance check will be in the mail sometime in the next year. So fortunately that did not happen, and here we are uh discussing strokes, which of course is a really, really important concern for all of us in the community, especially as we get older. As you learn, it is the fourth leading cause of mortality in the United States, and certainly something that we can do something about to prevent. And Dr. Pande's gonna run through that with me. So, as you know, for our MedEvidence programs, contrary to what you may think or what you may see, there's no free lunch here. Everybody has to work for their lunch. And the way that you work for your lunch is help answer some questions so that we can assess what the knowledge is in the community and also assess how we help our community through research and other interventions that we do, including seeing us as a patient on on time to time. So, with that said, this is the first question for the audience. And this is trying to target what your concerns are when you look at different healthcare matters that may affect you in the audience. So here we go. Number one, which of the urgent situations, which of these urgent situations concerns you most? Is it A chest pain that may or may not lead to an impending heart attack? Is it B breathing difficulties that may or may not lead to a pulmonary embolism? Is it C loss of speech or vision that may or may not lead to a stroke? Is it D loss of place in the MedEvidence sandwich line, which may or may not lead to missing out on a tuna fish sandwich? Or is it A, B, and C equally? Okay. So that that's what we thought the answer would be, and you can see that's highlighted. But I'm curious, is anybody more worried about a stroke than everything else? Yes, me too. Yeah, there you go. And and and this is not the first time it's seen that. So when you survey people, the the general population seems to be more worried about a stroke than a heart attack or pulmonary embolism, even though they're all horrible things. But the sense for a stroke is more devastating for most people.

Dr. Ravi Pande 3:27

Right. And it's uh Hi, I'm Dr. Pande, by the way, vascular interventional neurologist, director of the Stroke Center at the HCA Florida Memorial Hospital. So welcome. And I Dr. Koren mentioned earlier that stroke is fourth leading cause of death. And this just he's very updated with this kind of information because this just happened. The AHA statistics just came out this year. They updated stroke as the fourth leading cause. It used to be fifth leading cause until a few years ago. Uh do you know what was the fifth leading cause before? Fourth leading cause before stroke took over?

Dr. Michael Koren 4:07

We'll say COVID.

Dr. Ravi Pande 4:09

COVID. COVID deaths. So COVID dropped down from fourth all the way to 10th. So strokes take taken over. So yeah, it's definitely not just concerning for healthcare providers, but patients in general are fearful because you become very quickly disabled, and uh it's uh something you you it takes years or months to recover from.

Dr. Michael Koren 4:40

Right thats's the key thing is that this concept of being disabled is something that's really compelling for people. That's why you're fearful of it. So heart attacks are the number one cause of death.

Dr. Ravi Pande 4:44

Right.

Dr. Michael Koren 4:44

And but people have a sense that this stuff we can do, they can recover from that, et cetera, whereas a stroke you don't have that sense. So a lot of people mentioned that C was their number one concern, and there's a lot of support from other surveys that in fact that's accurate for many patient populations. So moving on to the next question, which is getting into an actual case, and this is the stuff that you see all the time. And I just want to see what our audience awareness is of how to deal with these things. And historically, we have very smart audiences.

Dr. Ravi Pande 5:14

Oh, yeah, yeah.

What A Stroke Is And Why Time Counts

Dr. Michael Koren 5:15

So I'm gonna guess that they get this one right as well, but we'll see. We'll see. That's why you have to work for this lunch. A 71-year-old suddenly develops slurred speech and has difficulty using her right arm. Which of the following is most urgent to rule out? Is it A low blood sugar causing confusion? Is it B a stroke affecting the brain regions that control speech and motor functions? A lot of people nodding. Is it C, can she sign a check with you with her left arm? Is it D, a side effect of volume causing slurring and poor coordination? Or of course it's it's B, right? So the the concept here is really, really important, which is that when somebody has a a sudden neurological limitation, you need to be worried about a stroke. So in your experience, when this happens, how often is it a stroke versus something else?

Dr. Ravi Pande 6:18

Uh it's 99% of the time it's going to be stroke versus low blood sugar. Uh low blood sugar is clearly one of the things we check when a person comes to the emergency room with stroke symptoms. It's check to make sure hypoglycemia is not causing the stroke-like symptoms. But obviously, the most urgent thing for you to worry about in this kind of patient would be stroke and calling 911.

Dr. Michael Koren 6:41

Yeah. So always be suspicious when people are having any kind of a neurological problem that involves speech or the use of an arm or limb about a stroke and getting help as quickly as possible, which is another question that we'll get to in a second. So, Dr. Pande, tell us what is a stroke? What's the formal definition?

