795-thousand people in the United States will experience a stroke this year. Not all the victims are part of the Social Security set. Researchers have noticed a startling increase in the rate of strokes among younger people in their mid-thirties through mid-forties. Strokes can affect people of all ages, even teenagers and kids.
Host Jonathan Fialkow. M.D. and his guest, neurologist Felipe De Los Rios, M.D., medical director of the stroke program at Miami Neuroscience Center, explore this troubling trend, talk about symptoms and risk factors, and look into whether there is any connection to the novel Coronavirus, on this episode of Baptist HealthTalk.
795-thousand people in the United States will experience a stroke this year. Not all the victims are part of the Social Security set. Researchers have noticed a startling increase in the rate of strokes among younger people in their mid-thirties through mid-forties. Strokes can affect people of all ages, even teenagers and kids.
Host Jonathan Fialkow. M.D. and his guest, neurologist Felipe De Los Rios, M.D., medical director of the stroke program at Miami Neuroscience Center, explore this troubling trend, talk about symptoms and risk factors, and look into whether there is any connection to the novel Coronavirus, on this episode of Baptist HealthTalk.
Announcer:
At Baptist Health South Florida, it's our mission to care for you when you're injured or sick and help you stay healthy and fit. Welcome to the Baptist HealthTalk podcast, where our respected experts bring you timely, practical health and wellness information to improve your family's quality of life. 795,000: that's how many people will experience a stroke this year in the US, and it's not just people over 60. Young people and strokes on this episode of Baptist HealthTalk.
Dr. Jonathan Fialkow:
Welcome back, Baptist HealthTalk podcast listeners. I'm your host, Dr. Jonathan Fialkow. I'm a practicing preventive cardiologist and lipidologist at the Miami Cardiac & Vascular Institute in Baptist Health South Florida, as well as chief population health officer at Baptist Health. One of the goals of this podcast is to bring on experts to answer the kinds of health questions my colleagues and I are asked on a daily basis.
Dr. Jonathan Fialkow:
Today, we're going to talk about strokes. If you're someone who thinks that strokes are only a problem for old people, well please listen up. I'll bet you didn't know that the rates of strokes in people 55 and older has actually decreased in recent decades while, at the same time, researchers have found a startling increase in strokes in younger people. I'm talking about people in their mid-30s and mid-40s. What's going on here? Why is it especially worrisome during this coronavirus pandemic?
Dr. Jonathan Fialkow:
Since May is National Stroke Awareness Month, I thought it'd be a perfect time to invite my colleague, Dr. Felipe De Los Rios to the podcast to talk about some troubling trends when it comes to strokes and to let us all know the signs to look out for. Dr. De Los Rios is a neurologist and the medical director of the Stroke Program at the Miami Neuroscience Institute, a part of Baptist Health South Florida. With great pleasure, welcome to the podcast, Felipe.
Dr. Felipe De Los Rios:
Thank you very much, Jonathan. Glad to be here.
Dr. Jonathan Fialkow:
So a lot to unpack there as usual with these podcasts, but let's start with the basics. In layman's terms, what's happening to the brain when someone has a stroke? We use the term quite frequently, but maybe people can really benefit from understanding what is a stroke and what's happening when people are suffering from a stroke.
Dr. Felipe De Los Rios:
Sure. So the brain uses blood to function and get its energy and specific areas of the brain have specific functions. So whenever there's a problem with blood supply, say an artery gets blocked or clogged, then an area of the brain doesn't receive enough energy to function and it starts to not work. And then you can see the effects of that on the person, so for example, not being able to move an arm or speak. If that lack of energy is sustained for too long, then there's permanent damage, and then the person can have disability from that event. We call that a stroke.
Dr. Jonathan Fialkow:
So you mentioned if that lack of blood flow happens too long. Can you speak a little bit before we start talking about the population in general, a lot of the activities that have been done with your leadership and others at Baptist Health towards that time is brain concept, which is when someone's having a stroke to get taken care of as quickly as possible because ...
