heart attack warning signs

>> on "health matters television for life..." stroke is the fourth leading cause of death in the u.s. yet it can be prevented.

heart attack warning signs, learn how to reduce your risk. plus... we'll take you inside the tele-stroke network. see how this high-tech approach

is connecting small towns to stroke care like never before. saving time. >> our goal is less than an hour. >> and lives. it's information everyone needs to know. >> "health matters" is made

possible by viewers like you, the friends of ksps. and by providence healthcare. >> my name is beth perez and i am a registered nurse and i work at holy family hospital on the labor and delivery unit. i'm about to have my second child, and i chose providence

because i love and trust the people that i work with, and why wouldn't i seek care from the people i love and trust. >> i'm dr. andrew boulet and my wife had a cardiac arrest. i chose providence because i knew that everything for her

complex care was available from the emergency room, to radiology, to the nursing staff, to the specialists we need for her care. >> good evening. i'm your host, teresa lukens, and welcome to another season of "health matters."

more than 140,000 people die each year from stroke in the united states. yet 80% of strokes are preventable. tonight, learn the signs and what to do if stroke strikes. first, let's meet our panel. dr. cynthia murphy is a

neurohospitalist with providence healthcare. she is based out of sacred heart where she is the stroke director. dr. jon ween is a neurologist with rockwood neurology center. christopher zylak is the director of interventional

radiology and as well as the director of neurointerventional radiology at inland imaging ps, dr. patrice stevenson is a physiatrist with st. luke's rehabilitation institute. i want to thank all of you for being here. tonight we do welcome your phone

calls and emails. it's an excellent opportunity to take advantage of our expert panel. also tonight we are live on facebook as well. dr. ween, let's start with the very basics when it comes to stroke.

what is a stroke? >> two kinds of strokes, teresa. one is a lack of blood flow to a particular part of the brain. that's called and ischemic stroke, usually from a blood clot or plughtd artery. the second kind of stroke is too much blood to a particular part

of the brain, a hemorrhage, usually from a he can laing artery, usually caused by hypertension or other conditions. there is a third kind of stroke which is a temporary stroke or transient event, a tia. that's an ischemic stroke that

gets better quick but it is a warning sign something is going on and that attention needs to be paid to what your risk factors are and particular causes you can treat and prevent a real stroke. >> are any of those more common than the other?

>> the most common cause of stroke is a blood clot plugging up an artery causing a large ischemic stroke. that's the most common event that you have. the small strokes from tiny little arteries being plugged in the brain are probably pretty

common as well but they tend to be silent, actually. and so they're detected more coincidentally when you come in for other reasons. >> dr. murphy, what is it that with a he talk a lot about heart conditions and stroke in the same breath?

how are they connected? >> well, i think the mechanism of disease is similar. i think cardiology is a field -- as a field has been very forward in terms of prevention and we've learned a lot from cardiology from a neurovascular sense, you know, looking at what a heart

attack is, versus what a stroke is, how to prevent, how to manage, have all kind of been hand in hand. i think we've learned a lot from cards. >> so there is that connection basically on the preventative side.

>> absolutely. cardiovascular disease is one of the five risk factors for stroke, high blood pressure, diabetes, high cholesterol, smoking and heart disease. so a lot of our medications are tailored for both type of disease processes.

>> dr. zylak talk about your role as an interventional radiologist and what that means when talking about strokes. >> i love my job, first of all. it's a very exciting part of my life, and it's -- the great thing for me is that all of this work that's grass roots,

tele-stroke, prevention, all these things you're talking about basically create a funnel to get the patient to me when they're having an acute stroke. my job in those situations is to open up a plugged artery to prevent the patient from having a major stroke.

>> quite often that happens very quickly because when they're in your office or at your facility at inland imaging you're seeing what's going on. >> all of these patients come in through the emergency room at sacred heart hospital or through this tele-stroke network that

you're going to learn more about and we'll talk more about today, and so all of these patients are seen and cared for by emergency personnel to start, and end up at the emergency room at sacred heart and then directly from there after iminling and evaluation by cynthia and her

team for their clinical aspects to see that they actually -- are actually having a stroke because there are many other conditions that can seem like they're a stroke or not a stroke, and that's really kind of the confusing part of getting patients in quickly.

because often the patient themself isn't able to indicate they're having a stroke because the stroke is keeping them from being able to stroke or being able to move. these are kinds of things when i say we're talking about the cardiology field why the

cardiologists are ahead of us. when the heart has blood stopping it hurts and patients have excruciating chest pain. but when they're having a stroke a lot of times, unfortunately, patients don't come in and we'll ask them why didn't you come in. they'll say i thought i just

slept on my shoulder funny or if i went back to bed i would feel better, or i didn't feel well, gnaws yaid. but the brain isn't actually hurting when you have a stroke. if it did we would be able to treat a lot more patients quickly.

