This isn’t the first study to point to links between stroke and dementia—in fact, up to 60 percent of stroke survivors develop some degree of post-stroke cognitive impairment, according to the ASA. Laura K. Stein, MD, MPH, associate professor of neurology at Mount Sinai, says the link underlines the importance of monitoring stroke survivors for cognitive decline and educating people about strategies that may confer protection against stroke and dementia.

First-Year Risk Greatest

For the study, a Canadian research team matched 180,940 people who had suffered a recent ischemic stroke (caused by a blood clot) or an intracerebral hemorrhage (caused by bleeding within the brain) with two control groups, one including people from the general population who had not had a heart attack or stroke, and the other including people who had suffered a heart attack but not a stroke. The researchers evaluated the rate of new cases of dementia starting at 90 days after a stroke, over an average follow-up of 5.5 years. In addition, they analyzed the risk of developing dementia in the first year after a stroke and over time, up to 20 years.

The analysis showed that the risk of dementia was greatest in the first year after a stroke, with a nearly threefold

increased risk. The risk halved by the five-year mark but remained elevated 20 years later. Dementia occurred in nearly 19 percent of stroke survivors over an average follow-up of 5.5 years. After accounting for dementia risk factors such as high blood pressure, diabetes, and high cholesterol, the risk of dementia was 80 percent greater in stroke survivors compared with people who had not experienced a heart attack or stroke. A similar increase in risk was seen in stroke survivors compared with people who had experienced a heart attack. The risk of dementia in people who had suffered an intracerebral hemorrhage (bleeding in the brain) was nearly one-and-a-half times greater than those in the general population.

Small-Vessel Disease Implicated

While there still is much we don’t undertand about the connection between stroke and dementia, Dr. Stein says we are learning more about the association between vascular health and brain health. “Researchers have recently identified the importance of the ‘neurovasculome’—a fancy term for the brain’s blood vessels, cells, and lymphatic system—to overall brain health and optimal cognition,” she says. “We know there is an association between dementia and damage to the small blood vessels of the brain, and there is evidence that cognitive outcomes may be better in people whose blood pressure is more aggressively treated.” She adds that damage from a stroke can damage brain structures and the connections between them, as well as the neurovasculome, and notes that this damage is especially likely in a brain with pre-existing susceptibility due to small-vessel disease and lower reserve (essentially the brain’s capacity to withstand harm). “In people with these vulnerabilities, a smaller stroke may have a greater impact than a larger stroke would in someone with greater baseline brain reserve,” she explains.

Post-Stroke Cognitive Screening Is Vital

While people with mild post-stroke cognitive impairment may recover fully, an improvement in cognitive impairment without a return to pre-stroke levels is more likely. Persistent impairment may be too mild to warrant a diagnosis of dementia, but still can affect your independence and quality of life after a stroke. This means it is important for stroke survivors to be evaluated for cognitive decline—indeed, a 2023 American Heart Association scientific statement recommends post-stroke cognitive screenings. If you are a stroke survivor and have not been screened for cognitive impairment, Dr. Stein recommends you discuss screening with your doctor. “Screening is especially important if someone is not meeting expected post-stroke milestones and may identify potentially reversible contributors to cognitive impairment,” she says. Possible contributing factors include depression, abnormal electrolytes (minerals that affect numerous body functions), thyroid disorders, low levels of vitamin B₁₂, and medication side effects. “Even if a reversible cause of cognitive impairment following stroke is not identified, a thorough cognitive evaluation can help an individual understand their cognitive strengths and weaknesses, identify areas for lifestyle modification and targeted cognitive therapy, and plan for the future,” Dr. Stein adds.

Safeguard Yourself Against Stroke

There is evidence to support that more severe and recurrent strokes are more strongly associated with post-stroke dementia. “This means that one of the most important things we can all do for our brain health is to identify and aggressively treat risk factors for stroke,” Dr. Stein emphasizes. These include high blood pressure, high cholesterol levels, the abnormal heart rhythm atrial fibrillation, diabetes, obesity, and smoking. Research suggests that having three or more cardiovascular risk factors may increase the risk of post-stroke dementia in older adults and has indicated that diabetes and atrial fibrillation may be particularly influential. See this month’s From the Editor for strategies to manage these risk factors.

Also be aware of symptoms that may indicate a stroke, including sudden problems with your balance and/or coordination, blurred vision or loss of vision, drooping on one side of the face, numbness/weakness in one arm, and slurred or incoherent speech. “Time is brain, and you should immediately call 911 if you think you or someone you know could be experiencing a stroke,” Dr. Stein concludes.

