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Lower Your Blood Pressure; Reduce Your Stroke Risk">

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ADA Moderator : Welcome to ADA Live!

Today our guest is Brett Kissela, MD, University of Cincinnati. Dr. Kissela's research is focused on the epidemiology of stroke (with special interests in racial disparities and the effects of diabetes), stroke outcomes and recovery, and acute stroke therapy. As a clinician, his interests include acute stroke, stroke prevention, and neurologic complications of diabetes.

Welcome Dr. Kissela.

Dr. Kissela: Thanks for having me.

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Cumberland, MD: My doctor said that salt is not the big high blood pressure culprit that they thought it was. Is that true? I love salty stuff!

Dr. Kissela: We're in the same boat, because I love salty stuff too. Your doctor is right that there is much more to high blood pressure than salt intake, and other factors like heredity, obesity, etc. are also important. And yet, it is clear that reducing salt intake can improve blood pressure for most people. I would work carefully with your doctor and try to limit salt intake as needed to obtain good BP control.

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San Diego, CA: What exactly is a stroke and why does having diabetes make it more likely that I'll get one?

Dr. Kissela: Most strokes are caused by a blood clot blocking a blood vessel that supplies the brain. During the time when the blood clot is present, the part of the brain fed by that blood vessel is not getting any oxygen and is thus "suffocating" in a sense. The brain cells fed by that blocked blood vessel will "die" (be irreversibly injured) if blood flow is not restored. During the time when the blood clot is blocking flow, the patient has symptoms related to the area of the brain not getting oxygen. For example, if the blood clot is preventing blood flow to the part of the right brain which controls movement of the left side of the body, the patient will have paralysis of the left side of the body. Blood clots that block flow can dissolve on their own. If they dissolve quickly, before permanent damage can occur, it is called a transient ischemic attack or TIA. In this case, the patient's symptoms go away when the blood clot dissolves. TIA's typically last minutes, although they can last hours. By definition, we call an event a TIA if the neurologic symptoms go away completely within the first 24 hours. A stroke is when the blood clot does not dissolve, resulting in permanent injury to the brain. The patient is left with symptoms that last more than 24 hours. The only other "variation" is that some strokes are related to a ruptured blood vessel, where a blood clot then forms in the brain leading to brain injury. "Bleeding" strokes account for about 10%, while the "blood clot" or ischemic strokes account for about 90% of strokes. Diabetes is the second most important risk factor for stroke after high blood pressure. Patients with diabetes have greater risk for high blood pressure, and the two together dramatically increase risk for stroke. Furthermore, diabetes is also associated with high cholesterol and obesity, and all of these factors increase risk for stroke (and heart attacks).

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new jersey: will just the act of exercising (walking for a half hour) lower my blood pressure? or is it the cumulative efffect of exercising over time and losing weight, etc. that lowers blood pressure?

Dr. Kissela: We believe that it is the cumulative effect over time that matters, and weight loss is an important part of lowering blood pressure.

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Jefferson City, Mo: Is the top number of blood pressure as important as the lower number?

Dr. Kissela: Both are important, and it has been proven that optimal control of BOTH systolic and diastolic BP (both the top and bottom numbers) is necessary to have the greatest benefit in lowering risk for stroke and heart attacks.

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albany new york: I am a 48 y/o male weight 286 lbs and inactive. I presented to the er with a comprehensive metabolic panel with a glucose,ser/plas of 151. have I managed to fall in the pre-diabetic range?

Dr. Kissela: You haven't provided enough information to answer the question. You did not mention if your blood test was done when you were fasting. The diagnosis of diabetes is best made by 2 or more elevated fasting glucose levels > 126. For fasting samples, levels of 100-125 are consistent with the "pre-diabetic" stage. It will be important for you to follow up with your physician. You definitely have risk factors for diabetes.

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Highland In.: I am a type 2 diabetic and struggle with the decision to take high blood pressure meds because my bp is within normal range. Can you please tell me why I should take it.I guess I should mention both my parents died of heart disease and other complications not diabetes.and I have had what they call the white coat syndrome where it seems my bp goes up a bit when I see my Dr. but otherwise its usually under 130/85or80.

Dr. Kissela: When deciding to take medications, it is important to consider the risks and the benefits. Your physician can tell you the side effects of the medications they prescribe (and if they don't, you should ask them). As to the benefit, there has been a great deal of research about the importance of controlling blood pressure in order to reduce risk of stroke or heart attack. The latest guidelines basically say that "the lower the blood pressure, the lower the risk". So 130/85, which is not too bad, is still worse than 120/80 and taking medications to lower your pressure to 120/80 will reduce your risk for stroke and heart attacks.

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Mt Pleasant, SC: Does stroke effect type 1 or type 2 diabetics?

Dr. Kissela: Stroke affects people with both Type 1 and Type 2 diabetes.