Dr. Felipe De Los Rios:
Yes. So time is brain, like you said it. Brain survives generally in the range of minutes. If there's absolutely no blood flow at all, so it's completely blocked, the brain doesn't survive too long, maybe an hour or so. Thankfully, many times there is some amount of blood going through, maybe through some side channels and then the brain can survive longer. In some instances, people can have benefit up to 24 hours after a stroke, but that's not the majority of people. So the sooner that we're able to open that blood flow to that area of the brain, the better the outcome and the less disability or problems the person's going to have from the event.
Dr. Jonathan Fialkow:
So if someone is at home and they recognize something, signs which we'll talk about, or a family member recognizes it because sometimes the patient may not see it, you want them to call fire rescue. You want them to get taken care of as quickly as possible specifically to preserve the brain and avoid a worsening disability, right?
Dr. Felipe De Los Rios:
Yeah. The key part of all of this is really the person or most often the family members, the relatives or friends that are with them, recognizing that it is actually a stroke. That's the first, most important piece. Many times people get delayed coming to the hospital because they felt they were having nothing serious, just maybe slept on their arm or something. And then they wait and that's very valuable time and brain that is lost. So that is absolutely the key part. And then once a stroke is recognized, then calling 911 is the way to go because they know which hospitals are able to care for stroke patients. Not every hospital, not every emergency room can care for stroke patients. So going to the right hospital at the first go, through 911 really saves time.
Dr. Jonathan Fialkow:
So that 911 call becomes paramount importance. What would be some of the more common symptoms of a stroke or signs of a stroke? What are the kind of things that you would recommend that someone should then call 911 if they're experiencing?
Dr. Felipe De Los Rios:
The key hallmark of stroke is sudden onset of loss of something. So for example, the person was perfectly fine, doing great, and then the next minute they can't feel an arm or a leg or they don't have strength on one side of their body or they are not able to see or speak. So that is the sudden onset of things is really what's a key hallmark of stroke. We use the acronym FAST from the American Heart Association and it's the F is for face, so face weakness on one side. The A is for arm weakness on one side. The S is for speech changes, so either the speech is garbled or the person can't articulate, pronounce the words. They don't sound their usual. And then T is for time, time to call 911. You only need one of them. So you don't have to have face, arm, and speech. You just need one of them to really start thinking stroke.
Dr. Jonathan Fialkow:
I'm going to ask a kind of side question and, again, comes from experience. Maybe you can explain the question. How can someone differentiate between a parasthesia and a stroke, a sudden tingling in an arm or something that's positional versus when it might be a stroke?
Dr. Felipe De Los Rios:
That can be sometimes tricky. I think the key part, really parasthesia when you think about it is a positive symptom, meaning you have tingling. You have a sensation that shouldn't be there. So it's a new thing. Usually when stroke, what we have is loss of, so people then feel it's numb. Many will say like if they had anesthetic or when they go to the dentist and they don't feel their lip, it's that similar feeling but on an entire arm, for example, or an arm and leg. It can get tricky.
Dr. Felipe De Los Rios:
I mean we've known cases of physicians, neurologists, that have a stroke, and then the stroke itself prevents them from understanding that what they're experiencing is, in fact, a stroke. So you really rely on your inner circle, the people that you're with to know how to recognize one and call 911. So it's good for us to teach those around us how to recognize a stroke.
Dr. Jonathan Fialkow:
Appreciate that because we do see that in the clinical practice is a lot of times people have that tingling from the arm being up when they're sleeping or something and they are obviously concerned about a stroke, which you still should get checked out if you are concerned.
Dr. Felipe De Los Rios:
Absolutely. Absolutely.
Dr. Jonathan Fialkow:
Now let's talk a little bit about the trends and then related to some things we're reading about in the papers. As we mentioned in the intro, prior to COVID we started seeing increasing strokes in young patients. Is that something you've been seeing in your role at Baptist Health?