Dr. Ravi Pande 6:57

So stroke, stroke occurs when you have either a blockage in a blood vessel that that's leading to the brain that can cause lack of blood flow to the brain and cause stroke, or rupture of a blood vessel. Like think of it like a plumbing, either a blockage in the in the pipe or a pipe bursting. And that can lead to symptoms of weakness, numbness, speech difficulty, all those things. Like we mentioned the latest numbers, fourth leading cause of death in the United States, about 800,000 people will have stroke every year in the United States. Billions of dollars, obviously, in costs, direct and indirect, obviously. Direct patient care, but families who have to quit their jobs and take care of the patient, that also adds to the costs. Some cool statistics for doctors, but for patient and their families to understand is two million neurons, two million brain cells die every second. We have trillions of brain cells, but you have to imagine if you wait for half an hour before you call 911 or you wait at home and call your son to come pick you up and take you to the emergency room, you're gonna lose billions of neurons while you're waiting. So two million, just remember that, you're losing millions of neurons every minute. And then the ischemic stroke, which is most predominant type of stroke, which is the blockage where the piping is blocked, uh, is about 85, 87% of all strokes are ischemic. And then the remainder of the strokes are 15, 13 percent of the strokes are bleeding strokes, where you have rupture of a blood vessel, and then you get leakage of the blood into the tissue or surrounding the tissue and causes swelling and damage from that.

Dr. Michael Koren 8:42

So why does the brain require this constant oxygen and glucose supply? Why don't you get us into a little bit of the physiology?

Dr. Ravi Pande 8:49

Yeah. It's just uh brain doesn't have it it about 20% of the human oxygen need uh is uh is dedicated to the brain. So the brain cells rely on this metabolic process to generate energy. So if you don't have glucose and oxygen to the brain tissue, it's gonna rapidly cause the brain cell to deteriorate, lose function, and cause the symptoms of the stroke.

Dr. Michael Koren 9:20

This ATP production, it gets a little jargony, but that's the molecule that's responsible for energy transfer in the cells. Right. And that's a key and important key element of what we call the pathophysiology of what happens with the brain and the the cells of the brain. And uh, as you mentioned before, is that there are either these more transient problems or more permanent problems. So you just want to define that for people?

Dr. Ravi Pande 9:48

So there's sometimes you'll have just lack of blood flow to the brain tissue for a few minutes or even up to a few hours, and then the blood flow gets gets restored automatically. So if it's happening very quickly for let's say um less than a minute or two minutes of lack of blood flow, your cells are not gonna completely die. And they might have a dysfunction and cause you just transient symptoms for less than one hour or two hours, and that's called TIA or a transient ischemic attack or a mini stroke. And if the blood flow is is stopped for a longer period of time, then you're gonna have a permanent loss of function to the uh or loss of neurons in that area that doesn't get the blood flow and that causes a full stroke.

TIA Versus Stroke And Types Explained

Dr. Michael Koren 10:39

So the the key distinction there is that if there's some permanent loss of function, it's by definition a stroke.

Dr. Ravi Pande 10:46

Right.

Dr. Michael Koren 10:46

That's the key take-home there.

Dr. Ravi Pande 10:47

And you can see it on the MRI as well. So when we get an MRI, TIA patients most of the time will have a normal MRI because their blood flow got restored quickly enough, they didn't have any damage evident on the MRI.

Dr. Michael Koren 11:00

So tell us about the types of strokes.

Dr. Ravi Pande 11:02

Yeah. So this is what I was mentioning earlier about the ischemic type of stroke where you have blockage in the blood vessel leading to the brain, either in the carotid or intracranial blood vessel. And that's those are the predominant types of strokes, about 85, 87 percent. And the hemorrhagic is the bleeding type, which is from a ruptured aneurysm or just high blood pressure causing one of the smaller blood vessels in the brain to bleed.

Dr. Michael Koren 11:27

So let me ask you this question. Um I was in my training years ago, we talked about three types of strokes, one being hemorrhagic, one being thrombotic, and the other one being embolic. Right. Is that still considered valuable information or not?

Dr. Ravi Pande 11:43

Yeah, so ischemic strokes could be there there's a subcategory of ischemic stroke as thrombotic or embolic. And what what we mean by that is thrombotic is when the blood vessel in the brain itself gets thickened from, let's say, plaque buildup or just chronic atherosclerosis. And that causes that blood vessel to plug up inherently inside the brain and cause the stroke. Embolic, on the other hand, would be something that flew from the heart or the aortic arch or even just the carotid. You have a little plaque that flew from the carotid into the brain, and that caused the stroke. So atrial fibrillation is one of the reasons why you can have a clot in the heart that can be thrown into the brain and cause stroke.

