October is Stroke Month Even in Korona-ka, don't hesitate to take an ambulance

October is Stroke Month. Various educational activities related to stroke, which is the fourth leading cause of death (* 1) in Japan, are carried out. Prevention and treatment of atrial fibrillation, which is one of the causes, is also important to prevent stroke. Therefore, we held a roundtable discussion with Dr. Kazuo Minematsu, the chairman of the Japan Stroke Association, as a moderator, and Dr. Yuji Matsumaru, a specialist in stroke, and Dr. Ken Okumura, a specialist in arrhythmia, about their prevention and treatment.

People with atrial fibrillation are more likely to develop a stroke

Minematsu First of all, what kind of illness is stroke? I would like Dr. Matsumaru to explain the basics such as the onset situation in Japan.

Matsumaru Stroke is a disease that occurs in the blood vessels of the brain. There are three types: cerebral infarction that occludes blood vessels, subarachnoid hemorrhage that ruptures blood vessels on the surface of the brain, and cerebral hemorrhage that ruptures blood vessels inside the brain. All are serious illnesses that develop rapidly. Among them, cerebral infarction is the most common. In Japan, it accounts for about two-thirds of all strokes. Stroke is the fourth leading cause of death in Japan in 2019. Approximately 8% of those who die in Japan, or approximately 110,000 people each year, die from stroke (* 1). Survivors often have severe sequelae, which can lead to bedridden and dementia. According to a 2017 report, there are about 1.12 million strokes (* 2) in Japan. There is also a report that about 300,000 people develop the disease (* 3) in one year.

Minematsu The most common symptom of stroke is numbness or numbness in half of the body, such as the face and limbs. Next, there are language disorders such as slurred speech, poor speech, and inability to understand what people say. These two account for about 80% of the symptoms caused by stroke. Other than that, I can't walk well or my body is out of balance. Symptoms may occur in the eyes, such as one eye becoming invisible or something appearing double. In severe cases, you may lose consciousness. Also, if you have a severe headache that you have never experienced, you may have a subarachnoid hemorrhage. If you experience any of the above symptoms, do not hesitate to call an ambulance. More recently, atrial fibrillation has received a great deal of attention as one of the causes of cerebral infarction.

Okumura Atrial fibrillation is a type of arrhythmia. There are four chambers in the heart, the upper two are called the atrium and the lower two are called the ventricles. Normally, the atrium and ventricle contract repeatedly in order, sending blood to the whole body. Atrial fibrillation is a condition in which the heart does not contract normally and begins to quiver finely. Symptoms include faster heart rate and more palpitations. You may also feel chest discomfort or shortness of breath. You may feel dizzy or faint. In early atrial fibrillation, symptoms usually subside within a few hours. However, with repeated attacks, it becomes difficult to stop and progresses to chronic persistent atrial fibrillation. It is important to note that about half (* 4) of people with atrial fibrillation have no subjective symptoms. Some people have symptoms at first, but gradually lose their feelings. However, if left untreated, it can cause various complications such as cerebral infarction. Atrial fibrillation is more common in the elderly and is said to be more likely to occur in men, hypertension and obesity, sleep apnea, and heart disease. It is important for people over the age of 65 to undergo regular medical examinations and to take regular pulse to detect them early. Please see the website of the Japan Stroke Association for how to take a pulse. There are various models of recent home blood pressure monitors that detect pulse disturbances. In addition, some types of digital gear such as the latest Apple Watch (* 5) have tools for diagnosing atrial fibrillation, so it is a good idea to utilize these. (* 6)

Minematsu Certainly, when you are treating a stroke, there are a lot of people who have atrial fibrillation. However, there are many cases in which the person or family does not know this and only realizes atrial fibrillation after having a stroke. In any case, there is a huge link between atrial fibrillation and stroke.

Okumura People with atrial fibrillation are more likely to develop various illnesses such as stroke, heart failure, and kidney disease. Many people die from it. There is also research data (* 7) that people with atrial fibrillation are about five times more likely to develop a stroke than those without it. With atrial fibrillation, the heart does not contract normally, causing blood to stagnate in the heart. Blood tends to clot when it stagnates, which makes it easier for blood clots to form in the atrium. The blood clot is carried to the whole body by the flow of blood at some beat, and it clogs the blood vessels of the brain, resulting in a cerebral infarction.