>> that's why patients are so hesitant to go to the emergency room. they don't realize it's happening. >> i think a big part is education and patients understanding not only what the warning signs are and what those

things can be and how then to -- why it's so important to then seek immediate care for these kinds of conditions when they come up we can really do some amazing things if we're given the opportunity to do so. >> dr. stevenson, i want to bring you in on the conversation

here. you actually see stroke patients after the fact at st. luke. >> right. so when prevention didn't work or immediate care didn't work to stop the stroke we see them there in order to take care of the residual deficits from

>> talk a little about that process. >> well, they usually will come to a place like st. luke's maybe in the first week after a stroke or longer if they had complications, and i always tell patients first there are different strokes for different

folks, which most people can relate to that phrase, but they have in their mind maybe what they've seen of somebody having a stroke before and if that doesn't fit with what their body is doing it's hard for them to relate to all that. so we really are looking at

their medical background and what type of stroke they had, where in the brain it was, which can predict what types of problems we're going to see. >> this comes in as sort of a team approach because you need a lot of people looking at different things when it comes

to post-stroke care? so we have the physiatrist or physician and we're managing their pled cull aspect and secondary stroke prevention and then we have rehabilitation nurses, physical therapists, occupational therapists, speech therapists, recreation

therapists, our rehab psychologist, social workers, case managers, and the whole -- just a bunch of other folks trying to work to get them better and out back to their life. >> let's talk about the signs and symptoms because they can be

all over the board. dr. zylak talked about a few of them. it's difficult because again folks, as dr. stevenson said, so what are we watching for? what do we need to be keenly in tune with? >> i think the most important

thing to realize number one is it affects a particular part of the brain and so you see deficits or lack of function in a particular part of the body. we like to use the fast algorithm, f.a.s.t. if you have -- is your face droopy?

if your speech is slurred. if your arm is weak. if you're staggering. things that are sudden and they're affecting one part of the body and not the other, you ever to call 911 right away. like chris was saying, strokes aren't painful, usually.

heart attacks are. in addition to that, strokes mess with your mind, literally. so you're not aware of your deficits. sometimes you can't communicate your deficits. sometimes you don't think there is anything going on at all and

you'll resist going to the hospital. and so it's really important not just the patient, you don't know you're going to be a patient until you are one, but that families also understand this and if they have risk factors like high blood pressure,

diabetes and the heart disease and the smoking and so forth, that the families are clued into this so they say, no, you're going to the hospital and now. i'm calling 911. it's really critical to understand the importance of 911 because you get seen quicker if

you come in on the gurney than if you walk in or if your family wheels you in in a wheelchair. that's just human nature that if you come in a gurney with sirens and lights, mpg is more acute. so don't drive in. don't call your doctor. don't call your family member.

call 911. and come in in an ambulance right away. >> people don't want to be alarmists, though. >> burr better to be an alarmist than have a stroke. so you're better safe than sorry.

>> so let's talk about some of the causes, what we can't control, what we can control, dr. murphy. >> there's modifiable risk factors. just like i mentioned, heart disease, diabetes, hypertension, smoking are all the big five

risk factors. as we get older, age becomes a risk factor that is nonmodifiable. we can't do much about it. atrial fibrillation becomes a risk factor. sleep apnea in terms of stroke risk reduction.

part of the -- part of the process of when a patient -- jon or myself is, you know, it's the acute management of stroke, identifying the cause of it, and prevention and recovery all in the same package. and it's sort of a multi-faceted type team approach that it

happens at the hospital as soon as they hit the trauma room. does the patient have cholesterol? do they need to be put on a statin? i know a lot of people don't like statives but it's shown good risk reduction of stroke.

do they need aspirin or anti-platelet therapy which helps also lowering risk so we're sort of doing that as part of the process of the admission on that first initial intake. >> because things have to move fast.

>> acuity is the big thing. no one wants to be an alarmist, but you don't want to miss it, either. so -- and jon and i will be -- i think we're the first ones on the scene, the first ones in the trauma room, we're looking for weakness on one side or the

other, numbness, tingling, looking for any focal neurologic deficits, taking a cat scan, looking at a ct angio, looking for clots and i'm on the phone with dr. zylak, we need you here and we are trying to see -- there is two options of treatment, tpa, tissue

plasminogen activator, a clot busting med we give to stroke patients, within a three to four-hour window. so we are treating as fast as we can to get that medication in. we want to then move on to interventional. so all this is happening while

the patient is coming into the cat scanner. the interventionallist is looking at the imaging. it's an exciting process, but it's something that's changed. so it's brought so much recovery to stroke. it's just been an exciting

time -- i love -- i'm the same way. i love when it works works. you are trying to get everything done. the real work will begin with dr. stevenson down in st. luke's. recovery starts as soon as we

hit the door but really upon discharge is when the real work begins. >> and some of the treatments are surgical as well. we talked about the clot busting drugs but there are procedures that can be done surgically. >> so the fda approved therapy

was initially and still is and remains first-line therapy is i.v. medication to try to dissolve the blood clot. that works well with small blood clots and didn't work well at all for large blood clots. so every single patient i treat has a large blood clot that

didn't get dissolved by the drug. now, sometimes that does happen and i always laugh when some of my colleagues that i work with that do the scrubbing and getting the patient ready and equipment, one time my friend came in and said i think they

brought the wrong patient into the room. you told me this patient was paralyze ant couldn't talk. this patient is sitting up asking why we're doing this. sure enough the clot busting medication solved that problem. i didn't have to do anything.