Dr. Michael Koren 12:29

All right. So here again, we're getting to that concept of the mini stroke. And even though it's mini, it's still a major warning. So just a couple words on that.

Dr. Ravi Pande 12:38

Yeah, it's the same thing we described earlier. If if there's a transient lack of flow to the brain tissue, you that'll be lucky. That's almost like a warning stroke. And uh most patients don't have symptoms lasting about an hour or two hours, at the most 24 hours, and they return completely back to baseline. That's the TIA.

Dr. Michael Koren 13:00

So let's say that somebody's at home, they have a visual loss that lasts for 10 minutes and they then they feel back to normal. Should they just go about their business or should they do something more urgently about that particular situation?

Dr. Ravi Pande 13:14

Yeah, so uh vision loss, vision symptoms are just like weakness, numbness. Uh if you have a transient vision loss in one eye, especially, or both eyes on one side or the other, those are signs of stroke. And they can either be a clot flying into the central retinal artery in the eye itself, or you can have a stroke in the back of the head that causes vision symptoms. So yeah, no, you've got to come call 911, come to the emergency room because you could have critical blockage in the carotid that and you flew a little clot into your eye, and the next thing you know, it's gonna completely shut off and cause you uh to have a major stroke.

Dr. Michael Koren 13:54

So this I think it lends itself to uh risk factors and then what to do in an emergency situation. So let's talk about the things not to do. And there's a whole laundry list. Are any of these more important than others, or how to advise patients on dealing with these things?

Risk Factors You Can Control

Dr. Ravi Pande 14:10

Yes. I mean, some of these are modifiable risk factors or avoidable risk factors, some obviously can't. But smoking, diabetes, high cholesterol, high blood pressure, obesity, lack of exercise, poor diet, heart disease, all of these are risk factors for stroke. One of the top risk factors that is controllable, I should say, instead of modifiable or avoidable is high blood pressure. Uh almost 50% of our strokes are attributed to high blood pressure. And about 25% of all of our strokes are attributed to high cholesterol. So those are the top two reasons for strokes in America. So basically uh cholesterol and high blood pressure.

Dr. Michael Koren 14:56

Yeah. And if any of you are curious as to where we got this fellow to model for this slide, I can tell you that I recently fired him as my life coach. Okay, the link between LDL and stroke.

Dr. Ravi Pande 15:16

So, yeah, high LDL or bad cholesterol obviously leads to atherosclerosis, plaque build up on the inside of the blood vessel, as you can see in that picture. That yellow stuff that's that's a plaque that's built from an injury to the inside of the blood vessel that leads to cholesterol, bad cholesterol accumulating and causing that. And that causes narrowing of the blood vessel, and that can lead to stroke, or it also leads to hardening of smaller blood vessels, and then that hardened blood vessel can easily rupture, cause bleeding in the brain. So it's linked with both ischemic and hemorrhagic types of strokes.

Dr. Michael Koren 15:57

So here we're getting back to the audience question. and this comes up all the time, so I'm curious to see your spin on that. If you think someone is having a stroke, should you give them an aspirin? This is constantly something that my patients ask me about. I'm sure you get these questions. So these are the multiple choice answers. A, yes. Aspirin helps prevent more clots from forming. Is it B, no, aspirin interferes with CT scans. Is it C, yes, aspirin can help delay the onset of symptoms?

Dr. Ravi Pande 16:27

Let's see.

Dr. Michael Koren 16:27

Oh, is uh not done yet. Is it D, no aspirin can make bleeding strokes worse, or is it E only if their symptoms seem mild? So let's let's just get the audience to weigh in on this one. This may not be so obvious. So who thinks it's A, aspirin helps prevent more clots from forming? And you should take it if someone is having a a stroke symptom. So a couple. How about B? No aspirin interferes with CT scans. Okay. Yeah, that's obviously not true. C, aspirin can help delay the onset of symptoms. Anyone think that's accurate?

Dr. Ravi Pande 17:05

A few, a few here.

Dr. Michael Koren 17:06

Maybe. Is it D, no aspirin can make bleeding strokes worse? Anybody?

Dr. Ravi Pande 17:12

This is not adding up to 100%, by the way. People are not a lot of people are not raising their hands at all, huh?

Dr. Michael Koren 17:18

And then E, only if their symptoms seem mild. It's only for the easy strokes, not for the hard ones. All right, so why don't you let us know what the answer really is?