It should be noted that cerebral infarction caused by Matsumaru atrial fibrillation causes a very serious disease called cerebral main artery occlusion, in which a blood clot clogs a large blood vessel in the brain.

Aiming to cure atrial fibrillation with catheter ablation treatment

Minematsu First of all, prevention is important for stroke. In addition to atrial fibrillation, other risk factors include high blood pressure, diabetes, lack of exercise and obesity, tobacco and alcohol, and excessive salt intake. The website of the Japan Stroke Association introduces 10 stroke prevention articles. Looking at this, I would like those who are applicable to try to prevent it. The first three of the ten articles are "Let's cure high blood pressure as a starting point", "I will regret if I leave diabetes alone", and "I will see an arrhythmia as soon as I find it". However, no matter how careful you are, it can cause a stroke. Therefore, the last of the ten articles is "Go to the hospital as soon as you have a stroke." In the unlikely event of a stroke, treatment is a race against time. It is important to go to the hospital as soon as possible.

Matsumaru In particular, treating cerebral infarction within a few hours after the onset has a great effect on the subsequent course. Treatments for cerebral infarction include intravenous alteplase (rt-PA), which is an infusion of a drug that dissolves a clogged blood clot (blood clot), and a machine that passes a catheter through a blood vessel to reopen the clogged area. There is a blood clot recovery therapy. These treatments should be given as soon as 1 minute or 1 second. If the treatment is given promptly, some people may recover from consciousness disorder or paralysis at the time of onset by the time they can walk home after the treatment. Stroke therapists are available 24 hours a day, 365 days a year because the sooner they are, the more likely they are to reduce sequelae. These treatments are available at stroke centers accredited by the Stroke Society. Even if the patient does not know the location of the stroke center, if the paramedics determine that the person they have accepted is a stroke, they will be taken to the most appropriate hospital. So don't hesitate to call an ambulance. Stroke also often has sequelae and dysfunction after treatment. Therefore, after treatment, I will be transferred to a convalescent hospital specializing in rehabilitation. Even in such cases, the number of cases in which rehabilitation can be achieved is increasing due to early rehabilitation. However, there are very many recurrences of stroke, and there are reports that about 5% of strokes relapsed in one year and about half of them relapsed in 10 years (* 8). After returning home, it is important to prevent recurrence. To do this, improve your lifestyle and take appropriate medicines. It is also important to manage and treat atrial fibrillation, which causes stroke.

Minematsu People with atrial fibrillation are especially prone to relapse of cerebral infarction. That is why it is important to treat atrial fibrillation in advance. Recently, new treatments have made it possible to cure atrial fibrillation.

Okumura That's right. Atrial fibrillation, which causes stroke and heart failure, should never be left untreated. Especially those who are at risk of developing cerebral infarction need treatment with anticoagulants for prevention. Anticoagulants are drugs that make blood smooth and hard to clot. However, taking anticoagulants makes it easier to bleed, and injuries make it harder for the blood to stop. Therefore, consult a specialist and try to take it properly. When you start treatment with anticoagulants, you will also be treated for atrial fibrillation itself. Among atrial fibrillation, paroxysmal atrial fibrillation, which is prone to palpitation, shortness of breath, and dizziness, is treated to relieve the symptoms. Until now, treatment with drugs has been the main focus, but recently it has become possible to aim for eradication of atrial fibrillation with catheter ablation treatment (see figure). This treatment involves inserting a catheter 2-3 mm in diameter into a vein from the base of the foot under anesthesia. It goes into the heart and electrically cauterizes or freezes the area that causes atrial fibrillation. In our hospital, in the case of paroxysmal atrial fibrillation, the treatment is completed in about 2 hours, and it is often enough to stay in the hospital for several days. With paroxysmal atrial fibrillation, about 90% of people will not have a seizure in the first year after surgery (our hospital data) (* 9). However, persistent atrial fibrillation is more likely to recur even with treatment. Therefore, it is important to receive ablation treatment at the earliest possible stage. As a complication of ablation treatment, about 1% of people may have a heart wall damaged and bleeding, or a blood clot may form during or after treatment and cause cerebral infarction (* 10). For more information on treatment, please consult an arrhythmia specialist. Also, it is important to properly treat people with high blood pressure or heart disease in order to proceed with the treatment of atrial fibrillation. It also helps prevent stroke and heart failure.

