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Make mounjaro cheaper, get rid of the increasing irrational fear of statins, and get everyone to stop smoking and I can cut the stroke rate by half in the next 20 years.
Debate over thrombolytics for acute ischemic stroke
Started by bougiecric
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In my ideal world, more meds wouldn’t be the answer.
Maybe not statins but I wouldn’t underestimate how effective GLP-1 agonists are
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This reminds me of my hospital’s phone call holding voice recording that claims patients need to seek help at the hospital because 40% of all strokes are preventable.
Absolutely agree.
However, history has shown us again and again that most patients won't/can't lose weight on their own. So its either meds or functionally nothing.
Sure plus it can be hard moving the needle aggressively on Apo B without drugs.
Look, I love y'all.
But we all know that using a drug to fix the problems caused by a drug, without addressing the use of the first drug (which often requires Draconian changes to life) is just the "cigarette/albuterol machine".
I don't think GLP-1's should be paid for by drug prescription / insurance premiums. Obesity is a medical problem that can universally be treated without drugs in 99.5% of people.
I agree with your other statement that people won't / can't lose weight on their own. But that doens't mean I need to partially pay for their mounjaro. For fricking sake we are steadily absolving people of all health care moral hazard in our society. I think if you smoke your premiums should go up, if you are fat they should go up, and if you eat a subway sandwiche with a side of cheetoes every other day, your premiums should go up.
Re statins: Maybe there is an irrational fear, but my cursory knowledge of them is that there is emerging evidence they really don't work well in many cases and that they are overprescribed.
charge 'em more $$
Under current practice, at some point, everybody of a certain age regardless of their lipid panel and blood pressure (could be the best lipid panel you’ve ever seen with a perfect blood pressure) will be recommended a statin. Those kinds of blanket recommendations don’t pass my personal smell test.
If you smoke your premiums DO go up. Its the one health issue that that ACA allows for.
You'll notice that I didn't say "make insurance cover mounjaro". I said to make it cheaper. $1200/month (or even $600 with a coupon) is absurd.
Yeah I don't care what your ASCVD risk score is, if you don't have diabetes or vascular disease I'm not prescribing a statin if your HDL is normal and your LDL is below 100.
Basically if you receive medical care regularly and haven't been started on a statin by around age 75, I'm not going to start one barring a second indication (MI at 78, for example).
We are both into nutrition and resistance training, so I do think in general lifestyle intervention/modifications are the best approach. I think I've just been absolutely burned too many times where these lifestyle intervention recs meet eyerolls—not just patients but friends (often these are physicians as well), colleagues, extended family members, etc.
See; this... THIS is the PRECISE moment (the eyeroll) that you need to double down on our position of "austerity breeds excellence". There's many strategies to do it.
The one that I find has the most "impact over intent" is getting the man to realize that he wants to protect his family.
"Dude, you and your family are in a car crash. Car is on its side. A small fire starts. Help is 20-30 mins away. You hear: 'Dad, I can't move. Help me. Get me out.' You need to free your family. Only you. You're gonna need some muscles. Better get them NOW."
I would legitimately love to see a study that looks into this. Could use motivational interviewing in the traditional sense in one arm and the other arm we'll call it rustedfox's tough love.
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Just one little thing. I was a firefighter for 9 years. Do you know how many MVCs had a fire?
I'll give you a hint: it's less than 1.
That's anecdotal, but, I would ask @southerndoc his experience, and too bad foughtfyr and DocB aren't around anymore.
Honestly, bro - I don't know where along the way we Americans lost the masculine desire for physical excellence, but we did. Guys will walk out of the theater after a spy movie and think that they're cool, crafty, clever, and can get the best of the bad guy in a scuffle - then go stuff their faces with fried food and a six pack of beer, placing the paper plate on their abdomentable while they sit on their couch.
Directing my criticisms at myself, I know what I need to do next. I need a martial arts class of some variety.
All of them have a fire in my thought experiment. Get out of here with your empiric facts. They don't help me to illustrate my point or stoke the desire for self-reliance in the man in question. I say this with love, bro.
About 10 years ago a local hospital system decided to launch a stroke truck and were trying to convince me to add them into our ems response matrix. Limited view CT and their only claim to fame was they could push thrombolytics sooner than in the ED. Any patient not appropriate for thrombolytics was punted back to EMS who would then transport to the ED for the stroke work up to start all over again.. At that time I found stats from AHA that showed during meta analysis that only about 2% of stroke patients get thrombolytics.