Aspirin Debate And What Not To Do

Dr. Ravi Pande 17:26

Yeah, no, aspirin can lead to not just if you have a bleeding type of stroke, the one that I mentioned from rupture of a blood vessel, aspirin will make things worse for those patients. But also you don't want to give them orally anything because a lot of times the stroke will impair your swallowing function. So you may give them something and it's gonna lead to the pill going down into their lungs. So we don't give aspirin orally to patients. Even if they have ischemic stroke, we find out they have ischemic stroke, we wait for someone to evaluate them and clear them from swallowing. Worst case, if we have to give them, we give them rectally aspirin. So I wouldn't give- do that at home for sure. Yeah, don't do that to your family.

Dr. Michael Koren 18:09

Yeah. So all right. Audience question number four. What is the most appropriate action for a bystander who recognizes possible stroke symptoms? Is it A, wait 30 minutes to see if her symptoms improve? Is it B, sit her down, give her water, and monitor her at her at home? Maybe if you give her vodka, that would help. Is it C, drive her to the nearest urgent care clinic when convenient? Sounds reasonable, no? Is it D, call 911 immediately because these are warning signs of her stroke? Okay. Or is it E, call Dr. Pande?

Dr. Ravi Pande 18:49

Yeah.

Dr. Michael Koren 18:50

Well, I would call you, but uh but you are you guys are absolutely right.

Dr. Ravi Pande 18:53

911 will be faster, I think.

Dr. Michael Koren 18:55

Absolutely. And so let's make that point. It's it's a super important one.

Dr. Ravi Pande 19:00

Yeah. Time is brain. Obviously, we work with closely with all the EMS personnel and their teams. We just recently had a drill at our hospital with JFRD (Jacksonville Fire/Rescue Department), and we do drills with them all the time to streamline the process. So they're getting your blood sugar before they arrive. They take your blood pressure, they start an IV. So all these things will expedite treatment for you when you arrive to the emergency room. So driving patient, unfortunately, people still walk in with strokes. We have anywhere from 300 to 500 walk-in strokes every year at Memorial. I don't know why. People just seem to bring their family members by car. It just delays slightly your care because, like I said, all these things have to be done then in the emergency room. And you've driven them obviously through traffic lights and stuff, whereas JFRD is able to bring them faster.

Dr. Michael Koren 19:54

Right. And and tell them like how the ER works for stroke alert so that they understand how important this is.

BE FAST Signs And Posterior Strokes

Dr. Ravi Pande 20:00

Stroke alert is a very streamlined process. We have very strong metrics for how when we receive the patient from uh what to do, where to go. We do drills to absolutely streamline this whole process several times every year. So as soon as you arrive with the EMS on the we don't even take the patient off the gurney. We take them directly to the stroke bay. JFRD or EMS will give us their handoff. We already have a tele neurologist or a local neurologist sitting right next to the bed. We have ED doc, pharmacist ready to give you medicine if needed, blood pressure medicine, all those. We have uh the CT scanner on standby waiting for you because usually EMS will let us know ahead of time that you're coming. So our metrics are door to as soon as you arrive into the door to the first slice of CT in five minutes. So as soon as we receive, get the information, weigh the patient, get a repeat blood pressure, we put them in the scanner, start the CT scan, and then we have another 15 to 20 minutes to make the TNK decision, which which is one of the medicines we'll talk about a little bit.

Dr. Michael Koren 21:12

Yeah. So every minute counts. So call 911 and gotta move fast. Okay, so here we go with recognizing the signs of stroke early.

Dr. Ravi Pande 21:20

So It's fast. You've heard of this probably FAST or BE FAST is uh you know a little bit longer version of that mnemonic that we use to educate patients or patients' families for symptoms of stroke. So B stands for balance. If you if you notice any family or friend having balance issues suddenly, they were normal one minute, they can't get out of bed, or they're leaning to the one side, that's that could be a symptom of stroke. E is for eyes, like I mentioned, if you're having double vision, loss of vision, visual field issues, that could be a sign of stroke. F stands for face if you ask them to smile and they Their smile is crooked, face is droopy. That's another sign. A is for arm, so the easiest one is to ask them to hold their arms up for a few seconds and see if it drops, if one of them is dropping. That's a sign of stroke. S is for speech, if they're having slurred speech, difficulty understanding you or instructions, or if they're having difficulty expressing themselves, that's another sign of stroke. And T just stands for time. Time is of the essence. Call 911, bring them to the hospital.

Dr. Michael Koren 22:30

Well, thank you. Super important. Additional warning signs of a stroke.

Dr. Ravi Pande 22:36

Yeah, some posterior circulation strokes are going to be a little bit unusual. They can present with confusion, disorientation, loss of consciousness, dizziness. Again, those are some other things like numbness.

