Stroke treatment often delayed

Stroke victims frequently fail to seek emergency treatment promptly enough, and even when they do get to the ER quickly, their treatment is often delayed, a new study shows.

"Our study shows that most people with stroke symptoms still do not get to the hospital in a timely manner," lead researcher Dr. Kathryn R. Rose, of the University of North Carolina, Chapel Hill, told Reuters Health.

"This precludes them from being considered for time-dependent treatments that can reduce disability and death following a stroke."

In most cases, strokes are caused by a blood clot hindering blood flow to the brain. A drug called tissue plasminogen activator, or tPA, can be used to dissolve the clot and limit stroke damage, but it must be given within three hours of a person's first symptoms.

In their study, Rose and her colleagues found that of 15,177 patients in a North Carolina stroke registry, less than one-quarter arrived at the hospital within two hours of symptom onset. Of these patients, just 24 percent received a CT scan within the recommended time frame.

The researchers report the findings in the journal Stroke.

A CT scan is considered crucial to stroke diagnosis, and one must be done before tPA can be given. National guidelines call for running a CT scan within 25 minutes of a patient's arrival at the hospital, regardless of when their symptoms began.

Yet, Rose and her colleagues found, among stroke patients who arrived at the hospital more than two hours after their symptoms started, only 9 percent received a CT scan within 25 minutes.

"While patients that arrive to the hospital within 2 hours of symptom onset are more likely to receive a timely CT scan than those who do not," Rose said, "most do not. This points to areas where stroke systems of care within hospitals can be improved."
ne way stroke sufferers might improve their odds of prompt treatment is to call an ambulance, the study suggests.

Patients who arrived via emergency medical services were twice as likely to receive a timely scan as those who arrived on their own, the researchers found.

Given the implications of timely arrival, Rose said, "it is important for people to recognize the symptoms of stroke and promptly call emergency services when they occur."

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Angiotensin Receptor Blockers (ARBs)

Angiotensin II receptor blockers (ARBs) have beneficial
effects similar to those of ACE inhibitors, but angioedema
occurs less, and cough rarely occurs compared to ACE
inhibitors.

Mechanism of Action
Angiotensin I can be formed by nonrenin enzymes such as
cathepsin or tonin. Angiotensin I may be converted to
angiotensin II by trypsin, cathepsin, or the heart chymase,
but the exact contribution of these alternative pathways
to the formation of angiotensin II remains unclear.
Angiotensin II activates two subtypes of angiotensin II
receptors, AT1 and AT2, but only the AT1 receptor
mediates all the known clinical effects of angiotensin II
described above in Section I. AT1 receptors are present in
the heart, kidney, vascular smooth muscle cells, brain,
adrenal glands, platelets, the placenta, and in adipocytes.
The AT2 receptor affects the inhibition of cell growth,
promotion of cell differentiation, tissue repair, apoptosis,
and perhaps to a small degree, the production of
bradykinin, NO, and prostaglandins in the kidney. Other
effects may emerge with further research. The AT2
receptors have been cloned and are present at a low level
in the adrenal gland, heart, brain, kidney, and uterus.
ARBs were expected to have clinical effects that would
be equal to or superior to those observed with ACE
inhibitors. Clinical trials during the past five years have
indicated that these agents reduce microalbuminuria and
glomerulopathy and delay time to end-stage renal disease
in patients with type 2 diabetes. ACE inhibitors have been
shown to be useful in causing similar beneficial effects
in patients with type 1 diabetes, but evidence in type 2
diabetic nephropathy is not convincing. Direct comparison
of ARBs with ACE inhibitors in this subset of patients
has not been tested. Head-to-head trials of ARBs and ACE
inhibitors in diabetic nephropathy need to be conducted to
determine their respective place in renoprotection.
Dual blockade of the renin-angiotensin-aldosterone
system with both candesartan 16 mg once daily and lisinopril
20 mg daily has been shown to be better than either
treatment alone in reducing blood pressure and better
then candesartan alone in reducing microalbuminuria.

Available Angiotensin Receptor Blockers
Several selective AT1 receptor blockers have become
available. They have a high affinity for AT1 receptors
and negligible affinity for AT2 receptors. These include:
1. Candesartan — dosage 4–16 mg daily, maximum
32 mg once daily
2. Irbesartan — dosage 150–300 mg once daily
3. Eprosartan — dosage 300–400 mg twice daily
4. Losartan — dosage 25–100 mg once daily
5. Telmisartan — dosage 28–80 mg once daily
6. Valsartan — dosage 40–160 mg once daily


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