but the reality is that those drugs don't work well in large vessel clots and so that's when i get involved in the case. those patients, i go in through the femoral artery with a small tube called a catheter, which is i direct up into the affected blood vessel, try to get through

the blockage safely, once i'm through the blockage, i deploy a device that looks like a stent, has mesh work to it, there's a couple companies that make those devices, and one -- and there's also a device i use that's like a vacuum cleaner and i tell people if you ever seen a

crocodile jump out of the water and grab on to the one of the wildebeests, it has that kind of effect where the wildebeest is the clot and you suck on the to the back and drag that clot out of the patient's body. so there is a vac weum cleaner device and these are all just

different techniques and tools available, but at the end of the day i'm a brain plumber. i'm unplugging a clogged drain and it's very much like having a clog in your sink where the lynn wicked drain owe is the medications we give and hopefully that will dissolve the

clot and if that does, i'm the roto-rooter guy that comes in with different tools to get that sink unplugged, so to speak. >> some of those things we can control. we can control with diet and exercise some of the factors that lead to stroke.

>> yes. it's really important to harp on the issue of prevention, because in stroke, an ounce of prevention really is worth a ton of cure. so you want to stay fit, diet, exercise, keep trim, just like chris.

you want to treat your hypertension, diabetes, if you have atrial fibrillation you need blood thinners. there is no amount of good smoking that's good for you. 80% of the risk wrapped up in stroke is embedded in those risk we could prevent 80% of stroke

if people would do those things. there are certain genetics predispositions and flukes of life and weird things that happen to people but i don't think any of us wouldn't mind being put out of business if people just paid attention to those things.

>> we have our first phone call this evening. we've talking with amil in calgary. hi. how are you? do you have a question? >> caller: i would like to ask one of the doctors there for

their opinion of symptoms of a a few years ago i was watching tv and all of a sudden my hands start shaking, especially my right hand, that i have to grab it with my left hand to stop it from trembling, and i noticed that i had a hard time walking, going upstairs actually to my

bedroom. and when i did go to my bedroom, i got into bed, and i stayed in bed for about two or three days, and i was really nauseated and bringing up and everything, and then when i went to see my doctor, i had to hang on to the walls because i just couldn't

keep my balance, and i asked my doctor if i had a stroke or whatever. and he said i didn't. but i've got atrial fibrillation and i am a 2 diabetic. >> in general, something that affects both sides of the body at the same time, most often it

is not a stroke, but it certainly is possible that because of the atrial fibrillation you sent off more than one blood clot and given the fact you had a hard time walking, holding on to stuff, it's certainly worth investigating.

>> nausea, is that common? >> so -- we talk about the carotid arteries in the front. we talk about the vertebral arteries in the back. the kind of symptoms you are describing sounds like they might happen from the arteries in the back.

so it's certainly worth i would wonder whether you were on coumadin or a blood thinner at the time and if that was therapeutic or not and if you had any scans and certainly worth checking that out so you get preventative treatment going on.

>> we have carl in spokane. hi, carl. >> caller: hi, there. >> do you have a question? >> yes, i go do. i have had a pacemaker implemented approximately 10 years ago, and -- my inr is steady, between 2 and 3, right

where my physician wants me to be, but about three, four years ago i changed over to prodaxa for the reason of simplifying things, and i have stomach issues from it, so i had to get back to coumadin, and now i've been told that maybe i should consider elequis.

the financial part is one consideration, but would it really give me additional help to prevent a stroke? that's my question. >> i think elequis -- they did a study looking at it versus warfarin, and the benefit and risk reduction of stroke with

elequis and lower hemorrhagic -- lower bleeding rates with coumadin versus he elequis, it'sa hard call to make. it's not inexpensive. it's hard to find insurance companies to accept it. part of me says if it's not broken don't fix it, but, you

know, i think you certainly need to be on some oral ant coagulant agent. it's worth a trial. but i think if you are tolerating the coumadin well -- perhaps more is less in that case. >> i think if you can manage

warfarin well and you can stay on it and adhere to it, and your r&rs are good, you watch your diet, the warfarin probably does a reasonably okay job and the cost-benefit is usually seen in populations of patient -- it doesn't help the individual person in the terms of

cost-benefit ratios. but i would say warfarin seems like the better drug for him since he was well controlled on that. >> we have deidre in calgary. >> caller: hi. i take blood pressure pills. i'm 76.

i think i've been taking them for probably about -- around 10 years. i exer lots. my weight is fine. am i still at risk for stroke? >> good question. >> i think the answer to that question is yes, we're all at

risk for stroke, even chris, who is the pinnacle of health. we're all at risk for stroke. you can't reduce it to zero. but you're doing all the right stuff and doing the best anybody could possibly do, it sounds like, to minimize your risk. >> does the risk increase as we

age? >> nothing we can do about it. >> some people try. >> well, we have an aging population so we're going to start seeing more -- >> we certainly will. absolutely. >> just one important thing is

some of the antihypertensives, the blood pressure medicines, seem to have neuroprotective effects. they protect brain cells. you have a lower risk of stroke, milder strokes, recover better from the strokes. so it's not to the point where

we can really say everybody should be -- we should it in the drinking water or anything but if you need those medicines they do tend to protect brain cells and are helpful. so stick with them. >> hypertension is a pretty prominent risk factor.