Dr. Michael Koren 22:53

Is there still the same urgency when this occurs compared to the others?

Clot Busters Versus Thrombectomy

Dr. Ravi Pande 22:57

Yeah. Post-recirculation stroke is just the back part of your brain. So same, same urgency. We've got to work on your blood pressure, give you the blood thinners or TNK in a timely manner. So those also help the posterior circulation stroke as they help the anterior circulation. So yeah, same, same kind of urgency.

Dr. Michael Koren 23:15

Thank you. All right. So I think we've made this point, but let's make it one more time about how important it is to move fast and why we do that.

Dr. Ravi Pande 23:24

Yeah. So I don't know if you know there is a medicine we give to ischemic stroke patients, not the hemorrhagic ones, the 85% of the ischemic stroke patients, there's a medicine FDA approved since the 90s. It's called TNK or uh Alteplase. It used to be called an Alteplase. There's a new uh there's also another new FD-approved drug called TNK or Tenecteplase. It's not a new drug, but it's uh newly FD approved recently for usage. And these drugs can be given in to the patients within certain number of hours of the stroke onset. So from the onset of the stroke symptoms, do you know how quickly they can be given? How many hours? Three or four hours, yeah. So it's four and a half hours now. So up to four and a half hours. So that's why that's another reason why you want to bring them quickly to the hospital because we like to the sooner you get the medicine, the better. So it's it's not that we wait till four and a half hours to make the decision. If you give them in two hours, you have better outcome than if you give them in four and a half hours. So you want to give them as quickly as possible to get the most benefit. So yes, it's time is important. If you call them, our goals are 30 minutes. So from the door, we like to give the patient from the patient entering our doors, we like to give the medicine within 30 minutes. That's our that's our goal. American Heart Association has a goal of 60 minutes from we call that door to needle. And we we cut that goal to 30 because we want to give the patients this medicine as soon as possible. We don't want to wait till 60 minutes. And there's another, you know, treatment that I do, which is thrombectomy, which is where we go in with a little catheter into the brain and we aspirate the clot out or take the clot out with a stent retriever from the brain if you have a large vessel occlusion. So that we can do up to 24 hours. But again, the sooner we can do it, the better. Most of the patients who have an excellent outcome are usually within the first six hours, 12 hours of their stroke symptoms if they have a large vessel occlusion. So for that, our goal is door to puncture less than 60 minutes. So we get them in the in our biplane room and we stick the groin within 60 minutes. That's our goal. So yeah, faster the better.

Dr. Michael Koren 25:43

Yeah, let me suddenly ask you a very important question about those two ways of dealing with it. First of all, again, these are both ways of getting rid of the clot that's blocking the blood flow. So you want to make sure every make sure everybody understands that. The first is chemical, and the sort of nerdy term is tissue plasminogen activator. And plasminogen is the natural substance in our body that's busting clots all the time. So these are clot-busting drugs that reproduces what our bodies do to get rid of clots. So that's one way to go. But that's something that you give and it affects the whole body. So it only not only affects the little place in the neck that's all clotted up, but it can cause bleeding in your legs or in your kidneys or someplace else. Whereas what Dr. Pande does in the lab is go for the exact clot that's causing the problem. So he's dealing with it right on that spot level.

Dr. Ravi Pande 26:36

Right.

Dr. Michael Koren 26:36

So my question to you is how do you choose between the two?

Mobile Stroke Units And Faster Care

Dr. Ravi Pande 26:40

So TNK is offered to everybody. If they're eligible to receive this IV medicine, we give it through the IV very quickly. And then if we find and it's it's good for big clots, small clots, but it's not very effective for bigger clots. So let's say if you have a big middle cerebral artery block, that's a big blood vessel in the brain, or an internal carotid artery that's coming from your neck going into the brain, it's clothed somewhere here. The TNK is not going to be able to dissolve this big clot. So that's where we do a study called CT perfusion, or we just do another type of studies to figure out if you have that big clot. And if you have a big clot and you're eligible to go for the thrombectomy, you haven't, it's not been like 24 hours since last no normal, then we activate our team, we go into the lab and we remove that clot. And that procedure is fairly successful and has excellent outcomes. If you come in early, we have several patients that have absolutely no symptoms after the procedure.

Dr. Michael Koren 27:46

And Dr. Pande is an amazing expert on this procedure, and he's a huge resource to the community because he does this procedure. So I would guess also the other thing that influences you, not only the size of the clot, but also the bleeding risk.

Dr. Ravi Pande 27:58

Right.

Dr. Michael Koren 27:58

Would you comment on that?