When I took this back to the stroke truck team and asked for their data on administration frequency, scene times, and % of time they punt back to EMS, they refused to provide that data. I told them I’m not delaying treatment for 98% of the stroke population so that 2% could get a “maybe will help” drug 10 minutes sooner - oh it’s pertinent to add that there’s several stroke centers in town and you’re never more than 10 minutes from one..
When I took this back to the stroke truck team and asked for their data on administration frequency, scene times, and % of time they punt back to EMS, they refused to provide that data. I told them I’m not delaying treatment for 98% of the stroke population so that 2% could get a “maybe will help” drug 10 minutes sooner - oh it’s pertinent to add that there’s several stroke centers in town and you’re never more than 10 minutes from one..
Car fires always explode in the movies.. number of cars I’ve seen explode in coming up on 3 decades = 0
*The Fast and The Furious* NOS!!!!
They always explode if you shoot them in the gas tank inlet à la Grand Theft Auto rules.
Another universal truth of movies - if they start bleeding from the mouth, they're dead.. if they don't start bleeding from the mouth, they can probably toss a 4x4 on their wound and continue the fight..
Obviously, bleeding from the mouth means that it’s internal bleeding.
My (neurologist) wife’s pet peeve is when they get shot right in the brachial plexus with a “shoulder wound” and are totally fine.
I'm not sure how universal that ever was. I think our biggest culprit is a combination of much more plentiful food for everyone, and much more sedentary jobs with a side helping of much more calorie dense food.
I used to be a big anti-TPA guy and would quote David Newman all the time. I think everyone has brought up great points. What's interesting is the NNT website has (what appears to me) contradicting opinions.
thennt.com
It looks like the NNT website now promotes TPA? Maybe I am reading this wrong.
Thrombolytics for Stroke – TheNNT
thennt.com
It looks like the NNT website now promotes TPA? Maybe I am reading this wrong.
Tissue Plasminogen Activator (tPA) For Acute Ischemic Stroke (2021) – TheNNTI used to be a big anti-TPA guy and would quote David Newman all the time. I think everyone has brought up great points. What's interesting is the NNT website has (what appears to me) contradicting opinions.
Thrombolytics for Stroke – TheNNT
It looks like the NNT website now promotes TPA? Maybe I am reading this wrong.
“This is the third NNT summary of thrombolytics for acute ischemic stroke. The first gave thrombolytics, as a class, a "red color recommendation: no benefit." The second gave alteplase, a single agent, a "green color recommendation: benefit>harm." As no relevant trials were published between the two, both author groups examined essentially the same data and arrived at opposing conclusions. We believe it would be hubris to presume this third summary will arrive at the one true answer. We focus, therefore, on the uncertainty we believe leads to conflicting interpretations.”
Thanks a ton. Didn't even see the 3rd one.
Five posts in and this is the on-the-ground reality.
I've worked at 5 hospitals since residency. At all but one a neurologist (either in person or via tele) is ultimately the one to hand down the thrombolytic go/no-go for launch. Even the relatively resource poor BFE hospital I locums at has rapidly available teleneuro who would give the rec. As such, it really isn't my battle to fight.
I think my neurologists dont trust me (the larger EM "me") to make that decision. They know TPA/TNK utilization will plummet by like 75% if they leave us in charge of it.
yes
I still have questions about the risk of inducing diabetes as being such a bad outcome in someone who has 'just' HLD beforehand, but I have chilled out enough to keep that concern to myself
yeah. it would.
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GLP-1s do more than just 'make you skinny'. They seem to blunt the urges for all vices. Not just hunger. Smoking. Alcohol. stimulant addiction (havent seen anything suggesting opiate addiction benefits), GAMBLING. They are an anti-vice machine and, at a currently ridiculous price, they can change your entire risk profile for all sorts of chronic maladies across the board.
And lets me honest, letting people keep more years of good CV health, more toes, and maybe deprive online casinos of more cash will lead to so much money saved for the nation just on healthcare costs for long term issues that eventually falls on medicare/aid. Also, less gambling vices.
No matter what happens to patients, the doctor will be held liable similar to the doctor when the patient went to the chiropractor or if they eat a lot
I've heard this argument too. My sister says that GLP-1s get rid of her "food noise" in her brain.
I guess society has had an Ozempic deficiency for decades!
The proof will be when insurance companies lower your premiums if you are on a GLP-1. Until then, I vote for society not paying for them.
I understand the potential benefits of GLP-1, but I'm still skeptical.
In 1950 obesity was rare especially among children. Starting in the 1980s it exploded to the point that most Americans are obese and unhealthy. Why can't we have a frank look at the root cause of this, rather than just put everyone on GLP1/Statins?
In 1950 obesity was rare especially among children. Starting in the 1980s it exploded to the point that most Americans are obese and unhealthy. Why can't we have a frank look at the root cause of this, rather than just put everyone on GLP1/Statins?