it's hard. you can't tell when your blood pressure is high. i think making sure you have good control of that over the course of the years to follow i think is essential. >> okay. we've talked a lot about how it

is critical to get care quickly when you're having a stroke. it's important to get to the hospital right away to be seen by a neurologist. but that level of care often isn't available in small towns. and we do live in a rural area. now, an innovative program is

called tele-stroke. it is changing that by connecting doctor to patient any time of the day or night. >> when you're having a stroke hospital right away and be seen >> when you're having a stroke, time matters. we treat stroke like a golden

if you can get tpa within one hour you have a significant chance of decreasing disability and improving the chances of a good recovery. >> tpa is a drug used to treat the most common type of stroke. it works by dissolving blood clots.

it's effective, but it needs to be used right away. it's also dangerous and requires the expertise of a neurologist. someone like dr. cynthia murphy, the stroke director at providence sacred heart. >> ma'am, do you have a history of stroke?"

>> when she's not in the hospital, dr. murphy is on call, ready to treat stroke patients across the region. >> sometimes i'm home, sometimes i'm pulled over on the interstate. >> using a laptop, dr. murphy is able to connect with one of 18

emergency rooms in washington and idaho who are part of the tele-stroke network. >> anywhere there is a wi-fi system you can beam in. >> when dr. murphy "beams in," she connects with a high-tech er equipped with robotic cameras. it lets her talk with the

patient, family and, of course, the on-site doctor who's done the initial diagnosis. >> i prefer to be there, in person, but i'll take my robot any day. >> a far cry from the days when dr. murphy would be on the phone.

with the visual link that tele-stroke provides, she's able to see her patients and really interact with them, allowing her to make a better assessment and diagnosis. >> that just wouldn't have happened three years ago. >> whether it's treatment on

site, admission or transfer, tele-stroke brings 24-hour access to high quality stroke care. saving time and lives. >> thanks, bye. >> it's wonderful. it's tremendous. >> there are 18 hospitals that

participate in tele-stroke. we've posted a map on our website that shows all the locations. to see it, go to ksps.org and click on "health matters." dr. murphy, how much of a difference has tele-stroke made? >> oh, it's tremendous.

a third of our patients are coming now to spokane through tele-stroke, but these are small regional hospitals, 15, 25 bed. they're 150 miles away from spokane. to be able to deliver quality stroke care via telemedicine has been tremendous.

the outcomes are huge. i'm going -- i don't know if i can give a shout out to bonis ferry but they had a case with a patient 15 minutes tpa. they were able to send to here for intervention. i think you took care of the patient.

it was a left m2 where the vessel was reopened on the left hemisphere. it was tremendous. without it, she would have been completely aphasic and able to speak and follow commands. so seeing more and more of these coming through in small regions.

it's outstanding. the best part, i think s because people want to stay. i think a lot of people like their hometown, like their region. if you can give them the same quality of care, either without having to come into spokane, and

they can stay and have the same quality of care, i think that's what they want. so i think you're seeing a lot more hospitals in a smaller region staying more interested in stroke, building their programs. it's been an exciting time

statewide. >> this type of technology is just going to become such an integral part of what you do. >> oh, absolutely, without question. yes, definitely. >> i think what's actually very interesting about that is the

imaging piece to it is really helping patients stay at home, really, or identify patients that need to come to us for large vessel occlusions. so my partners doing imaging, they are reading these imaging studies and helping the neurologist interpret the ct

scans to determine which patients have brain that's not dead already from the stroke. that is a large vessel clotted that would benefit from coming to spokane, and which patient doesn't have that condition and actually can get just as good treatment in their local

facility with i.v. therapies, et cetera. and having said that, a lot of patients are transferred for higher level care at sacred heart depending on the severity of their stroke even if it itisn't something they can open up. they would still benefit from

higher level services, rehabilitation services. but the imaging piece that is providing i think is a real nice supplement or augmentation of this whole tele-stroke program. >> you can't do it without imaging. you can't.

>> we know that stroke is one of the number one killers, but it is the number cause of disability, dr. stevenson, and again that's where you come in at st. luke's. what are we talking about as far as rehabbing? what do you see in patients?

paralysis? speech impairment? that sort of thing. how difficult is it to rehab that from? >> well, like i said before, with the different strokes for different folks it depends on what part of the brain was

affected. the left hemisphere is going to cause problems for most people with language and right-body paralysis. the opposite side would have left paralysis, but also affects your visual/spatial functioning and people may not be aware they

had a stroke. strokes in the back part could affect your overall coordination and balance and nausea and vision problems, brain stem strokes can act almost like a spinal cord injury where they can have weakness on both sides if it's bilateral, they can have

swallowing problems, and there's a whole variety of different things we can see with that. >> a lot of frustration i would imagine for patients when they start this process. >> yeah, i've never had anybody come in and say i'm so happy i particularly the language part

is really frustrating for people when they can't get across what they want to say. sometimes people don't understand they're not making sense and they think every one around them has gone crazy. >> so it can be quite a long i always tell people, you see

your most recovery for at least the first six months. so at st. luke's, like in 2015, we had 476 stroke patients with an average length of stay of about two weeks. so really just seeing them for a little snippet of that early recovery to get them going in

the right pathway, but they have a lot of work to do for several months. >> we have another phone call from cindy here in spokane. hi, cindy. are you there? we may have lost -- okay. we lost cindy.