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Hyper vs. Hypo

The thyroid is a small butterfly-shaped gland situated in the neck, just below the larynx. Its function is to absorb iodine, an element that occurs mainly in salt, bread, and fish, and convert it into triiodothyronine (T3) and thyroxine (T4). These hormones control your metabolism, influencing everything from the speed at which you digest fats and carbohydrates, to the rate at which your heart beats.

Another hormone—thyroid stimulating hormone (TSH)— also plays an important role in thyroid function. TSH stimulates the thyroid to produce T3 and T4. As such, measuring the level of TSH in the blood can flag underlying thyroid issues. High TSH levels may indicate that the thyroid is not producing enough thyroid hormone (hypothyroidism, which also is known as underactive thyroid), while low TSH levels may mean that your thyroid is producing too much thyroid hormone (hyperthyroidism, or overactive thyroid).

Hypothyroidism

This is the most common thyroid disorder and occurs when T4 levels are too low. Low T4 levels cause body processes to slow down— as such, symptoms typically include fatigue, weight gain, sluggish bowel movements, and increased sensitivity to cold. However, in older adults, these symptoms are less common—instead, an underactive thyroid may cause depression, loss of appetite, weight loss, and joint pain. Since these symptoms are associated with other diseases that are common in older age, recognizing hypothyroidism is challenging. Dr. Arakawa adds that it also is possible to develop subclinical hypothyroidism, in which TSH levels are only slightly elevated while levels of T3 and T4 are normal. “People who have subclinical hypothyroidism may report nonspecific symptoms, such as an altered mood and cognitive impairment, while many don’t have any symptoms,” she says.

HYPOTHYROIDISM RISK FACTORS

You are at increased risk for underactive thyroid if you have a family history of thyroid disease, have been treated for an overactive thyroid, and/or have had extensive surgery or radiotherapy to your neck. Some medications also raise the risk— for example, the cancer drugs sunitinib (Sutent®) and imatinib (Gleevec®) can cause or worsen an underactive thyroid, as can amiodarone (Corderone®, Pacerone®), which is used to treat heart arrhythmias.

It also is possible for underactive thyroid disease to arise from an autoimmune condition called Hashimoto’s thyroiditis, which impedes the thyroid gland from secreting hormones. Hashimoto’s usually causes a goiter, which is a swelling in the neck arising from enlargement of the thyroid gland.

TREATING HYPOTHYROIDISM

Dr. Arakawa emphasizes that treatment has not been shown to have a significant impact on symptoms in older adults with subclinical hypothyroidism. Although subclinical hypothyroidism is associated with an increased risk for progression to overt hypothyroidism and adverse cardiovascular events, the policy is to monitor people with subclinical disease and initiate treatment only if overt hypothyroidism occurs.

Treatment for overt hypothyroidism is a synthetic version of thyroid hormone called levothyroxine (Synthroid®, Levoxyl®). The drug is one of the most prescribed medications in the United States, but overusing it is known to increase the risk of osteoporosis. Recent research suggests that levothyroxine overuse also may increase the risk of cognitive issues in older adults. The 2023 study (JAMA Internal Medicine, Oct. 23) included 65,931 older adults and focused on thyrotoxicosis (excess T3 and /or T4 levels in the body). The new study suggests that thyrotoxicosis caused by medication raises the risk of cognitive decline. Dr. Arakawa says the data are a useful reminder for doctors to be cautious when prescribing thyroid hormone to older adults. “It’s important to regularly monitor people who are taking levothyroxine and decrease the dose if needed,” she notes.

Hyperthyroidism

This occurs when the thyroid releases too much T3 and T4, and it causes the body to “speed up.” Younger people may experience symptoms like an increased appetite, palpitations (the sense your heart is “skipping” beats), a tremor in the hands and arms, more frequent bowel movements, excessive perspiration, anxiety, and insomnia. But—as with hypothyroidism—overactive thyroid symptoms may be different in older adults, who “tend to present more nonspecifically, with fatigue, weight loss, and mood changes,” according to Dr. Arakawa. “Cardiovascular manifestations of hyperthyroidism also tend to predominate, particularly the abnormal heart rhythm atrial fibrillation,” she adds.