Dr. Ravi Pande 28:00

Yeah. So the IV TPA or the Alteplase TNK, they can cause systemic bleeding, like Dr. Koren mentioned, they can cause bleeding in the brain as well. So that bleeding risk is about 6% overall. The the procedure that we do has slightly lower bleeding risk because we are just removing the clot. It depends on how far the clot is as well. So if you if the clot is too far deep in the brain, obviously there's gonna be slightly higher risk of bleeding. But yeah, they do have both of the procedures have some bleeding risk. I'm biased towards if you have a large vessel occlusion, I'm biased. Uh, and I think our it every center has different data on the bleeding. Our data is a lot better than most of the centers.

Dr. Michael Koren 28:48

You guys do a great job. Thank you. Thank you for that. Okay, so talking about mobile stroke units.

Prevention First: Diet And Habits

Dr. Ravi Pande 28:53

Yeah, so this is new to Jacksonville. This is through a grant from the city. UF has our first mobile stroke unit in the city now. And it's really working mainly in up north because there's a lot of underserved area up north and west of downtown. And what this is, is there's this is one with JFRD and UF combined, but they they take patients anywhere depending on where the patient wants to go and where they're located. But there is tele, there is a tele neurologist inside of the equipment inside of the machine. There is a CT scanner in there, there's a CT tech and a nurse that sits with this unit all the time. And they'll come to your doorstep when if you have a stroke, let's say in Callahan or one of those areas up north, and nobody's, you know, not extremely close to the comprehensive stroke centers. They will come to your doorstep, they take the patient into the scanner, they get a scan, they have the neurologist see them, they have the nurses work on the patient, and as soon as they determine that the patient's eligible for receiving the IV medicine, they give them medicine right into the in the machine, uh, in the unit.

Dr. Michael Koren 30:08

So they bring the hospital to the patient, basically, which is pretty cool.

Dr. Ravi Pande 30:11

It's very it's very effective for underserved areas for sure.

Dr. Michael Koren 30:16

So I think we covered this pretty well. So I'm gonna just go through this particular slide. Other than just reminding everybody, the sooner the treatment starts, the more brain tissue is saved. So I think we're covered well. But now I want to talk about something that's even more important than what you guys do in the ER, which is how to prevent strokes.

Dr. Ravi Pande 30:34

Right.

Dr. Michael Koren 30:35

So it's a stroke prevented is much better than a stroke treated. Would you agree with that?

Dr. Ravi Pande 30:39

Right. You know, I as I was mentioning earlier, about 800,000 people will have stroke in America this year. And if you look at the numbers, about 25% of the strokes were attributed to high cholesterol. That just means if we take care of cholesterol of our numbers for our population overall, about two you could avoid about 200,000 strokes next year. If everybody's cholesterol was perfect in America, let's say. You could avoid 200,000 out of the 800,000. So yes, stroke prevention is better than you know having to go into surgeries and take out the clots for sure.

Dr. Michael Koren 31:17

Yeah. And that's that's very powerful to me. It's a very, very powerful message, which means that if everybody got their cholesterol under control, it would be 4,000 fewer patients per state that would have this problem. And in a community like Jacksonville, you're talking about hundreds of people who would not have to go through a stroke treatment process and not have to deal with the disability for the rest of their lives related to a stroke. So this is a very, very powerful message. So let's talk about how you prevent strokes through, first of all, diet. Diet's of course very important.

Dr. Ravi Pande 31:53

Yeah. I think you were talking about that on your the podcast.

Dr. Michael Koren 31:58

AI, my AI competitor.

Dr. Ravi Pande 32:00

Right. So yeah, just heart and brain healthy food, you know, choose good fats, healthy fats like olive oil, avocado oil, and eating nuts and instead of relying on you know red meat for diet for your protein, you could eat chicken or turkey or fish. You could eat eggs and beans. Same thing with grains, you try to have incorporate brown rice or whole wheat bread in your diet instead of just uh white bread. And just uh increasing fruits and vegetables in your diet for sure.

Dr. Michael Koren 32:36

Yeah. It's interesting. There's a comment here. If fresh uh vegetables is too expensive, you know, the way I like to think about that is if you don't eat them, then they're expensive. So they're fresh, but it means you have to eat them relatively quickly after buying them.

Dr. Ravi Pande 32:54

Right.

Dr. Michael Koren 32:54

But uh I f you know this is where your MBA hat comes in, but I would think that it's still pretty cost-effective to eat fresh fruits and vegetables.

Dr. Ravi Pande 33:02

Yeah, that that's that definitely is true. You either pay for the good food and nutrition now, or you're gonna pay for a rehab and uh nursing home later. So.

Dr. Michael Koren 33:13

And what to avoid and limit? What what are your words wisdom there?