again, we do welcome your phone calls and emails on stroke this evening. dr. ween, you briefly mentioned tia, or what we commonly call a ministroke, is that correct? same thing. >> i think the term ministroke because it means so many

different things. a transient ischemic attack is a stroke that goes away within by definition 20 hours, but on average 30 minutes. it is a warning sign of stroke. it means something is going on. you want to make sure that your krawd arteries are clean.

you need to have those imaged and looked at. want to make sure your heart is okay. hemorrhages usually don't cause tias so much but there are a number of tests you need to have done and there are very effective treatments.

at deaconess we pride ourselves we take them seriously. we actually open up the carotid artery within three days because that's when the highest risk of recurrence of stroke occurs in those situations. so we want to be aggressive with those.

i like to say in the statewide situation we spend a lot of money on hyperacute stroke treatment once the brain is damaged but tia gets -- tias need to be taken seriously. >> people can sometimes have several. there is something called

crescendo tia which is a buildup of the symptoms that get more frequent. that's very dangerous. you need to see your doctor quickly for that. or go to the emergency room if you have one and get it taken care of right away.

>> another term we are hearing dr. murphy is wake-up stroke? what is a wake-up stroke? >> a wake-up stroke is folks that go to bed, say you go to bed at 10:00, wake up at 4:00 in the morning and they can't move the left side, and so by the time they come to the emergency

room, they're -- it's -- say it's 5:00 or 6:00 a.m. and now they're four-and-a-half hours outside treatment window, and so a lot -- there's a good number of high percentage of strokes that happen during the middle of the night and wake up with symptoms.

it's -- and it's -- it's a very exciting time to -- decide on treatment and how can you proceed with treatment for folks that wake up with wake-up strokes. there are active trials enronling right now to see what can you tpa someone outside that

treatment window if they are a wake-up stroke. can you intervene on them intervascularly if it's a it's becoming an exciting time. how do we manage these folks? it's a lot of them. and it would bring huge amount of support.

>> and there's some really exciting imaging capabilities now we've got that distinguish between brain that has decreased blood flow and not a fixed stroke and how much brain is a fixed stroke. you can wake up with your brain at risk, we had a case at deacon

us just this morning. that's why i have the big bags under my eyes. there was a lot of brain at risk for damage. we were able to suck the clot out of the carotid artery and restore blood flow quickly. a lot of trials that dr. murphy

is referring to is about how you use those kind of perfusion blood flow studies to help direct your care even outside the six-hour time window because we know that the three-and-a-half hour, four-and-a-half howr, six-hour time windows are all statistical

things and it's a question of the population of patient benefiting more than you hurt. there are always going to be some people at the top of the curve you could possibly benefit. those are the ones you want to identify with the fancy imaging

modalities we're identifying now. >> dr. , you come in on this conversation as well. >> i think the part for me that's most interesting and i want to expound a little bit, what is a time window and a wake-up stroke, what does that

mean exactly? a time window in our lingo means when were you last seen well? and so if you were last seen well, we're all here together, we all know we're by some definition well at this point, and if all of a sudden i were to start having symptoms you would

know precisely, chris started having -- he couldn't talk, slumed that over in his chair at 7:33. that's my time onset of my and so within a four-window i can receive tpa, but that's all from the time of onset oso the wake-up stroke, to talk about it

a little further, the patient went to bed at 10:00 at night, fell asleep watching a tv show, and they were last seen well at 10:00. well, if their stroke happened at 10 to 3:00 but someone -- no one knows that, right, they don't know that that stroke

happened at that time, so their referenced in our medical jargon and funneling and triaging, they were last seen well at 10:00 at night, in fact they may have not have a stroke until 4:00 in the morning about that we said the last time you saw him well was 10:00 at night therefore you

can't get i.v. tpa. i hone we can get to the imaging, the salvageable brain determines whether a patient is a candidate for treatment and time windows are out the window, because even if a patient is 10 hours out but they still have salvageable brain, i don't care

that they're 10 hours out. why should i not try to save that brain. you can make the argument the brain that's been damaged by the stroke is at a higher risk if i unplug the artery that the brain that is damaged is more friable or more at risk for restored

blood flow to cause bleeding. but my argument back has always been, i know that if we don't treat that patient that large stroke, they have a really high risk of doing poorly. they're going to never talk or move the right side of their body or potentially die.

a left mca stroke occlusion untreated has in some studies between a 50 and 70% chance of death or major disability. a stroke that's in your posterior circulation that dr. ween was talking about, if if that artery remains plugged, they have over an 80% chance of

dying if that artery doesn't open up. and so when you're looking at time windows i think we're really limited and excluding patients that can be treated by these life-saving therapies because of what we had at the time when these studies were

created was a time window, a time of onset, and these newer studies that dr. ween and dr. murphy are referencing i hope are going to get away from a time paradigm and totally look at brain viability based on perfusion and ct imaging and these are mris and ct scans to

help determine which patient is a candidate, who has salvageable brain and how can we best triage and treat those patients. so hopefully within 10 years from now you'll have us back and we'll be talking not about time windows and treatment windows, but really talking about

salvageable brain tissue that we can all be very enthusiastic and help a lot more patients. >> that's very exciting. let's take another phone call. we have wanda in b.c. hi, juan did you. thank you for waiting. >> caller: good evening.

i wanted to ask a question. i have a mechanical heart valve. am i at any higher risk for a stroke because of that? >> i would say yes without anti-coagulation. i assume you're on anticoagulation? >> yes, ma'am, coumadin.