HYPERTHYROIDISM RISK FACTORS

In older adults, hyperthyroidism usually is related to abnormal growths that form in the thyroid gland. Called thyroid nodules, these can produce more T3 and T4, which is what makes the thyroid overactive. An overactive thyroid also can be caused by an autoimmune condition (Grave’s disease). Studies have linked Grave’s disease to an increased risk of cognitive decline. In other cases, drugs may trigger thyroid overactivity— for example, amiodarone, which can trigger both overactive and underactive thyroid disease.

TREATING HYPERTHYROIDISM

Untreated hyperthyroidism is known to increase the risk of developing osteoporosis, a condition that raises the risk of fractures. “Hyperthyroidism also can impact the pumping and rhythm functions of the heart, which may lead to conditions such as heart failure and atrial fibrillation,” Dr. Arakawa says. “These risks are augmented in people ages 65 and older, so treatment is recommended to correct hyperthyroidism.”

Treatment options include anti-thyroid medications, such as methimazole (Tapazole ®), which blocks the production of thyroid hormones. Alternatively, radioactive iodine can destroy the overactive thyroid cells, rapidly shrinking an enlarged thyroid gland. This can leave the thyroid unable to produce any hormone, and it’s likely you’ll eventually become hypothyroid and require treatment for that.

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A study published in the Journal of the American Medical Association, May 30, provides more evidence that active surveillance is an effective alternative to immediate surgery or radiation to manage prostate cancer with a low risk of progression. For the study, researchers at Seattle’s Fred Hutchinson Cancer Center looked at data from 2,155 men, median age 63, who had been diagnosed with grade 1 disease. Up to 10 years after being diagnosed, 49 percent of men whose disease was managed using active surveillance—which includes regular prostate-specific antigen testing, biopsies, and digital-rectal exams to monitor whether the cancer is growing or becoming more aggressive—remained free of treatment or progression. Less than 2 percent developed metastatic disease (cancer that has spread to other areas of the body) and less than 1 percent died of prostate cancer. The researchers note that about 30 percent of men diagnosed with prostate cancer fall into the low-risk category and may not benefit from invasive treatments that can cause debilitating side effects, including urinary incontinence and impotence.

Cancer Risk After Breast Cancer

A new study (Lancet Regional Health – Europe, April 24) adds to evidence that breast cancer survivors are at greater risk of developing second cancers. The study, from the UK’s University of Cambridge, analyzed data from more than 580,000 female and 3,500 male breast cancer survivors. Women were at double the risk of developing contralateral cancer (cancer of the other breast) compared with the general population and at 87 percent greater risk of endometrial cancer, 58 percent greater risk of myeloid leukemia, and 25 percent greater risk of ovarian cancer. Men were 55 times more likely than the general male population to develop contralateral breast cancer, although the risk still was extremely low. They also were 58 percent more likely than the general male population to develop prostate cancer. If you are a breast cancer survivor, ask your doctor what you can do to lower your risk of subsequent cancers.

Yoga May Help Heart Failure

If you have heart failure, consider taking up yoga. According to a small study presented at Heart Failure 2024, a European Society of Cardiology annual meeting, this gentle form of exercise and meditation may help improve heart failure symptoms. The study included 85 people, up to 70 years of age, who were receiving outpatient treatment for heart failure at Kasturba Hospital in Manipal, India. All had undergone a cardiac procedure within the past six months to one year and were taking guideline-recommended heart failure medications. About half of them participated in supervised yoga sessions for one week and then did yoga at home once a week for 50 minutes, while continuing to take their medications. A control group took medications but did not do yoga. At the end of the 12-month study, the yoga group experienced improvements in their heart’s pumping ability, their blood pressure, and their ability to do ordinary activities such as walking and climbing stairs.

Gum Disease and A-Fib

If you’ve recently had an ablation procedure to treat the abnormal heart rhythm atrial fibrillation (A-fib), it’s worth having your dentist check you for gum disease and treat the condition if you have it. A recent small study from researchers at Japan’s Hiroshima University (Journal of the American Heart Association, April 16) included 97 people who had undergone radiofrequency catheter ablation (a procedure in which radio waves are used to destroy small areas of heart tissue that contribute to A-fib) and received treatment for gum disease within 90 days of the ablation procedure, along with 191 ablation recipients who did not receive gum disease treatment. During an average follow-up period of 8.5 months to two years, A-fib recurred among 24 percent of the study participants. Those whose gum disease was treated were 61 percent less likely to have a recurrence of A-fib.