Minematsu Can anticoagulants be stopped if catheter ablation treatment is performed and atrial fibrillation disappears?

Okumura There is still no evidence of how long anticoagulants should be continued. General guidelines state that the risk of stroke is low and that it can be discontinued after 3 months if there is no recurrence of atrial fibrillation. However, if you have a risk factor for developing cerebral infarction, or if you have cerebral infarction, long-term anticoagulant therapy is necessary.

Establishing a system that can be used for medical treatment and treatment even in the case of Korona-ka

Minematsu By the way, there is now a danger of medical collapse due to the Korona-ka. The reality was that ambulances couldn't take patients to the hospital smoothly. Under such circumstances, it seems that there are cases where patients are refraining from seeing a doctor. Is it okay to call an ambulance as before, even if I suspect a stroke? Some people may be worried. How about Professor Matsumaru on this point?

Matsumaru Both overseas and in Japan, the number of stroke patients undergoing medical examinations and treatments is decreasing when lockdowns and emergencies are declared. It is speculated that one of the reasons may be that mildly ill people are refraining from seeing a doctor. As a stroke therapist, I am very concerned about refraining from such a consultation. The first onset of a stroke can be mild, but it can be severe thereafter. It may be too late if you refrain from seeing a doctor because your first symptoms are mild. We, stroke therapists, pay close attention to the prevention of infection even in the case of corona sickness, and have established a system that allows medical treatment and treatment as before. Therefore, if you suspect a stroke, don't hesitate to call an ambulance.

Minematsu However, some patients and their families do not know exactly when to call an ambulance.

Matsumaru So the guideline is "ACT-FAST" (see figure). F is Face, A is his Arm, and S is Speech. You should call an ambulance as soon as you have any of these three symptoms. The last T is Time, which is the time of onset. Intravenous alteplase (rt-PA) therapy by infusion should be given within 4.5 hours, the sooner it is, the more effective it is. Therefore, it is important to check the time when the symptom occurred.

Minematsu Getting the general public familiar with stroke and atrial fibrillation, including "ACT-FAST," will lead to effective prevention and treatment. Therefore, the Japan Stroke Association has been focusing on educational activities for many years. In Japan, October will be Stroke Month from this year, and we will carry out various educational activities such as public lectures under the slogan "'It's okay to heal". Furthermore, October 29th will be World Stroke Day with the slogan "Minutes can save lives", and educational activities will be promoted worldwide.

Okumura Regarding atrial fibrillation, March 9 is designated as pulse day (3: mya, 9: ku), and one week from 9 to 15 is designated as atrial fibrillation week (Japan Stroke Association and Japan Arrhythmia). Electrocardiographic Society). During this period, we are conducting educational activities to make people familiar with atrial fibrillation and to take a pulse on a daily basis.

Minematsu I hope that they will deepen the understanding of the general public. Finally, please give us a word from each of you.

Matsumaru The brain and heart are inextricably linked. If the blood vessels in the brain are blocked, it is a cerebral infarction, and if the blood vessels in the heart are blocked, it is a myocardial infarction. The two are similar in terms of illness, but there are major differences. Patients with myocardial infarction have chest pain and fear of death, so everyone calls an ambulance without hesitation. On the other hand, people with cerebral infarction do not have much pain or suffering, so it seems that many people do not call an ambulance immediately after symptoms appear and watch the situation. Elderly people in Japan are particularly patient, so they tend to refrain from calling an ambulance because it is a nuisance to the neighborhood in the middle of the night. But that is fatal. Stroke is a time-consuming illness. If you have symptoms such as face, hand paralysis, or speech problems, I would like you to call an ambulance immediately, no matter how mild or Korona-ka.

Okumura Atrial fibrillation, which is a major cause of stroke, can occur in anyone as they get older. Therefore, it is important to take care of your health and prevent it, and to take regular pulse, detect it early, and receive a medical examination. Also, if you know that you have atrial fibrillation at an early stage, you can prevent cerebral infarction with appropriate treatment and aim to cure atrial fibrillation itself with a higher probability. Don't leave your pulse turbulent, talk to your GP, cardiologist or arrhythmia specialist.