>> i think making sure that level is always therapeutic. i think lower levels on a mechanical valve -- the problem with a mechanical valve is it has a tendency to form clots on the valve. so we anticoal late folks with ma can come valves to prevent

formation of clots that form on the valve to the heart, clot goes to the brain. so that's our rationale. so it's always essential to be anti-coagulated with a mechanical valve. >> does that answer the question?

>> caller: yes, i just -- i just didn't know if it would change if i wasn't -- didn't have a mechanical heart valve. >> your risk is higher. >> caller: okay. >> wanda, thank you for your phone call. we're hearing some very

specialized questions this evening, very particular to the cases that we're hearing. let's talk about the general population again and aging population. what can we do as far as nutrition and exercise? what do you recommend?

are we looking at a heart healthy diet the same way that we look at preventing stroke? >> actually, i think most of the research is playing towards the mediterranean diet as being the thing. lots of vegetables, fruits, olive oil.

there was one research trial looking at carotid stenosis or blockage of carotids that had their patients drink a quart of olive oil a week. they actually could measure regression or shrinkage of that plaque in the carotid artery with the olive oil.

so the american diet is all french that fries and hamburgers and steaks and fatty stuff. away that from and more toward the olive oils and green leafy vegetables, lean meats and fish and smaller portions. >> and exercise, what do you recommend?

>> 10,000 steps every day. >> doing something? >> yeah. >> that's what it says. i have this watch that reminds me to move, and it's already gone off once while we're sitting here. if you think of how long we have

been sitting here talking, all of us should have been up and made a little lap around the those are things that are hard to do when we're all doing our job and our daily work, and there's lots of innovative ways to be moving around at work or to motivate yourself and all of

these fit bits and things like that i think are great re miners for people to do simple things like take the stairs at work instead of an elevator. if you did that every day and multiply about that multiple steps and days -- there are simple things you can do if you

can't make it to the gym, i have friends back home that call me and say what do you do here, what do do there? you can drop down and give me 10. there it goes again. so it didn't -- >> how often does that go off?

>> it don't move it goes off again. it gives me a couple little shots there. >> let's take a phone call from rene in spokane. hi, rene. >> caller: i have a couple of short ones.

the first one is, several years ago in a small community in oregon my husband and i went to take my mother to dinner and thieves sitting on the floor and had symptoms of a stroke, that is, she would respond with only common phrases. she didn't initiate speech.

she couldn't really tell us much of anything. because of experience with my dad who had had a stroke and had been aphasic and eventually could talk a little, right away i picked up on it. i also knew that she'd had some tias.

we got her to the community hospital, and they -- and i told them she was having a stroke. they totally ignored me because her pupils were level. i want to know what can you say to medical personnel to get them to listen to you if someone's having a stroke and the symptoms

don't quite match in their minds. >> come in in an ambulance. >> i didn't have -- we didn't have any choice. >> i know. it's unfortunate. if you come in in an ambulance on a gurney and the family is

saying stroke, the heat is on. the level of attention is just greater. in terms of the pupils being symmetrical, i mean, that's neither here nor there for the kind of symptoms your mom was having. >> i think stroke is becoming,

even the last five, 10, 20 years more -- even among the medical communities that aren't neurologists, this is what i do, but for a lot of folks in the e.r. setting are learning more signs of stroke itself. i think it's not only the public at large but it's also the

medical community, also understanding the signs and symptoms of what to look for. i'm sorry that happened. i agree with you. if you had an ambulance, it's a lot easier. but -- because they do descend upon you a little faster.

>> what happened -- i even if a patient comes into the emergency room without a family member who may be recognizing the signs of stroke, but doctors are reacting more quickly. they're seeing the signs quicker. is that correct?

this process is happening faster than we've ever seen it happen. >> i think for me all of this is motivated by our treatments that have been relatively new over the last, say, 10 years to to speak, a and particularly so with more recent studies coming out showing we can prevent large

strokes from progressing to be permanent deficits that the whole medical community is much more involved and interested. that's how tele-stroke is popping up. that's why people really want to be a part of giving ivtpa because there are immediate

treatments that can have massive benefits. i can tell you my enthusiasm for my job is so incredibly high because when you take a patient who is paralyzed and can't speak and you remove the blood clot and next day they're back to their normal self, there is

nothing i do that gives that sort of satisfaction. so when the whole medical community gets behind that event because although i'm the one removing the blood clot, it was the efforts of everyone here for sure, and in addition to the ambulance people, the medical

personnel, everybody is involved in having those successes and the rehabilitation of the patient afterwards, getting them back up to their top level that they can get. so the whole medical community is really, i think, excited about these kinds of outcomes,

whereas truthfully 10 years ago if you had a stroke there wasn't anything to do, and so there weren't these therapies and there wasn't a way to reverse it. so this has all been sort of a big snowball that's starting to gain that critical momentum and

starting to come crashing down the hill and it's really exciting. >> we have an email this evening from candice who says: what role might genetics play in having a stroke? >> it has a very complicated role.