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Primary and Secondary Prevention

The study we reference (BMJ Medicine, May 21) included 415,737 people, ages 40 to 69, who were surveyed between 2006 and 2010 to gather health information that included their usual dietary intake of fatty and non-fatty fish, and fish oil supplements. Nearly one-third of the participants said that they regularly took fish oil supplements.

The researchers set out to examine the association between fish oil supplements and the primary prevention of a range of cardiovascular disease outcomes over an average 12-year follow-up. The disease outcomes in question included the abnormal heart rhythm atrial fibrillation, major adverse cardiovascular events (such as heart attack and stroke), and all-cause death in people who either had no known cardiovascular disease or were at high risk of cardiovascular disease.

“Primary prevention essentially is defined as preventing a disease or disease-related event from ever occurring,” explains Mount Sinai cardiologist Bruce J. Darrow, MD, PhD. “The researchers also assessed the modifying effects of fish oil supplements on atrial fibrillation and other outcomes in people with known cardiovascular disease for the purpose of secondary prevention—that is, preventing the recurrence of disease or disease-related event in people who already have a specific health condition.”

Role Playing

The analysis indicated that regular use of fish oil supplements played different roles in cardiovascular health, disease progression, and death. “For people with no known cardiovascular disease at the start of the monitoring period, regular use of fish oil supplements was associated with a 13 percent greater risk of developing atrial fibrillation and a 5 percent greater risk of suffering a stroke,” Dr. Darrow notes. “Among people who had atrial fibrillation at the start of the trial, regular use of fish oil supplements was associated with a 15 percent lower risk of heart attack during follow-up. People with heart failure who took fish oil supplements had a 9 percent lower risk of dying during follow-up.”

No Strong Proof

Dr. Darrow points out that this was an observational study. “An observational study is a type of study in which researchers are not attempting to influence the results through some type of intervention, such as a drug,” he explains. “Observational studies cannot prove cause and effect. With this specific study, it’s hard to draw any conclusions about who was taking supplements for what period of time across the 12-year follow-up.” He adds that there are other important things we don’t know about the study participants. “For example, those who reported being healthy may have had heart disease that had not yet been diagnosed. We also don’t have any information on the formulation or dosage of the supplements taken by the participants— previous studies have shown that very high doses of fish oil raise the risk of atrial fibrillation.”

Better Evidence of Benefit

The 2018 VITAL study remains the largest randomized controlled trial to look at fish oil supplementation in people with no known cardiovascular disease. The results suggested that the supplements reduced the risk of heart attack and all cardiovascular disease-related events by 28 percent and 17 percent, respectively. The effect of fish oil on atrial fibrillation was not studied, and there was no increase in stroke.

“VITAL was a randomized, controlled trial, and because the formulation and dosage of supplements was carefully monitored in the study, the results are stronger proof of the possible benefits of supplementation,” Dr. Darrow says. “Further studies would be useful to determine whether any outside influences modify the effects of fish oil supplements and clarify how the supplements might influence the development and prognosis of cardiovascular disease-related events.”

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The U.S. Food & Drug Administration (FDA) has announced a recall of the HeartMate II and HeartMate 3 left ventricular assist devices (LVADs) after the devices were tied to 273 known injuries and 14 deaths. However, as of late April, the two devices are not being removed from the market, and the manufacturer says that people whose devices are functioning normally have no cause for concern. Both LVADs are used to help the heart pump blood when it cannot effectively do so on its own and can provide short- and long-term support to people with severe or end-stage heart failure. In rare cases, biological material can deposit in grafts connecting the devices to the heart. Such deposits can slow blood flow through the heart. The recall affects several models distributed starting April 21, 2008, and involves 13,883 devices. If you use an LVAD and have not been contacted by the device manufacturer, double-check with your cardiologist whether you are affected by the recall. Also stay alert for low-flow alarms emitted by the devices, and immediately contact your doctor if the alarm sounds.

Sweetened Drinks and AFib

Consuming too many sweetened drinks is linked to the abnormal heart rhythm atrial fibrillation (AFib), according to research published in the March issue of Circulation: Arrhythmia and Electrophysiology. For the study, researchers at Shanghai JiaoTong University looked at more than 200,000 people who were free of AFib. During a 10-year follow-up, there was a 20 percent increased risk of AFib among people who said they drank more than 2 liters per week of artificially sweetened beverages, and a 10 percent increased risk among participants who drank a similar amount of sugar-sweetened beverages. People who said they drank 1 liter or less of pure fruit or vegetable juice each week had an 8 percent lower risk of AFib. Since the analysis is based on dietary questionnaires that may not be accurate, the results show an association only, not cause and effect. However, previous research has linked artificially sweetened and sugary drinks to obesity and type 2 diabetes.

