2017 gave us numerous dramatic advances in stroke neurology. We were treated to compelling data regarding the favorability of patent foramen ovale closure in well-selected individuals with cryptogenic stroke.1,2,3 Endovascular therapy matured with the extension of the treatment time window.4 We even saw promising rehabilitation data regarding surgical nerve transfer for chronic spastic arm paralysis.5 Conversely, some widely used therapies such as head positioning6 and oxygen supplementation7 were shown to be ineffective. The list of figurative leaps goes on.
As an early career neurologist in a vascular neurology fellowship, I found myself reflecting on the year’s advances, in part to find my place in the field. While thoroughly inspired by the major advances of 2017, I couldn’t help but dwell on the findings of a secondary analysis of the Insulin Resistance Intervention After Stroke (IRIS) trial.
The IRIS trial randomized non-diabetic patients with stroke or TIA to pioglitazone or placebo and followed them for several cardiovascular outcomes.8 The primary analysis was published in 2016; patients randomized to pioglitazone had a lower risk of recurrent stroke or heart attack.
In a secondary analysis published in Neurology in 2017, Katherine Epstein and colleagues evaluated the association of smoking cessation and recurrent stroke, myocardial infarction, and death.9 In an observational design, they followed individuals who were smoking at the time of their index stroke and quit, and compared them to individuals who did not quit. The 5-year risk of stroke, MI, or death was 16% in quitters versus 23% in non-quitters (adjusted hazard ratio 0.66). Quitters had half the risk of death compared to non-quitters.
Granted, this was observational data. Individuals who were motivated to quit smoking may have made other healthy decisions. And, these results are not ground breaking either – we know that smoking cessation is “the most important thing one can do for one’s health” (as we are taught to tell patients in medical school).
Regardless, the results are memorable. While advances in acute stroke care, surgical interventions, and novel pharmacotherapies are a testament to scientific ingenuity, we must not neglect the low-hanging fruit. Are neurologists trained to effectively aide in smoking cessation? What are the best tools for this purpose? Are such services adequately incentivized? Some argue that advances in stroke systems of care may now yield more public health gains than scientific advances. If we accept this notion, we must acknowledge that it does not apply exclusively to the acute stroke treatment arena.
Included in the AHA/ASA’s Life’s Simple 7 paradigm, and a focus of the FDA’s newest public education campaign entitled “Every Try Counts”,10 smoking cessation deserves our fullest attention. To support these programs and to empower our patients to quit, we must identify and incorporate the best tools available into our practice.
- Mas JL, Derumeaux G, Guillon B, Massardier E, Hosseini H, Mechtouff L, et al. Patent Foramen Ovale Closure or Anticoagulation vs Antiplatelets after Stroke. NEJM. 2017:377;1011-1021.
- Saver JL, Carroll JD, Thaler DE, Smalling RW, MacDonald LA, Marks DS, et al. Long-Term Outcomes of Patent Foramen Ovale Closure or Medical Therapy after Stroke. NEJM. 2017:377;1022-1032.
- Søndergaard L, Kasner SE, Rhodes JF, Andersen G, Iversen HK, Nielsen-Kudsk JE, et al. Patent Foramen Ovale Closure or Antiplatelet Therapy for Cryptogenic Stroke. NEJM. 2017:377;1033-1042.
- Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, et al. Thrombectomy 6 to 24 Hours After Stroke with a Mismatch between Deficit and Infarct. NEJM. 2018:378;11-21.
- Zheng MX, Hua XY, Feng JT, Li T, Lu YC, Shen YD, et al.
- Anderson CS, Arima H, Lavados P, Billot L, Hacket ML, Olavarria VV, et al. Cluster-Randomized, Crossover Trial of Head Positioning in Acute Stroke. NEJM. 2017:376;2437-2447.
- Roffe C, Nevatte T, Sim J, Bishop J, Ives N, Ferdinand P, et al. Effect of Routine Low-Dose Oxygen Supplementation on Death and Disability in Adults With Acute Stroke: The Stroke Oxygen Study Randomized Clinical Trial. JAMA. 2017:318;1125-1135.
- Kernan WN, Viscoli CM, Furie KL, Young LH, Inzucchi SE, Gorman M, et al. Pioglitazone after Ischemic Stroke or Transient Ischemic Attack. NEJM. 2016:374;1321-31.
- Epstein KA, Viscoli CM, Spence JD, Young LH, Inzucchi SE, Gorman M, et al. Smoking cessation and outcome after ischemic stroke or TIA. Neurology. 2017:89;1723-1729.
- Every Try Counts Campaign. Food and Drug Administration. https://www.fda.gov/tobaccoproducts/publichealtheducation/publiceducationcampaigns/everytrycountscampaign/default.htm
Neal S. Parikh, MD, earned his MD from Weill Cornell Medical College and completed residency training in neurology at the same institution. He is now an NIH T32 neuro-epidemiology and vascular neurology fellow at New York-Presbyterian Hospital/Columbia University Medical Center. He tweets @ NealSParikhMD and contributes to Blogging Stroke as a blogger.