Cholesterol, Statins, And Myths

Dr. Ravi Pande 33:17

Just you know, sugary beverages, obviously, sodas and sweet teas. I know it's hard to quit these, but I quit myself coke. I used to have Coke Zero addiction pretty bad. As you can tell, a lot of people love sodas in America, but it's once you quit it, you actually see the difference. So avoid sugary drinks, desserts, cookies, candies, sugary cereals, limit salty pretzels and popcorns, processed meats, frozen packaged meals and uh canned soups, obviously. If you have to have some canned soups, choose the healthier, low salt versions, and just uh pick the better condiments, maybe with less salt.

Dr. Michael Koren 34:04

Yeah, I had an interesting interaction with a patient yesterday. A fellow was about 70 years old, struggled with weight loss and lost about 35 pounds in six months. Now, when he first started to lose weight, he was using a GLP 1, and I assumed that he was still using a GLP 1. But he told me, no, yeah, I've been off of that for about three months, and I continue to lose weight. And he said, What I learned from the GLP 1 is why I was having trouble in the past, which is I had this appetite for processed food. Right. And once I got myself conditioned to know what that was, and I lost my appetite for those foods because of the GLP 1, I didn't need the GLP1 anymore. I realized that, oh, well, these are the foods that are getting me in trouble. I understand that, and I avoided them, and I continue to lose weight just because I'm not eating processed foods. Right. So it's a really interesting interaction, and I think there's a lot a lot of wisdom there. I agree. Okay. So back to the audience questions. Which proven benefits occur with healthy eating? Is it A lower cholesterol and triglycerides? Is it B lower blood pressure? Is it C lower blood sugars? Is it D, lower risk of diabetes, heart disease, and stroke? E lower weight, or F all the above. Okay, you guys are smart and absolutely right. And again, the key word here, these are all proven. We have clinical trial studies that show that eating healthy in many different ways leads to these beneficial results. Okay, so a little bit of nerdy stuff. You want to tell us about the SPARCL study?

Dr. Ravi Pande 35:42

Yeah, so this was one of the breakthrough studies for for the stroke world when it came out in 2006. This is uh this treat uh they took patients who had the stroke or TIA and gave them high-dose cholesterol medicine called Atorvastatin, it's or Lipitor, you probably know about this drug, 80 milligram, and they followed these patients for years. And as you as you can see, the on the graph, the placebo group had on the Kaplan-Meyer curve, you can see the placebo group had more strokes, fatal and non-fatal strokes, as compared to the Atorvastatin. And this led to changes in the our guidelines to recommend all the stroke patients high dose of Atorvastatin, which is 80 milligram Atorvastatin, and kind of do and we don't necessarily just use that drug and that dosage. We kind of tailor to each patient and their age and their risk profile. But we started taking this very seriously around that time, and all the stroke patients, their guy, our metrics we started counting was to add statin at the discharge from the hospital.

Blood Pressure Targets And Follow‑Up

Dr. Michael Koren 36:51

Yeah. And a Atorvastatin is Lipitor, for those of you that know it by its trade name. And these were breakthrough studies to show that cholesterol lowering indeed works, and statins improve neurological outcomes. And one of the things that I see in my cardiology practice all the time is people say, oh, don't statins cause dementia, or don't statins cause you to lose your memory. No, it's the opposite, is that statins lead to less brain cell loss, and people tend to do better. In fact, the reason some people think that statins cause dementia is because statins keep them alive so that they're old enough to lose their memory.

Dr. Ravi Pande 37:29

So yeah, so this study, there was about 16% absolute risk reduction. And Dr. Koren's right, a lot of patients will have, I think there's a lot of online misinformation about statins causing dementia. But there have been several studies on this. The overall number of patients who have memory loss or reported memory loss on statins is extremely low, 0.2%. But if you notice, the placebo arm also has the exact same number. So there's no causation that between statins and the memory loss. At least there's no data that has proven and it this has been studied repeatedly for the last 30 years. And in fact, what Dr. Koren was saying, that there's a recent study that came out that shows that patients who were on statin actually had less memory loss in long-term after stroke. That's because it reduced the incidence of post-stroke or like vascular dementia being on statin. So there is absolutely truth to that. There is a slight increase risk of hemorrhagic strokes in the statin population, but again, it's not significant and completely outweighs the benefit you get from it.

Dr. Michael Koren 38:45

Yeah, absolutely. And this is another study showing that getting that bad cholesterol as low as possible makes a difference in terms of avoiding stroke.