Stroke and Depression

A study carried out by researchers at King’s College London underlines the risk of depression faced by stroke survivors. The study (The Lancet Regional Health—Europe, March 25) included 6,600 stroke survivors, median age 68. Over an 18-year follow-up, nearly 60 percent of the participants experienced depression compared with 22 percent of the general population. About 88 percent of depression cases occurred within the five years following a stroke. Depression that occurred within three months of a stroke tended to be more severe, had a longer duration, and was more likely to recur than mild depression. Previous studies have associated post-stroke depression with poor functional ability and increased mortality. American Heart Association guidelines recommend routine screening for post-stroke depression—alert your doctor if you have not been screened.

How to Move More

Inactivity increases the risk of high blood pressure and other chronic health conditions, but it can be a challenge to get moving if you’ve fallen into sedentary habits. A new study led by researchers at Kaiser Permanente Washington Health Research Institute used a relatively simple approach to successfully reduce sitting time for a group of older adults by around 30 minutes a day. The study (JAMA Network Open, March 27) included 283 people, ages 60 to 89, who reported sitting for more than six hours per day. In the study, participants who used an activity tracker and took part in 10 health coaching sessions over six months sat for 32 minutes less per day, on average, compared with a control group who received health coaching only. If you need motivation to sit less during the day, a simple activity tracker may spur you to get moving, as long as you actually use it—you also may be able to find a fitness coach through your local gym.

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Historically, patients who had A-fib were evaluated and managed based solely on the duration of the irregular heartbeat that is A-fib’s primary symptom. Now, the guideline emphasizes that A-fib requires a variety of strategies at its different stages—from prevention to therapeutic treatment—with an emphasis on modifiable lifestyle habits such as exercise, diet, and reduced alcohol consumption.

Recognizing A-fib

A-fib, is the result of irregular beating of the heart’s upper chambers. It leads to disrupted blood flow and an increased risk of stroke, heart attack, and heart failure. A-fib manifests as heart palpitations or irregular heartbeat, sometimes accompanied by other symptoms, including lightheadedness, fatigue, chest pain, and shortness of breath. It is the most prevalent heart rhythm disorder, and its incidence is growing. The American Heart Association estimates that there are 50 million people worldwide who have A-fib. The prevalence of A-fib increases with age, and is more common in women than men. What’s more, “Women are more symptomatic and report worse quality of life with A-fib and are at higher risk of stroke,” says Jessica M. Peña, MD, Weill Cornell Medicine, Director, HeartHealth, Dalio Institute of Cardiovascular Imaging.

Preventing and Managing A-fib

Making lifestyle changes and tweaking other modifiable risk factors to prevent onset, progression, and adverse outcomes of A-fib are the backbone of the guideline. “While advising patients to improve modifiable risk factors has always been part of A-fib management, the new guideline is more focused on this aspect. For example, the guideline specifies the amount of exercise recommended to reduce the burden of A-fib, and also advocates for 10 percent weight loss in individuals with A-fib who have obesity or are overweight,” says Dr. Peña. The guideline states that moderate-to-vigorous exercise for 210 minutes per week has been shown to reduce A-fib symptoms.

Reassessing Anticoagulation

The guideline reassesses the role of anticoagulation therapy, which plays a key role in A-fib management. A-fib is associated with an increased risk of blood clots, which can lead to stroke, and anticoagulants help prevent the formation of blood clots. The guideline suggests that doctors use a “risk score” calculation to gauge how likely it is that someone will develop a blood clot, and then base their use of anticoagulation medicine on the score. Because anticoagulant therapy carries a risk of bleeding, it can be especially concerning for people with a high risk of bleeding due to factors such as advanced age, history of gastrointestinal bleeding, or use of medications that increase the risk of bleeding, such as aspirin and non-steroidal anti-inflammatories. “The decision to start or continue anticoagulation takes into account a person’s risk of stroke and bleeding, as well as their preferences and other risk factors,” says Dr. Peña.

Catheter Ablation

The guideline includes recommendations for changing how and when people seek certain treatment options. An example is catheter ablation. This is now considered a reasonable first-line treatment for A-fib. The surgery, which takes from two to four hours, entails having an electrophysiologist—a specific kind of cardiologist—perform a procedure that blocks irregular electrical signals within the heart to reduce arrhythmia episodes. According to the guideline, scientific evidence shows that ablation is superior to any available antiarrhythmic drug.