Dr. Felipe De Los Rios:
Yes. This is definitely a national problem, a world problem. But you might be surprised. About 10% of all strokes happen in people age 18 to 50 years. So it's not really that uncommon. What we've been seeing is that it has been increasing over time. So just to put an example, from the nationwide inpatient sample, if you look at 1995 to 2012, the rate of hospitalizations for stroke among males 18 to 34 has almost doubled, has essentially doubled. Within 35 to 44 years of age, there's been a 41.5% increase. So I mean that I think speaks volumes to what we're seeing in the hospital.
Dr. Jonathan Fialkow:
I'm going to ask you in a second why we think that might be the case. But before we get to that, can you articulate a little bit about the different kinds of strokes, specifically atherosclerotic disease, embolic strokes and how that might be also related to some of these age-related phenomena?
Dr. Felipe De Los Rios:
That's a great question because when we're talking about stroke, I'm thinking just spontaneously I tend to focus on the most common one, which is ischemic stroke. Ischemic strokes, where there's a lack of blood flow to an area of the brain, is the bulk of them. So it's about 85, 80, 85% of all strokes. And then the other 15% or so are hemorrhages. It's not that there's a lack of blood flow, but actually there's too much, meaning an artery ruptured and then you have blood where there shouldn't be, kind of like a flood. The brain is flooded with blood where there shouldn't be and that causes damage as well.
Dr. Felipe De Los Rios:
So these trends and what we're speaking mostly about now is ischemic type where there's a lack of blood flow. That is mostly what has been increasing in young adults, too. It's the ischemic type, not so much the hemorrhagic type. And then what causes the artery to be blocked, so not enough blood flow can go through, there's different things. One of them, the most common form is when there's just longstanding damage to the arteries on the whole body, the heart, the brain, elsewhere from just what we call traditional risk factors. High blood pressure is the most common one, diabetes, high cholesterol, tobacco, just damages to those smaller arteries. And then there's others. For example, if you have heart disease such as atrial fibrillation or some valvular disease, then you can get strokes from heart conditions as well.
Dr. Jonathan Fialkow:
So going to the different kinds of strokes, and we mentioned now that trend in younger people for more strokes, is it the ischemic strokes is what we're seeing as a higher rate in younger people?
Dr. Felipe De Los Rios:
Right, yes. It's mostly ischemic strokes.
Dr. Jonathan Fialkow:
And can we define why that's happening? What do you or what do researchers think?
Dr. Felipe De Los Rios:
We don't know exactly all the reasons behind it. Like many things in medicine, it might be multifactorial with multiple things acting at the same time. One thing that is notable, when you look, for example, this was a study that looked at the probability of having three to five of these common risk factors for stroke and heart disease that we can see in older adults, high blood pressure, diabetes, high cholesterol, those sort of things. And the prevalence, so the amount of people with more than three risk factors among males, so we're talking about males from 2003 to 2011 and '12. It increased from 9% to 16% among 18 to 34-year-old males.
Dr. Felipe De Los Rios:
And then if you go to a higher age group, for example, 35 to 44-year-old males, that increased the prevalence of having three or more of those factors from 19 to 35% during that time period. The same thing we see for females. So what we're seeing really is these risk factors happening at earlier life, and that could be related to diet, lack of exercise, obesity, tobacco, all these other exposures that we may have. But I think that probably explains most of it. And then you have other things like, for example, recreational illicit drugs, some for which we can have tests, some for which we can't test very well. So all of that, I think, plays a factor.
Dr. Jonathan Fialkow:
So we don't want to instill fear in our listeners, but we want to give them information which gives them power. We do want to recognize that strokes are not just a disease of the elderly. So if you're having symptoms or signs, take it seriously, call 911. But going to the points you just well-stated, the risk factors for other chronic diseases, cardiac disease, which includes obesity, lack of exercise, smoking, poor diet are equal in terms of their risks for strokes.
Dr. Felipe De Los Rios:
Yeah. There's some things that you wouldn't know that you have unless you go to a doctor for your regular checkup, especially young adults. I'm going to add myself into that category and think that we're kind of invincible and that nothing's wrong with you and you can do it all.
Dr. Jonathan Fialkow:
Just give it a few years.