It was just discovered a few years ago that we have an ozempic deficiency!
Cos we know the root causes. Unfortunately since no one is willing to regulate corporations that sell fast food or allows you to get it delivered to your door without ever getting off the couch, and because advising lifestyle changes simply doesn’t work for the majority of people, it’s unfortunately not a choice between GLPs versus addressing the root causes. It’s a choice between GLPs versus continuing having the same amount of fatness that clogs the hospital with complications of said fatness.
Isn't it interesting that AHA has been bought completely by big pharma/big food?
With proper patient selection and a touch of sense, the benefit absolutely outweighs the diabetes risk.
Does it induce DM, or is it more like it gives a little nudge ahead in line for people who are already walking in that direction?
Early on, I got a transfer from outside hospital for B leg tingling after cocaine use. Was about to send them home when I saw that they'd been tPA'ed at the OSH.
You assume people have sense.
I had a patient transferred to me emergently for an "open fracture. Needs IV abx and Ortho admission".
It was an avulsed toe nail that had already been appropriately removed and addressed by said PCP. There was a "well corticated tuft fracture" on the same toe, still not sure why they got an XR in the first place as the reason for the avulsion was as close to atraumatic as can be (nail vs sock.)
But you know. Sense is rare.
David Newman said the data is pretty suggestive, but not 100% conclusive, that it induces DM de novo.
Then he got himself more famous than he should have, and his opinions on chronic cholesterol management became less relevant.
Can't say for sure, but I'd be shocked if it's the former.
I've been on Crestor for 13 years. Highest A1c was 5.2 when I got fat during early COVID.
And, in my mind, I hear Captain Picard selling the Crestor!
My gut says it tips the scales a bit for those who are genetically inclined or environmentally on the path anyway.
I still think it's the right choice to treat.
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I wonder if there is a benefit to getting TPA/TNK in the LVO cases that go for thrombectomy due to the inevitable downstream showering of clots during and after the procedure?
I agree with the comments here though that the data doesn't match up with the wide population we give it to. It may have a small benefit in very specific circumstances, but bathing every stroke patient in it because HHS and the admin teams say it must be so is defeating.
"Compliance not science."
-a wise older attending of mine
They’ve done non-inferiority trials looking at tPA/thrombectomy vs thrombectomy alone. It was unfortunately found to ‘not be non-inferior’ so we are stuck with tPA for now.
I think we "lost" because it does work. A bit. Not a miracle cure and plenty of risk. More risk than most things we do. I used to use a diagram similar to the AHA one that shows people colored red, green, or grey for worse, better, or unchanged after TPA. I don't like the AHA one because it doesn't show outcomes in the placebo arm so people assume 100% of people in the placebo arm ended up horrible vegetables which isn't true. About 20% of people in placebo arm of original trials ended up with an NIHSS of 1 or less. Definition of a TIA used to be resolution within 24 hours so some TIA 's got thrombolysed in those trials and continue to get lysed today.
The one I had only had 30 people and mixed outcomes by color for placebo and TPA arms
I basically said
Here is 30 people who have had a stroke. For about 6 of them even if we do nothing they are going to make a pretty full recovery. Back to normal or nearly normal. If we give the clot buster another 3 are probably going to make a near full recovery. But 3 are also going to get severe bleeding in their brain and for one or two of those it will be so bad that you will end up either dead or a total vegetable. For the other one or two the bleeding won't kill them but they probably don't get much better. For the other 18 it seems the clot buster makes them a bit better. But by a bit better I don't mean you are going to dance at your daughter's wedding. I mean it might make the difference between you being able to brush your own teeth or sort of feed yourself or not.
Me personally if it comes down to it I hope I get thrombectomy or a pillow over my face.
At least once a month I go to a stroke alert where I tell neuro, "I'm not sure what this is yet but its not a stroke." They usually agree and I'm usually right. Especially true in places where medics initiate the alert in the field.
"Work"
No one ever really bothered to re-test NINDS, and – why would they? Genentech stopped sponsoring investigators and supplying drugs to new trials that might diminish the effect size. It probably helps more often than it hurts, but not to the extent where I'd use the pharma-approved AHA propaganda.
Those trials from decades ago aren't generalizable to modern practice, either; we're enrolling different (read: milder) strokes, in general, and we're including comorbidities excluded from those trials and kept on as relative contraindications for years. That said, once you shake out the LVO from those old trials and send them to EVT, yeah, perhaps then you can build back some more of the benefit – small vessels, small territories, reasonable collateral circulation/oxygen diffusion. Too bad we'll never really know.