The guideline underscores the need for a comprehensive and proactive approach to patient care, integrating treatment with lifestyle interventions. “By taking proactive measures including lifestyle changes, risk management, early catheter ablation, and stroke risk reduction, we can prevent, detect and manage A-fib and its consequences,” says Dr. Peña.

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“There are many different types of arrhythmias. Some come from the top chambers of the heart and some from the bottom,” explains Marwah Shahid, MD, clinical instructor, UCLA Department of Cardiology. “Depending on the type of arrhythmia, various populations can be affected. In general, as we age, we are at higher risk of heart disease, and this puts us at a higher risk for a variety of arrhythmias.”

Types of Arrhythmias

One of the most common arrhythmias is a condition known as atrial fibrillation (Afib). If you have Afib, your heart’s upper chambers (atria) beat out of rhythm with your lower chambers (ventricles). The atria quiver erratically, so circulation throughout the body is compromised. Blood can also pool in the heart, possibly leading to blood clot formation and a higher risk of stroke.

Other types of arrhythmias include bradycardia, an abnormally slow heart rate, and tachycardia, an abnormally fast heart rate. There are other kinds of arrhythmias that cause heart palpitations. If you are diagnosed with any heart rhythm disturbance, you should work with an electrophysiologist, the type of cardiologist who specializes in the heart’s electrical system.

Prevention Strategies

“Atrial fibrillation may be prevented by treating high blood pressure, eating healthfully, avoiding excessive alcohol, and treating obstructive sleep apnea,” says Dr. Shahid. “The more serious arrhythmias, those that come from the bottom chambers of the heart such as ventricular tachycardia, may be averted by preventing ischemic heart disease.”

Ischemic heart disease (IHD), also known as coronary artery disease or coronary heart disease, is a condition that primarily affects the blood vessels that supply the heart muscle with oxygen and nutrients. It is the most common type of heart disease. IHD occurs when the coronary arteries, which are responsible for carrying blood to the heart muscle, become narrowed or blocked due to the buildup of fatty deposits called plaques within the artery walls. These plaques can restrict blood flow to the heart, leading to a reduced supply of oxygen and nutrients to the heart muscle.

Risk Factors

If you have had a heart attack or any type of heart disease, you’re at a higher risk for an arrhythmia. A preexisting heart condition also raises your risk of developing sudden cardiac arrest symptoms, such as palpitations and a sudden loss of pulse and consciousness. If you have a type of arrhythmia known as ventricular fibrillation, in which the ventricles beat abnormally, your risk of sudden cardiac arrest is somewhat elevated. Unlike a heart attack, which is the result of blockage in the arteries within the heart, sudden cardiac arrest is usually the result of an electrical problem in the heart.

Treatment Options

Lifestyle adjustments can sometimes be a treatment, for example, identifying and avoiding substances or activities that can trigger arrhythmias, such as caffeine, alcohol, certain medications, or stress. Likewise treating underlying medical conditions, such as high blood pressure, diabetes, or thyroid disorders, which may contribute to arrhythmias is also helpful.

Some people may need antiarrhythmic drugs, which help regulate heart rhythms by either slowing down a rapid heartbeat or stabilizing irregular rhythms. The choice of medication depends on the specific type of arrhythmia. If drugs can’t control the heart palpitations and other problems associated with the abnormal heart rhythm, interventions may be necessary. This often means a catheter procedure called an ablation, in which the tiny portion of heart tissue presumed to be the cause of the electrical disturbance is destroyed. Implantable devices that help regulate the heart’s rhythm may also be advised. The choice of treatment depends on the specific arrhythmia, its cause, and an individual’s overall health. Regular follow-up appointments are often necessary to monitor the condition and adjust treatment as needed.

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New blood thinners developed over the last decade have made blood clot prevention less onerous, but a study published in Circulation, Aug. 27, 2023, suggests that switching from stable warfarin (Coumadin®) may not be the best option for frail elders. The new drugs, called direct oral anticoagulants (DOACs), include apixaban (Eliquis®), dabigatran (Pradaxa®), edoxaban (Savaysa®), and rivaroxaban (Xarelto®). Many doctors now prescribe DOACs as initial therapy because warfarin, while effective, has numerous food and drug interactions that raise the risk of bleeding. The study, from researchers at University Medical Center Utrecht, in the Netherlands, randomized 1,323 frail adults, mean age 83, who had been receiving their warfarin at a special thrombosis service, to switch from warfarin to a DOAC or remain on warfarin. The results showed that those who switched to a DOAC had an elevated risk for a major or clinically relevant non-major bleeding complication over the next 12 months (15.3 percent vs. 9.4 percent among people who did not switch), with no beneficial reduction in blood-clot related events (2.4 percent vs. 2 percent). Part of the reason for this is that they had been taking the warfarin for a while without having a serious bleed. These data suggest that physicians shouldn’t consider switching frail older adults who are stable on warfarin to a DOAC without a specific reason.