Dr. Felipe De Los Rios:
Yes, exactly. And then you don't go. You don't get your cholesterol checked. You don't get your glucose checked. You don't get your blood pressure checked. These things can just creep on you without noticing and they do damage over years. So the only way that you're going to really know is if you go for your regular checkup.
Dr. Jonathan Fialkow:
So speaking to my bailiwick, prevention prevention prevention. Don't wait for things. Identify your risk and prevent the bad outcomes. That's well said. Now, let's bring it into some of the stuff in the news. COVID-19 certainly does not leave the neurological system alone. What have you been seeing on two accounts based on your experiences? One is, have you seen Baptist similar to what's been reported around the country of decreasing patients coming in through the emergency room with strokes? And if so, why do you think that's the case? And secondly, what are you seeing or what's being reported in COVID-19-related factors towards the strokes we're seeing?
Dr. Felipe De Los Rios:
Right. So the first thing and the most important thing, I think is what you mentioned first as well, which is what we're seeing is people are afraid of getting COVID or exposing themselves to COVID and they're not coming to the hospital for things that they should come to the hospital. That is affecting a much larger population than what COVID is as it pertains to stroke. So the people that normally would get stroke in the community during this time period are having their stroke or their TIA, so transient symptoms of a stroke, and they're not coming to the hospital to get the evaluation that they should because of fear. So our volumes in the hospital have decreased about 30% compared to earlier in the year and about 40% compared to the same month last year. That has been seen across the nation.
Dr. Jonathan Fialkow:
You actually just brought something up I want to follow up on for a second. You mentioned transient symptoms. So we tend to think of stroke as, as you said, the lack of sensation, the lack of strength, the speech difficulty. What if someone has, for example, a half an hour where they can't move their arm, but it gets better or difficulty speech, but it improves within an hour. Obviously, we don't want them to wait the hour, but is that someone who should also be taking their symptoms seriously?
Dr. Felipe De Los Rios:
Absolutely. That person is being lucky that they're getting a warning sign that the artery is not healthy and, for whatever reason, blood flow is not getting to that area of the brain for a small period of time. There's some interventions that we have in the hospital that can help prevent the stroke from happening altogether and then having that disability. So it's much better, obviously, if you can prevent any damage from happening rather than treating it acutely. We do have treatments to try to reverse damage if we do it fast. That's another reason why go to the hospital right away. But if you can prevent it altogether, obviously that's the way to go.
Dr. Jonathan Fialkow:
Great. Now, regarding COVID-19, reports of young people having strokes. First, is it true? If true, what do we think the reasons are beyond what we were seeing prior to COVID-19? Are there COVID-19-related things we're seeing in younger people, again, below the age of 50, let's say, related to strokes?
Dr. Felipe De Los Rios:
Yeah. So thankfully, stroke is not a common manifestation of COVID. Most patients with COVID will not experience a stroke or TIA. We have seen that about maybe 3% or so, maybe upwards of 5% of patients that are severely sick with COVID in the ICU have had evidence of a stroke. But outside of that, and especially if they are healthier, the risk of having a stroke is likely very, very low. Now, infections in general, and this is not just restricted to COVID, but infections in general increase the risk of stroke. But they do so to a mild degree, let's put it that way. So we're not surprised that there are some hospitals that are reporting some cases of stroke and COVID potentially related to each other and more so in young adults. Because we know that infections, especially in young adults, tend to increase the risk of stroke to a mild degree.
Dr. Jonathan Fialkow:
Interesting. I appreciate that. I think that's also worthwhile for the listeners. In other podcasts we've talked about paying attention to reliable news sources and not social media. So while the news may promote young people with strokes and it does happen, it may not be something to be at the forefront of their concerns in terms of their particular risks.
Dr. Felipe De Los Rios:
Absolutely. Yes. I do think that we should all be able to recognize a stroke, just like we're well-versed in recognizing heart attack. I think maybe more education is needed towards that end. But it's not something that people should be fearing in general like, "I'm going to get COVID and then I'm definitely going to have a stroke," or something along those lines.