some people have genetically determined types of strokes. they are inherited conditions. there's probably genetic predispositions, hypertension, heart disease are probably a genetic factor, in addition to environmental factor. it's not a modifiable thing.

so you have to focus on the things that you can modify. i don't think we've gotten to a point where you do genetic counseling for having children and stuff yet based on some of these diseases. but there's certainly a role, and if you have lots of family

members who have had stroke should possibly be looked at for some of the genetic causes. >> dr. stevenson, how big a role can family and friends play in recovery? >> it's really important because they're a huge motivator pour shunts as going through therapy

and saw for the for when they leave inpatient rehab. it's the rare stroke patient that has such a good recovery that they actually can go home totally alone. they need someone to help them out. they can't drive for a while.

it's very important. >> what can you tell them about that process when they're trying to help someone in their family who has gone through it? >> if they're there on admission we explain what the whole rehab process is, advise them to come to therapies, and as they get

closer to discharge, we actually schedule formal training with they can also be very supportive in helping the patient stop smoking and modify the risk so like when i have a patient there, i say, your risk -- your family history just got worse because your mom had a stroke.

so that usually gets their attention for maybe making some changes themselves and things. >> if a patient is able, how important is maybe having a support group to go through this. >> we have them start in like some support group activities

while they're an inpatient and they can continue that as an outpatient. some patients aren't really into that kind of thing but i think for other folks it's very helpful. >> to be able to bounce -- you're not alone sort of thing?

>> let's take another phone call from john here in spokane. hi, jon. >> caller: hello. it has two folds. i am, and my wife, were both vietnam vets exposed to agent orange. my wife died of a cerebral

hemorrhage this last march. i myself have a pacemaker, and i've had a blockage. i was told i did not have ischemic heart disease. but stroke has always been in my mind for both of us. what are your feelings about exposure to the agent orange

having to do with strokes? >> i started my training in boston and spent a lot of -- as dr. murphy also did -- spent a lot of time at the va and we heard a lot about agent orange. there's so much controversy surrounding that. i don't know if i can wade into

that controversy. >> i'm not familiar with the association of stroke and agent it is a controversy, you're right. >> there are probably other risk factors and things that go along with your situation that are more important than the agent

orange exposure, i would suspect, but that gets to be a complicated thing, and i think seeing stroke prevention clinic where they can help you sort some of those factors out would be a help fu thing for you. >> talk about the relationship with affib.

>> atrial fibrillation is an irregular heartbeat. folks with affib and other vascular risk factors are at higher risk of stroke and it can be as high as 12, 15% a year without any treatment. so there's treatment options of anticoagulants or therapy.

there's the wharf warfarin and then there's -- we call them novel anticoagulants, newer agents like the gentleman that called earlier about elequis, prodaxa, and essentially the purpose of anti-coagulation is to lower -- it can lower risk reduction by 70%.

you take that 12% risk and drop that by 70%, that's 3 to 4% risk yearly of having a stroke. so there's clearly benefits of i had gone to a lecture about affib today and they were saying it is still an undertreated population that we're not addressing all the folks with

affib that are at risk for stroke, and -- because -- and the problem with affib and stroke is that they're the bad they're the ones with the giant they are the ones we have to the send -- a lot tend to be worse with affib than other types. what we did discover it's still

an undertreated type disease. >> another thing to keep in mind about affib is it can come and go. you can have periods of time where you don't have it and periods where you do have it. some of the recent -- some exciting studies about longer

term monitoring of your heart looks at monitoring people up to two years, and at which point you have an 80% chance of picking up this intermittent atrial fibrillation. there are steps to go through detect it but sometimes it's difficult to identify it.

>> we catch it on the inpatient -- their heart rate is fast and irregular. >> but kit present sort of almost out of the blue like frequently with people that have strokes with atrial fibrillation, they have that stroke -- they didn't have the

heart rate beat fast before. >> you can't feel it. sometimes you can, but for the most part you can't. so someone would not know if they were in affib. so it's -- we look for it -- it's one of the things we look for both in the acute setting

and the outpatient setting and holter monitors to detect affib. it's such a significant risk factor. >> a few minutes to go. i want to see if we can get a few more phone calls in. tom from leavenworth. >> caller: for having this

conversation. it's fantastic. my question is i had a massive stroke about three months ago and i was lucky enough that my wife knew exactly what it was and got me in an ambulance and got me to care and they did a fabulous job, and -- as far as

the neurologist said, one of the miracle childs. but my -- i'm getting back to work and doing everything and no real problems to speak of. i'm very, very, very lucky. but my problem now is that i used to be such a happy go lucky good guy, and i have a real

tough time with patience with my wife and kind of being rude and short and kurt with her over things that i would never, ever have thought to do anything like that before. >> sometimes you can have some personality changes or adjustment to the stroke.