Sleep Cooler, Sleep Better

Lowering the overnight temperature in your bedroom may help you sleep better, according to a new Harvard study (Science of the Total Environment, November 2023). For the study, monitors were used to check how well 50 older adults slept and record the nightly temperature in their bedrooms. The analysis showed that the participants slept better when the temperature in the bedroom was between 68 and 77°F. The results likely are linked to the fact that your body signals your brain that it’s time to go to sleep by lowering your core temperature, and sleeping in a hot bedroom interferes with this.

Hobby Means Happy

Older adults who have a hobby are happier, less likely to experience depression, and more likely to report better health and life satisfaction, according to a recent University College of London study. For the study (Nature Medicine, Sept. 11, 2023), researchers looked at data from 93,263 people, ages 65 and older, who reported hobbies that included volunteering, being part of a club, reading, gardening, playing games, and arts and crafts. Of the four outcomes, life satisfaction was most strongly linked to having a hobby. Hobbies may contribute to life satisfaction in our later years through many mechanisms, including finding a purpose in life. Keep in mind, though, that the association also may work in reverse—that is, people with better mental health may be more likely to take up a hobby.

Poor Sleep After Menopause Linked to Atrial Fibrillation

Many women sleep badly and feel more stressed during and after menopause. A study from Santa Clara Valley Medical Center in California suggests that these symptoms could make postmenopausal women more likely to develop the irregular heart rhythm atrial fibrillation (A-fib), which increases the risk of blood clots, stroke, and heart attack. The study (Journal of the American Heart Association, Sept. 5, 2023) reviewed data from more than 83,000 questionnaires completed by women ages 50 to 79 who took part in the long-running Women’s Health Initiative (WHI). During about a decade of follow-up, 25 percent of the women developed A-fib. For each additional point they scored on the WHI Insomnia Rating Scale, there was a 4 percent greater likelihood of developing A-fib. For each additional point scored on the WHI Stressful Life Event Scale, there was a 2 percent greater likelihood of A-fib. The researchers say that hormonal changes that accompany menopause may underpin the associations between stress, insomnia, and A-fib.

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A diagnosis of atrial fibrillation (A-fib) was associated with a 45 percent increased risk of mild cognitive impairment (MCI) in a study of more than 4 million people. MCI is an early stage of cognitive decline that can indicate development of early dementia-related disease. In addition to the increased risk of MCI after an A-fib diagnosis, the study found that older people, women, and people with a history of depression and stroke also had a higher MCI risk. Furthermore, for individuals over age 74, A-fib and MCI were frequently diagnosed when other conditions, including diabetes, depression, high cholesterol, and peripheral artery disease were present. Patients with A-fib who were treated with digoxin, a drug used to control heart rate and rhythm, did not experience an increased MCI risk, and the risk of MCI was higher in patients with A-fib who did not receive either oral anticoagulants or amiodarone, an arrhythmia treatment. The researchers suggest, based on their findings, that integrated A-fib care, such as combining anticoagulation and comorbidity management, could help prevent cognitive deterioration. Further studies are needed to confirm this.

Researchers Reframe Lasting Effects of Acute Respiratory Infection as “Long Colds”

A new study has found that people may experience long-term symptoms—or “long colds”—after acute respiratory infections. Some of the most common symptoms of the long cold included coughing, stomach pain, and diarrhea more than four weeks after the initial infection. The findings suggest that there may be long-lasting health impacts following non-COVID acute respiratory infections such as colds, flu, or pneumonia. The research compared the prevalence and severity of long-term symptoms after an episode of COVID-19 versus an episode of another acute respiratory infection that tested negative for COVID-19. Those recovering from COVID-19 were more likely to experience lightheadedness or dizziness and problems with taste and smell compared with those who had a non-COVID-19 respiratory infection. While the severity of an illness appears to be a key driver of risk of long-term symptoms, more research is being carried out to establish why some people suffer extended symptoms while others do not.

