
At 88, doctor pursues a long-ignored treatment for strokes, heart attacks - helloworld
https://www.statnews.com/2018/04/06/victor-gurewich-harvard-stroke-heart-attack/
======
arkades
What this story leaves out is why we are moving away from thrombolytics -
besides them kinda sucking.

Once a clot has matured they tend to be useless, which is part of why there’s
a solid upper cap on time to administration. You cross a line where any clot
they’re likely to bust isn’t one you want to bust. So, a window of a couple of
hours. Urokinase doesn’t change that, to my knowledge.

Surgical removal of the clot, on the other hand, has recently been shown to
offer enormous benefit to at-risk tissue (tissue not yet dead but in the
watershed area) 24 hours later, without risk of hitting the wrong clot. It’s
no miracle either, but evidence is piling up that it’s got more Pros and fewer
Cons.

Thus, no one really following armchair hypotheses (one old non RCT trial not
withstanding) about combining two increasingly undesirable drugs.

I respect the guy’s thought and effort, and have to admit he might be right
about their combined effectiveness, but this article leaves out a lot of the
context as to -why- this isn’t getting attention. Writing a hagiography-by-
omission is below what I’ve come to expect from statnews.

~~~
robbiep
Whilst angioplasty or clot retrieval is the optimal treatment (have not seen
evidence for clot retrieval for strokes in longer timeframes but will be
interested to jump into some research tomorrow) in countries where there are
enormous distances between tertiary referral centres (ie Australia)
thrombolytic agents are still strongly used.

Our ambulances are equipped with r-tPA or similar (there is a tendency to
avoid streptokinase as rural/indigenous populations have high exposure to
streptococcus/hx rheumatic fever and therefore high risk of added
complications) and in the event of STEMIs can be administered en route to ED.
Similarly many peripheral sites will administer tenecteplase or similar in
Emergency Departments as there are almost no sites that are set up to perform
out-of-hours angioplasty once you are out of the major cities; even less
chance for neuro-radiological intervention, I think there are only 6 or 7
sites in the country and they are all in major cities.

If his research does bear fruit, I could see it immediately becoming the
standard of care in Australia outside of major centres

~~~
thomasfedb
I'm a volunteer ambulance officer in Western Australia. We certainly don't
carry thrombolytic agents. What we do have though is a protocol for getting
stroke patients (with good predicted outcomes) into a helicopter or fixed-wing
aircraft ASAP so they can get to a hospital with a thrombectomy (clot
retrieval) service. If called promptly, then there shouldn't be many patients
that we can't get to the right care within a suitable timeframe.

~~~
autokad
> "If called promptly, then there shouldn't be many patients that we can't get
> to the right care within a suitable timeframe."

I worked with stroke centers, doctors, etc in building stroke access systems,
and that doesn't fly with reality.

Number 1, is that its hard for patients to recognize they are having a stroke.
so "If called promptly" is a bit of unrealistic idealism.

Although they say 4 hours, tPA administered after 1 hour has lost most of its
benefit, and places that can do thrombectomy 24/7 (in US dedicated stroke
centers) is not numerous. You are losing a lot of that hour just for time for
the helicopter to warm up, find a spot, and land + your ambulance time getting
to /stabilizing the patient.

I'm sure the patients on your beat had suitable access, but that's a bit of
selectivity bias no? In the US, although the majority of the population is
within the golden hour, there are still a ton of population that does not have
access to a stroke center. I find it extremely hard to believe that this is
not the case in Australia - where I have heard stories of people getting a
finger cut off and having to drive 3 hours to the nearest hospital.

~~~
thisrod
Remember that Australia is ridiculously urbanised. About 80% of Western
Australians live in Perth. Contrasted to the US, the most remote Australians
must be a lot further from a referral hospital, but the median Australian
might actually be closer.

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notadoc
Here's an alternate and more informative headline for anyone who wants a bit
more detail rather than clicking through and trying to skim for the needle in
a digital haystack:

>>> "At 88, doctor pursues clot-busting medication combination to aid in
treatment of heart attacks and strokes"

~~~
downrightmike
This is a much better title. Considering that the now favored course of action
is surgery, a potent drug combo would be my choice. Once you start cutting,
Docs often want to keep cutting.

~~~
projektfu
The favored course of action is interventional radiology and those guys like
to get done and move onto the next patient to rake in the dough.

~~~
neuro_imager
Actually, its interventional cardiology for heart attacks and
neurointerventional surgery/interventional neuroradiology(NIR) for strokes.
(Not IR which cover non-neurological and non-cardiological interventional
procedures).

I'm a NIR and most of us are not paid per surgery/intervention. Also these
interventions tend to be loss leaders in terms of hospital reimbursements.
Funding for stroke centres can be profitable but that's a very long
discussion.

In addition, at least 7 randomized clinical trials have shown the benefit of
thrombectomy in acute stroke (actually something of a modern medical
technological miracle).

~~~
projektfu
I find that surprising. What's the typical compensation model? Salary or
hourly?

~~~
neuro_imager
Salary (unless you're moonlighting - which is less common, and overall less
attractive).

Why do you presume that our intentions are nefarious when you have no idea
what you're talking about?

~~~
projektfu
I don't at all presume nefarious intentions. As if physicians don't try to
make money. My original comment was a tongue in cheek defense of the status
quo because I took offense at the comment that surgeons just like to keep
cutting. Sure, I'm "just" a veterinarian, but I like to cut as little as
possible.

I do know that doctors like to keep it moving. Surgeons like to start early
and finish early. Nobody wants to get bogged down in a specific procedure. As
far as profitability (or cost recovery, whatever euphemism) is concerned,
doing several short procedures beats one longer procedure, even when surgery
time is billed by the minute.

