Stroke and COVID 19

The Washington Post recently wrote about an increased risk of stroke in patients with diagnosed COVID 19, "Young and middle-aged people, barely sick with COVID 19, are dying of strokes.”

The article’s subhead added that “doctors sound the alarm about patients in their 30s and 40s left debilitated or dead. Some didn’t even know they were infected.”

Now, that is certainly a headline that will get your attention. It’s also one that makes me more convinced of the need to be mindful and very cautious about how medical information is communicated to the public. There is such an abundance of data and a myriad of studies being reported now. And in the absence of prior knowledge and the context necessary to interpret and truly understand all of this material, reporting these statistics may be far more fear-provoking than it is helpful.

First, we have to remember that even if we test positive for COVID this does not mean we have the illness. For example, did you know that approximately 90% of adults are positive for Epstein Barr virus (EBV)? While EBV can cause mononucleosis, the operative word here is “can.” Testing positive for something doesn’t necessarily indicate the presence of active disease; rather, it reflects that the individual either has antibodies against the virus or at some point has been exposed to it. The same holds true for this coronavirus.

While this latest article noted that patients who suddenly were stricken with stroke-like symptoms had been “previously healthy,” as a medical doctor this tells me very little about what underlying factors may have increased the risk of strokes in these younger individuals. Comorbidities, defined as the simultaneous presence of two chronic diseases or conditions in a patient, are not being widely discussed by the media.

What has been generally spotlighted over the last three months are:
 1.   Risk factors: Individuals are at a higher risk of severe disease complications if they: have a serious medical issue such as diabetes, lung, liver, cardiovascular or kidney disease; are immune-compromised; identified as obese; history of smoking; or are 65+ years of age.
2.   Effects of social isolation: Fear, a sense of panic and resulting dramatic economic downturn have increased reported stress levels to an all-time high.   

Stress and strokes.
Stress alone is a major concern as there is evidence of an association between both acute and chronic emotional stress and higher risk of stroke. A University of Michigan study identified that males who were more physiologically reactive to stress (as measured by elevated blood pressure readings) were 72% more likely to suffer a stroke. Stress and negative emotions, both acute and ongoing, activate the hypothalamic-pituitary-adrenal axis and this activation of the brain’s stress center influences blood clotting. While this particular study included males ages 45 to 84, there are additional studies that have focused solely on the incidence of strokes in young people, further supporting the need to identify preexisting risk factors that can impact patient outcomes.

Most recently, researchers found too that the psychological impact of being in quarantine after just one month included increased stress, declining physical and mental health statuses, and a self-reported reduction in life satisfaction.* These and multiple other studies make it clear that stress can play such a significant role in our health regardless of our age and circumstances.

Influenza infections and increased risk of stroke and heart attacks.
There is increasing evidence that acute bacterial and viral infection represent trigger factors that temporarily elevate the risk of ischemic stroke. During and after influenza epidemics vascular death rates and hospitalizations for stroke are increased.  With any infectious trigger if unchecked we see high levels of inflammation, known as a cytokine storm, which is thought to cause most of the damage in the lungs. Dysfunctional coagulation is a common complication in pathogenic influenza and other viral infections. Importantly, emerging evidence shows that an uncontrolled coagulation system, including both the cellular (endothelial cells and platelets) and protein components (coagulation factors, anticoagulants and fibrinolysis proteases), contributes to the pathogenesis of influenza by augmenting viral replication and immune pathogenesis.  And now, a coagulopathy has recently been described in COVID 19 that may be associated with these incidences of stroke as reported in the news media.

The takeaway from these reports and study results: right now, there is still so much we do not as yet know. The speed with which our world has changed over just three months’ time is dizzying for our healthcare community and especially for patients. Sifting through the barrage of information is more than challenging…it’s overwhelming and, quite frankly, can lead to the very stress that we need to reduce rather than add to the demands with which we already live.

When I see articles with headlines that are designed to make us sit up and take notice, I have to stop and reflect upon the intent as well as the content. And we know that it’s easy to just read the headline and not focus on the details of the story – even though we may seem to have more time on our hands, the distractions that surround us now in the wake of changed lifestyles are actually more profound.

My best recommendation is take a breath, even walk away from your television or device screens, and find a way to detach from these external stressors in some way. Meditation, even for a few moments, can break that cycle of constant scrolling and commensurate anxiety. And always remember that if you have questions about your health, please don’t hesitate to reach out to us, to your family doctor or a trusted counselor for information and help that is truly relevant to your individual wellbeing.

We’re here for you, in health and hope,
Dr. Suzanne Gazda

References:
*Stephen X Zhang, Yifei Wang, Andreas Rauch, Feng Wei. “Unprecedented disruption of lives and work: Health, distress and life satisfaction of working adults in China one month into the COVID-19 outbreak.” Psychiatry Research, 2020; 112958 DOI: 10.1016/j.psychres.2020.112958

André-Petersson, Lena, MS; Engström, Gunnar, MD, Ph.D.; Hagberg, Bo, Ph.D.; Janzon, Lars, MD, Ph.D.; Steen, Gunilla, MS Adaptive Behavior in Stressful Situations and Stroke Incidence in Hypertensive Men. 2001 American Heart Association, Inc.

Boden-Albala B, Sacco RL. Lifestyle Factors and Stroke Risk: Exercise, Alcohol, Diet, Obesity, Smoking, Drug Use, and Stress. Current Atherosclerosis Reports. March 2000.

Akizumi Tsutsumi, MD; Kazunori Kayaba, MD; Kazuomi Kario, MD; Shizukiyo Ishikawa, MD. Prospective Study on Occupational Stress and Risk of Stroke. Archives of Internal Medicine, 2009.

Everson, Susan A. PhD, MPH; John W. Lynch, PhD, MPH; George A. Kaplan, PhD; Timo A. Lakka, MD, PhD; Juhani Sivenius, MD, PhD Jukka T. Salonen, MD, PhD, MScPH. Stress-Induced Blood Pressure Reactivity and Incident Stroke in Middle-Aged Men. Psychosomatic Medicine, 1999.

Truelsen, Thomas, MD, PhD; Nielsen, Naja, BMsc; Gudrun Boysen, MD, DMSc, Grønbæk, Morton, MD, DMSc. Self-Reported Stress and Risk of Stroke. Stroke, 2003.

https://www.ersjournals.com/press/2203/respiratory-infections-trigger-stoke-mycocardial-infarction

https://www.ahajournals.org/doi/pdf/10.1161/STROKEAHA.110.596783

Influenza and coagulopathy
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4947825/
 
H1N1 and thrombotic events
https://academic.oup.com/cid/article/52/2/e14/376301