Dr. Jonathan Fialkow:
Right. What can someone expect if someone feels they're having stroke-related symptoms and they call fire rescue? What makes the stroke program that you help lead unique? What experiences can they expect to help them minimize the impact of the stroke?
Dr. Felipe De Los Rios:
Right. So I think we're especially blessed in our community here in Miami and the same may not hold true to all of the communities. But we're very blessed in that we have quite a few stroke resources in the community, and we work very closely with 911 and EMS. So if someone is having a stroke and they call 911, 911 will perform some quick stroke scales when they go to the house. And then they're going to determine what level of service that person needs, whether it's a comprehensive stroke center like ours that can handle all types of strokes from the most simple to the most complicated ones, or a more mild severity where you just need the closest center that can give, for example, a medication called alteplase TPA to destroy the clot.
Dr. Felipe De Los Rios:
They will take you to the closest center that has that level of solution of care that they can provide. If they come to our center, to Baptist Hospital of Miami Comprehensive Stroke Center, we have a very well-oiled machine. Just to put it into perspective, the goal in general is to give this medication, the alteplase, when it's needed within 60 minutes of the person arriving to the emergency room. We generally give it in about 20 minutes. We do that consistently on hours, off hours, weekdays, weekends, Christmas, New Years. We just have this pat down. Time is brain. So we're very proud of that.
Dr. Felipe De Los Rios:
If someone needs the vascular surgery, for example, to remove a larger clot that just can't be destroyed by the medication alone, we're able to provide that also 24/7, any day of the week. So I think that goes down to your question, it's just reliable, 24/7 comprehensive care.
Dr. Jonathan Fialkow:
Comprehensive team-based approach, which I think is what makes it unique. Well, again, you've answered a lot of questions that I had and others have had, and you did it very eloquently, which I appreciate. Strokes do occur in young people. We're seeing more, maybe related to a worsening lifestyle and a higher risk population. We do know call 911 when you have those symptoms, face, arms, speech, time. I like that. Don't call your doctor and say, "I think I'm having a stroke." Don't go on the internet and say, "I think I having a stroke." Call 911. Loss of something I think is a great take home point. Anything that we missed, anything you'd like to add before we wrap up? I think you hit all the high points.
Dr. Felipe De Los Rios:
I think I would just add just so for people to understand the magnitude of effects. We worry about COVID and its effects, rightly so, but you have to take into account that the risk of mortality, of death associated with COVID is actually quite low in general. It might be upwards to maybe 2, 3%, probably a little less when you take into account everyone who is infected that doesn't come to the hospital. It can be higher as we age. Maybe it can be up to 8, 10%, maybe a little bit higher, 12, 14% if you are on the older, more frail group. But stroke is just devastating, stroke and TIA.
Dr. Felipe De Los Rios:
So for young adults, almost 40, 45% of those that have their stroke are disabled a couple of years after their stroke and they can't do things independently. For older adults that have a stroke, the mortality can be quite high as well, 25, 30%, upwards to a year or two after the stroke. So when you put things in balance, I know it's a concern to have COVID, but for things like stroke and heart attack, you just have to go to the emergency room. You just cannot stay home.
Dr. Jonathan Fialkow:
Again, I thank you for that point. We're doing a lot of communications to let people know that they should feel safe and they'll see the safety of visiting the emergency rooms and the medical practices based on the preparations and the distancing and various other things that have been put in place. So that should not prohibit you from getting taken care of. A fear of COVID exposure should not prohibit you from getting taken care of if you need medical care.
Dr. Jonathan Fialkow:
Again, Dr. De Los Rios, I appreciate your expertise, your passion. You've really elevated our game in the Baptist system, which I and our listeners appreciate. To our listeners, as usual, if you have any thoughts or ideas or topics or suggestions, please write to us at baptisthealthtalk@baptisthealth.net. Thank you, Do Los Rios. And to all of you, stay safe and as best as possible, stay home.
Announcer:
Find additional valuable health and wellness information on our resource blog at baptisthealth.net/ news, and be sure to interact with us on our social media channels for live and upcoming events. This podcast is brought to you by Baptist Health South Florida, healthcare that cares.