Prevention is important for stroke.Treatment is a game against time

Early detection of atrial fibrillation with regular pulse

Get a medical examination as soon as possible, whether it is Korona-ka or mild

(* 1) Source: Ministry of Health, Labor and Welfare "Overview of Reiwa 1st Year (2019) Vital Statistics Monthly Report (Approximate Number)"

(* 2) Ministry of Health, Labor and Welfare "Overview of Reiwa 1st Year (2019) Vital Statistics Monthly Report (Approximate Number)"

(* 3) Takashima N, Arima H, Kita Y, Fujii T, Miyamatsu N, Komori M, Sugimoto Y, Nagata S, Miura K, Nozaki K. Incidence, Management and Short-Term Outcome of Stroke in a General Population of 1.4 Million Japanese: Shiga Stroke Registry. Circ J 2017 (in press)

(* 4) Esato M, Chun YH, An Y, et al. Clinical impact of asymptomatic presentation status in patients with paroxysmal and sustained atrial fibrillation: the Fushimi AF Registry. Chest 2017; 152: 1266–1275. PMID: 28823813

(* 5) Apple Watch is a trademark of Apple Inc.

(* 6) https://www.apple.com/jp/watch/why-apple-watch/

(* 7) 1) Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke 1991; 22: 983-988.2) Krahn AD, Manfreda J, Tate RB, Mathewson FA, Cuddy TE. The natural history of atrial fibrillation: incidence, risk factors, and prognosis in the Manitoba Follow-Up Study. Am JMed 1995: 98: 476-484.3) Levy S, Maarek M, Coumel P, Guize L, Lekieffre J, Medvedowsky JL, et al. TEXT of different subsets of atrial fibrillation in general practice in France: the ALFA study. The College of French Cardiologists. Circulation 1999; 99: 3028-3035.

(* 8) HATA, J. et al .: J. Neurol. Neurosurg. Psychiat,. 76. 368-372, 2005

(* 9) Okamatsu H, Okumura K, Kaneko S, et al. Ablation index-guided high-power radiofrequency application shortens the procedure time with similar outcomes to conventional power application in atrial fibrillation ablation. Circ Reports. Doi: 10.1253 / circrep. CR-21-0099

(* 10) Murakawa Y, Nogami A, Hirao K, et al. A brief report on the nationwide survey of catheter ablation in Japan / the Japanese Catheter Ablation Registry (JCAR). J Arrhythm 2012; 28: 122–126

The Japan Stroke Association has the basic principles of the "Basic Law for Stroke and Cardiovascular Disease Countermeasures", World Stroke Day (WSD) and "Minutes can save lives" in "Stroke Month". We will promote awareness of "Stroke Month" and support the WSD campaign. As part of this, the monuments and buildings in each region will be lit up in the symbol color Indigo Blue. Sun Tower (Osaka Prefecture), Aomori Prefecture Tourist Product Center Aspam (Aomori Prefecture), Showakan, Historical Site Ashikaga School, Tokushima Medical University Hospital (Tochigi Prefecture), Rinkokaku (Gunma Prefecture), Yamanashi Prefectural Office Annex (Yamanashi Prefecture), World Heritage Nagiyama Reflector, Mt. Fuji World Heritage Center, Shizuoka City Hall Main Building Dome (Shizuoka Prefecture), Johnson & Johnson Institute Tokyo (Kagawa Prefecture), Tokushima University Hospital, Tokushima Prefectural Central Hospital (Tokushima Prefecture), Takamatsu Symbol Tower, Prefectural Shiratori Hospital (Kagawa Prefecture), Kaikyo Dream Tower (Yamanashi Prefecture), Kumamoto University Hospital Clock Tower / Promenade (Kumamoto Prefecture) will be lit up. * The venue is subject to change without notice.

Click here for details on each area: http://www.jsa-web.org/citizen_event/4800.html

Cooperation: Japanese Standards Association for Stroke http://www.jsa-web.org/ Japanese Standards Association for Arrhythmic Electrocardiography http://new.jhrs.or.jp/

Provided by: Johnson & Johnson Co., Ltd. https://www.jnj.co.jp/

(Planning and production: Media Business Bureau, Asahi Shimbun)