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Sammamamish,Wa.: my blood level keeps jumping from normal to high,I have not been told I was diabetic.

Dr. Kissela: The diagnosis of diabetes is best made by 2 or more elevated fasting glucose levels > 126. For fasting samples, levels of 100-125 are consistent with the "pre-diabetic" stage. It will be important for you to follow up with your physician. You definitely have risk factors for diabetes.

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NY, NY: I have been diagnosed with diabetes for 20 yr and I've had TIA before. Does this mean that I'm going to have a stroke in the future? Do I need to do anything special to stop stroke from happening?

Dr. Kissela: Anyone who has had a TIA before is at higher risk for having a stroke in the future. It is important to see your doctor regularly and to do everything possible to reduce all stroke (and heart attack) risk factors such as high BP, high cholesterol,etc. It is important to keep good control of your blood sugars, follow a healthy diet, and exercise regularly.

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ADA Moderator : What is Transient Ischemic Attack?

Dr. Kissela: A transient ischemic attack (TIA) is a transient stroke that lasts only a few minutes. It occurs when the blood supply to part of the brain is briefly interrupted. TIA symptoms, which usually occur suddenly, are similar to those of stroke but do not last as long. Most symptoms of a TIA disappear within an hour, although they may persist for up to 24 hours. Symptoms can include: numbness or weakness in the face, arm, or leg, especially on one side of the body; confusion or difficulty in talking or understanding speech; trouble seeing in one or both eyes; and difficulty with walking, dizziness, or loss of balance and coordination.

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Bronx, NY: How does diabetes contributes to high blood pressure and in turn how does how blood pressure leads to a stroke?

Dr. Kissela: Patients with diabetes are more likely than those without diabetes to have high blood pressure, high cholesterol, and obesity. All of these risk factors, individually and together, increase risk for stroke and heart attack. How they directly cause stroke is not clear. These factors certainly lead to increased atherosclerosis (hardening of the arteries) and this accounts for some strokes. These risk factors can also lead to heart attacks and heart failure, which can ultimately cause stroke when a blood clot forms in the heart and then moves "upstream" to block a blood vessel carrying oxygen to the brain.

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Lincoln, Neb: I recently had a heart attack. Thanksgiving day 2005. I am on blood thinner and a heart wonder drug called Coreg. I take 30mg of actos every day. My numbers are good. In the last week since the heat index has risen...I get very dizzy...I live in the Desert and it was 102 today. the heat has never bothered me in the past. I am type 2 diabetic...I can not get a good answer from my doctors. Could this be a blood pressure thing? Any ideas...It usually gets me between 10am an 3pm.

Dr. Kissela: It could be a BP thing. It would be helpful for you to see if the symptoms come on a few hours after the medications, and even to have your pressure checked when dizzy. If it is very hot and you are dehydrated, your blood pressure will be lower so be sure you drink lots of fluids.

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New Wilmington, Pa: I have been looking through the articles that I can find on the internet and can not find any kind of list of symptoms of diabetes. My family seems to have some concern about me and I am trying to convince them that they are worring needlessly. Ny sister is a diabetic (as was our mother) and as such she likes to check my

Dr. Kissela: Randomly measured values of glucose > 200 are indeed consistent with diabetes, as is having protein in your urine. Gaining weight is an important risk factor for diabetes, and type II diabetes does run in families. It sounds like your sister is not overreacting, and I would recommend that you follow up with your doctor. the ADA website is terrific and would probably be most helpful in understanding the symptoms and diagnosis of diabetes (www.diabetes.org); try also http://www.diabetes.org/diabetes-symptoms.jsp. Another good site is http://diabetes.niddk.nih.gov/dm/pubs/diagnosis/

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Tampa, FL: I have t2 diabetes and I was told to start blood pressure medication to keep me from getting kidney damage. Is that right?

Dr. Kissela: I am a neurologist, and not a kidney doctor. I can say that there have been many studies showing that some of the blood pressure medications (angiotensin converting enzyme inhibitors and angiotensin receptor blockers; ACE inhibitors or ARBs) are useful in patients with diabetes to prevent kidney damage, thus preventing long term complications like dialysis.

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blacklick ohio: does diabetes cause depression?

Dr. Kissela: I don't think that anyone knows what truly causes depression just yet. We know that it runs in families, but we just don't completely understand what is happening biologically, or why it happens. We do know that there are risk factors for depression, and diabetes is one of them. Most studies suggest that patients with diabetes have a 2-3 fold higher risk of being diagnosed with depression.

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ADA Moderator :

Those are all the questions we have time for today. Thanks so much for being here Dr. Kissela.

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We hope you found this interesting and informative and that you'll join us again next time here at ADA Live. Rite Aid Pharmacists and Diabetes Care Specialists will be with us next at 1:00 p.m. EDT June 1, 2006. See you then.