Dr. Ravi Pande 38:53

Yeah, this study was a little bit more recent one. And this instead of targeting or picking a drug, they targeted the lower number for of LDLs. So they let the doctors choose between statin or statin and Ezetimibe. Ezetimibe is a another drug that reduces, especially in combination with statin, will reduce your LDL levels. And this study again proved the same thing. LDL less than 70 is safe, feasible against the same minor side effects, but outweighs the benefit outweighs the risks. And you can see the lower LDL target, which is the red line, uh, versus the higher target group, had significant difference in the outcomes and a similar risk reduction in future strokes.

Dr. Michael Koren 39:43

You could see Dr. Amarenco was the first author on both of those papers, and he's been doing this for over 30 years. In fact, a little trivia is I told you that anecdote about the woman I took to the New York Knicks game, I actually referenced Dr. Amarenco to her during the

Dr. Ravi Pande 40:00

I thought she was Dr. Amarenco.

Dr. Michael Koren 40:01

And that was in 1990.

Dr. Ravi Pande 40:03

Oh, okay.

Guidelines And Ongoing Monitoring

Dr. Michael Koren 40:03

So he's been doing this for a while. Oh, and then here's the SPRINT study. It's a hypertension study, so I'll just mention it is that aggressive lowering of blood pressure in this NIH-sponsored study led to fewer strokes. And so not all doctors are aware of this. Is it in this particular study, they looked at using a target of 120 over 80 as a more aggressive target for blood pressure lowering versus a higher target of, say, 140 over 90. And getting the blood pressure down to this lower target made a difference.

Dr. Ravi Pande 40:36

It's very interesting. You say that some of the doctors are not, you know, they're not aware of some of these data. You have to be careful because recently I was uh reviewing the data on the stroke patients receiving statins. And repeatedly from mass cohorts of patients, they have found out that post-stroke, only about 60 to 65 percent of patients are on statins or any cholesterol management or any have received any cholesterol uh medication or education about cholesterol from their doctors. So that's yeah, you have to advocate for yourself. If you've had a stroke, you know, not just go to the hospital, but after the hospitalization, talk to your primary doctor about managing your blood pressure, you know, managing your cholesterol, making sure your cholesterol levels are low.

Dr. Michael Koren 41:28

Yeah, and if you have somebody that you know that's in that situation, let us know. And in the research world, we help people with this all the time. So we actually take patients who are being undertreated on their cholesterol and their blood pressure and getting them into a good program. Some of those people end up participating in the clinical trials, but not necessarily. But we will for sure give you information that's very, very important for management. In many cases, people come into the clinical trial center wanting to be in a trial, and we say, well, you know, you would be great for the trial, but have you just tried a statin first? And and we're happy to do that. But that's the nice thing about the clinical trial center is we give information that's geared and relevant to each of the patients that we see. All right. And lipid management for stroke prevention, obviously not going to read through all this, other than saying that these are major guidelines that supposedly help guide all physicians on what to tell their patients.

Clinical Research And How To Join

Dr. Ravi Pande 42:20

Yeah, these these these just came out literally less than a month ago. Again, the the category one level A evidence is the highest level of medical evidence based on multiple studies, randomized control, double-blind studies, and recommend the same thing. If you've had stroke or TIA, making sure your cholesterol is checked and treated in the hospital, not just because it's helping with the plaque, but also it reduces inflammation in the blood vessels in the brain and leads to faster recovery for these patients. And then there's also evidence to monitor cholesterol, not just get it treated in the hospital when you get discharged beyond statin, but monitor every six months or three months for some patients.

Dr. Michael Koren 43:08

And this is also a segue to the work we do in clinical research. Both Dr. Pande and I are very active in clinical research, as as I think you know. And people love the process of clinical research. My favorite statistic to quote is when people have not been exposed to the research environment, they're a little skeptical. Only 40% of patients say they would be interested in research study. But once somebody has been exposed to research study, and you ask them, Would you do it again? 97 to 99% of people say yes. So think about that. What other product can you think of where there's a lot of skepticism before you actually experience it, and then you experience it for the first time and all of a sudden you're sold for life. So we like to let people know that there are programs out there, they're all free of charge. We never charge our communities a cent for anything. And in some cases, you actually Get compensated for the for helping us. And by doing this, you help us find new cures for both you and for your family members. You get this incredible attention. You get assigned to a coordinator who looks at all the details of your history and gets information to and from you. You get additional monitoring, and you're actually a hero because your information is used to create guidelines that Dr. Pande just showed you for the rest of the world. So we appreciate the work that you do when you volunteer. So hopefully, if you haven't done it yet, you'll check it out because I think you'll enjoy the experience.

Closing And Where To Learn More

Announcer 44:34

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