that's one reason we use rehab psychology to sort that out when that's the case and help patients and their families kind of learn how to understand what's going on with that. it could be due to the stroke residual. >> would you recommend that he

talk to someone? >> post-stroke depression is also very common. and antidepressants are oftentimes very helpful, not necessarily for ever but at least for a short period of time. but sorting out what is a

residual from maybe some residual brain injury from the stroke and what is a post-stroke depression can help with the management and treatment for there are a lot of good treatments for that now. >> we have bob calling from george.

hi, bob. >> thank you for waiting. >> caller: thank you. my question is, i guess -- well, i'm going to get a little choked up here. my girlfriend of five years had three major strokes last year, and she had one, went to the

hospital and had two more during care at the hospital. she actually came through it pretty well with a little bit of rehab and this and that, but since that time i know for a fact that she keeps having what they -- i guess they call ministrokes.

she's almost showing signs these days of parkinson's disease where her nerves -- she limb that's on the right side a lot more. it was a right-sidestroke. i guess it has more to do with stress related, not sure. but i'm having a hell of time

getting her to go to the doctor. she has high cholesterol. she has a problem with the diet. so we're trying to eat better, but what could she do holistically -- i guess i'm trying to say without coumadin, the other blood thinners. i know you guys are actually

prescribers of prescribed medicines, but what could i get her to do because she is more of a holistic healer to help with the blood thinner, blood thinning. you mentioned the mediterranean diet. we tried to do the vegetables

and fruits and things, but -- i'm just concerned. >> bob, thank you for your call. we can hear your frustration and your concern. is there anything he can do to help with holistic medicine? >> well, the problem for us with holistic medicine is there's not

a lot of research behind it and so we can't make firm recommendations one way or the other. sounds like you're trying to do all the important and things that you can do in terms of diet and exercise. a point comes, though, in some

of these situations where these things keep happening that you do need to take medications and there is no holistic way because the impact ole holistic treatment isn't necessarily that powerful. i'd be suspicious that you may have tiny strokes occurring

causing parkinson's like syndrome. oftentimes aspirin medicines can help, making sure your blood pressure is in good control, diabetes is in good control and exercise. and i just have to say, if your doctor isn't listening to you,

find another one. or beat him up until he listens. >> dr. murphy, are you a fan of any supplements when it comes to preventing stroke? >> i'm thinking. you know, i don't see it that much in the acute side. i wish -- i don't know if you

prescribe any on the outpatient side for prevention -- i don't use them much in terms of the inpatient setting for supplements. again, i would like to see some evidence of the holistic approach for stroke prevention. i am sort of a fan of the

current fda recommendations. >> with a about an aspirin, baby aspirin? >> well, if nothing else, i certainly would recommend that. >> there's been a bit of back and forth on that, women as well, because we had heard men, yes, women no, where are we at

with aspirin and women? >> again, sometimes the effect size in the research is so small it's hard to say which is best for whom. looking at the biochemistry and physiology of it, it wouldn't make a whole lot of difference. a baby aspirin is what i

recommend for this particular woman. >> we are getting close to the end of the show. i want to get some final thoughts, final bits of advice for our viewers on stroke, and dr. zylak, let's start with you. >> you know, i'm obviously

biased for people having large strokes that i can help them with, and i'll just tell you that the sooner you can call 911, if you see someone you love having trouble, the sooner they're going to get the help they need to prevent a major so call 911 if you think you're

having a stroke. >> dr. ween? >> i think it's very exciting to be here in spokane. we're in a large and growing community. we've got two good stroke centers now at deaconness and sacred heart.

we have whizbang interventions at both institutions. we have imaging that sorts things out in great detail. we have great rehabilitation. we have a system of care. we can just put all these pieces together coordinated we can serve our community very well.

i look forward to working with all my colleagues in town to see that happen, because the population is getting older, we're going to see more of this, it's not going to go away, no matter how holistic and healthy we are, it's going to keep having the capacity, expertise

in town, really working to make it work well for the population, that's very exciting. >> dr. murphy? >> i agree. i think spokane has gotten very exciting with stroke care, certainly st. luke's what you are doing with rehabilitation.

image goinging. i think for folks out there just to know that it's not the end of the road. you know, for some people, a very small segment of people do not always to well, but many do have recovery, they do -- they -- they can overcome what's

facing them. they can work towards prevention. we've seen so much exciting change in the last 10, 15 years, and i think both from the public at large and from us as medical providers, you know, trying to bring families together,

establish independence, bring back function and quality of life and what defines that. so it's i think going to be an exciting time in stroke care. >> well, we have run short on time but i want to thank all of you for being here and that's going to do it for this this

edition of "health matters." our thanks to everyone who called in and email add question and a big thank you to our panel for being here and sharing their he expertise. join us on october 20th when our topic will be lung health.

i'm teresa lukens. good night. "health matters" is made possible by our viewers, the friends of ksps, and by providence healthcare. when my wife had a cardiac arrest.