Mobile Stroke Units Increase Odds of Patient Recovery

Receiving a clot-busting drug in an ambulance-based mobile stroke unit (MSU) increases the likelihood of averting a full-blown stroke and achieving complete recovery compared with standard hospital emergency care, according to a study performed by researchers at Weill Cornell Medicine and five other medical centers across the U.S. The study determined that MSU care was associated with increased odds of averting stroke compared with hospital emergency medical service (EMS), and a higher percentage of patients having an earlier resolution, within 24 hours after stroke. The researchers evaluated 1,009 patients: 644 received tissue plasminogen activator (t-PA) delivered intravenously (IV) in an MSU, and 365 received EMS care. The study found that with t-PA treatment in a mobile unit about one in four patients who had a suspected stroke recovered within 24 hours and one in six averted a stroke with no demonstrable trace of brain injury on an MRI. The outcome improved for patients treated by an MSU since the time from symptom onset to treatment was 37 minutes faster than for EMS care, meaning many more patients received vital t-PA within the crucial first hour.

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Healthy lifestyle choices can help you control conditions and reduce your risk for stroke. For example, high cholesterol and high blood pressure increase your chances of having a stroke. Eating foods low in saturated fats, trans fat, and cholesterol and high in fiber can help prevent high cholesterol, and limiting sodium in your diet can lower your blood pressure.

“The chief risk factors for stroke include high blood pressure, high cholesterol, and diabetes,” says Dana Leifer, MD, a neurologist at Weill Cornell Medicine. “People who control these factors through diet, exercise, and medication can significantly reduce the risk of stroke.” Cigarette smoking and the use of other forms of tobacco or nicotine are also major risk factors. “Smoking cessation is the single most important way of preventing strokes in anyone who smokes,” explains Dr. Leifer.

Stroke Risk Reduction

Maintaining a healthy weight and getting regular exercise also can reduce your stroke risk. Physical activity can help you stay at a healthy weight and lower your cholesterol and blood pressure levels. For adults to maintain health, the Surgeon General recommends 2 hours and 30 minutes of moderate-intensity physical activity, such as a brisk walk, each week, but any amount of exercise is a step in the right direction.

Limiting alcohol consumption and taking the medications prescribed by your doctors are also instrumental in reducing the risk of stroke. Because alcohol can raise blood pressure, the CDC recommends that women have no more than one drink per day. If you have heart disease, high cholesterol, high blood pressure, or diabetes and you have been prescribed a regimen of daily medications, be sure to follow your doctor’s orders. Set an alarm on your smartphone to help you remember to take medicine at the same time every day. It’s a simple way to lower your risk of stroke.

If you take estrogen supplements, talk to your doctor about your risk of stroke. “Estrogen supplements increase the risk of clotting and therefore of stroke and should be used with caution, especially in women who use tobacco or nicotine or have other risk factors or a prior history of stroke,” warns Dr. Leifer. “In addition,” he says, “an irregular heart rhythm such as atrial fibrillation is also a risk factor for stroke. Therefore strong bloodthinning drugs should be considered in patients who have atrial fibrillation.”

Stroke Warning Signs

Dr. Leifer describes the warning signs of stroke as sudden onset of any of the following:

• Facial droop

• Limb weakness on one side

• Difficulty speaking

• Loss of vision in one eye or one side

• Double vision

• Numbness or tingling on one side

• Dizziness • Unsteady gait

• Decreased coordination

• Severe headache

“Sudden onset of these problems is a reason to go to an emergency room immediately. Even if these symptoms last only a short time, they should be evaluated urgently because they may be transient ischemic attacks (TIAs),” he explains. A TIA is the same as a stroke, but the symptoms last a short time. People get stroke symptoms when experiencing a TIA because a clot is blocking the blood supply in the brain. When the clot moves away, the stroke symptoms stop. Having a TIA is a warning that a stroke may be imminent. “The same things that cause TIAs can also cause strokes. TIAs are a risk factor for stroke, and the greatest risk of stroke is probably within 24 to 48 hours after a TIA,” explains Dr. Leifer.

Importance of Quick Treatment

Stroke patients who are taken to the hospital in an ambulance may get diagnosed and treated more quickly because emergency treatment starts on the way to the hospital. The quicker someone gets treated, the better the chance for recovery, which is why recognizing the signs and symptoms of stroke is vital.

While stroke poses a significant risk of death and disability, making healthy lifestyle choices reduces the risk considerably, and recognizing the signs of stroke—and acting quickly if they occur—can increase the likelihood of survival.

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