You ignore the fact that many doctors leave the strict employ of the hospital
for a private practice that still bills through the hospital. While they are
still salaried, they also get a profit share, usually divvied out on
productivity. There is no one model. But you're right, I have no idea how it's
typically done in IR, NIR, IC etc.

~~~
neuro_imager
For the sake of completeness, I'll expand:

It's rarely up to the interventionalist if and when they will treat a stroke.
There are clear guidelines on treating these patients (which mostly take place
at comprehensive stroke centres), mostly defined by the neurology service,
which functions somewhat independently. These guidelines have been expanding
as newer evidence has shown a role in wider time windows but this point
remains the same. There is very little opportunity for an individual
interventionalist to increase his patient volume independently (at least for
ischemic stroke).

I agree in principle with most of the points you make, although I think
perverse incentives are largely a function of the US healthcare system in
general rather than the domain of any particular specialty.

In specific relation to the original article, I'm extremely doubtful that
combing two anti-thrombotic agents would be a miraculous therapeutic regime
for treating stroke but I'd be happy to be proved wrong by a legitimate trial.
However, I'd worry that we'd be sacrificing patients that could otherwise be
treated if we assigned them to an arm of a trial that precludes established
therapy.

------
helloworld
For me, it was the persistence of the researcher -- well into his ninth decade
-- that caught my eye, rather than the somewhat arcane details of the
thrombolytic therapy that he's been pursuing.

A strong sense of purpose seems to be a factor in health and longevity. Is it
just good fortune that allows some people to develop that sense of purpose, or
can it be consciously and effectively nurtured?

~~~
baxtr
Hell yeah. I wish I’ll be that persistent when I get old. But then again,
relaxing and traveling the world might be nice, too. Well, we’ll see

~~~
justherefortart
Travel the world now, it gets harder as you age.

~~~
ams6110
Travel is overrated, and environmentally catastrophic. Enjoy where you live,
or if you don't like it, move.

~~~
Retric
Travel is fairly trivial environmentally. Having a long commute by car is
worse than traveling around the world by air every year which is extremely
uncommon.

On average a passenger mile on a modern jet uses significantly less fuel than
driving that same mile.

~~~
ekianjo
Erm no, since you don'r fly a plane for 5 miles usually. Plane flights are by
nature long distance and consume way more than your yearly car consumption
even if you have a 2 hours commute every day.

~~~
Retric
Sure, but it is reasonable to consider a long trip vs a longer commute in
terms of lifestyle and environmental costs. At which point you care about
total fuel costs not direct equivalency.

747 burns approximately 5 gallons of fuel per mile and holds 568 people. They
are over 70% full on average which works out to:

568 x .7+ / 5 ~= 80+ MPG. At the equator the world is 24,901 miles ~= 300
gallons at worst though most most people consider around the world to be US >
EU > Asia > US which is shorter than that.

Edit: US average is 75mpg per passenger in 2014 though longer trips are above
that.
[https://en.wikipedia.org/wiki/Fuel_economy_in_aircraft](https://en.wikipedia.org/wiki/Fuel_economy_in_aircraft)

On the other hand at 3 gallons (which is far from extreme) / day x 48 x 5 =
720 gallons ignoring all other driving.

PS: On top of that for longer trips aircraft tend to take more direct routes.
You can't just drive from NY to LA on a strait line which significantly
reduces cars effective MPG.

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INTPnerd
That's brilliant, using heart attacks to treat strokes

~~~
giancarlostoro
At first I thought oh I guess the symptoms aren't as awful then I realized you
interpreted the title differently from me... Wow yeah I guess they hit the
title length limit for HN and had to get creative.

~~~
vanderZwan
Couldn't OP have replaced the last comma with an ampersand?

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sabujp
uggh, i need to use summarizers. Several paragraphs in and it finally said the
cocktail was a combination of tpa and urokinase precursor

~~~
stuntkite
I seriously couldn't get past the first full page. Someone needed to give me
an idea of what his treatment was. I love that he's old and still doing
something. The comments here tell me it's somehow using heart attacks to treat
strokes, but this thing had so much crap before giving me a detail I could
process.

I hope he saves more people and lives to 120, but yeah, summary... or at least
slightly better writing.

------
lvs
>What if tPA worked like the starter motor that turns on a car, and urokinase
was the gasoline that ran it?

No comment on the underlying science, but I will express my continued
frustration with popsci writers and their counterproductive analogies. It's
especially unhelpful when it's wrong on the dumbed-down end. A starter motor
does not run on gasoline. It's an electric motor that runs off the battery.

~~~
twic
That's the whole point of the analogy. From the next paragraph:

> When a clot forms, tPA in the bloodstream is quickly recruited to the site
> to begin dissolving it. But too much of a clot-buster could lead to bleeds,
> so once the process is sparked, the body rapidly clears out tPA. Urokinase
> comes along, carried on the surface of platelets and certain white blood
> cells, to finish the job.

tPA kicks off the process, and once it's started, urokinase does the rest. I
don't know the biochemistry in enough detail to say whether this is a really
good metaphor (can urokinase only be activated if tPA has acted? is urokinase
consumed by this process?), but the author is not suggesting that a starter
motor runs off gasoline.

~~~
skosch
OP simply mis-parsed the last "it" of the sentence to refer to the starter
motor, when the author intended for it to refer to the car.

~~~
smallnamespace
That's a strange mis-parse since the rule is that pronouns refer to their
closest reasonable antecedent (in this case 'car' is closest to 'it').

------
skookumchuck
I hope I'm still productive at my job at 88.

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ganashaw
Did anyone else read this title as implying that heart attacks were a
potential treatment for strokes?

