ISC 2019 Presidential Address

Ivor J. Benjamin, MD, FAHA, delivered the Presidential Address during the opening Main Event session at the International Stroke Conference 2019 in Honolulu, Hawaii on Feb. 6, 2019. Below is a transcript of his speech. To see details on the science presented at the conference, visit the ISC19 Science News page.

Aloha! On behalf of the American Heart Association and American Stroke Association, thank you for taking the time and effort to join us. The beauty of our surroundings is matched only by the importance of the purpose that has drawn us here.

Our International Stroke Conference continues to be the world’s premier event dedicated to understanding, preventing and treating stroke and its consequences. You’ve all dedicated your careers to stroke in one way or another, and for this, I salute you. My appreciation comes not only as the president of this organization, but as the son and grandson of women who endured strokes. In fact, I see the progress in the fight against this disease exhibited in my own family’s experience.

When I was 9, my beloved grandmother suffered a stroke and died a year later. When I was in residency, my mother also suffered a stroke. But advances in secondary prevention helped her survive and thrive for many years. Thus I hold a profound respect, fondness and gratitude for everyone in the stroke community.

Here at ISC, we benefit from the worldwide perspective you all bring, and we can all enjoy the broad professional and scientific range we have here. We’ll be able to explore the latest in science and medicine, using approaches from the most fundamental to lessons learned from numerous populations and relevant to all professions.

Regardless of our roles in this spectrum, however, I believe it's important for us to have the opportunity to be informed by all areas of science and public health — and you will have that opportunity here. I believe you can also gain perspective on the strides being made by the Stroke Association, and the impact we continue to have.

This is also a time to celebrate our joint successes. Advances in cerebrovascular and cardiovascular sciences have reduced deaths from stroke and heart disease and increased life expectancy in many places around the globe.

Of course, we're concerned about recent data confirming that, in the U.S., these advances are flattening out. However, I know we're also hopeful that the deployment of new strategies for prevention, treatment and rehabilitation of stroke will soon bring those declines in stroke deaths back on track. I take pride in knowing that many of our advances first aired at this very meeting … with more hopefully stemming from our time here in Hawaii.

Let me raise two concerns, however, that I think we need to keep in mind. First, the aging of our global population has raised the stakes for us all. And second, the inequities we see every day in health burden need to be addressed.

The fact that people are living longer is inherently a good thing. But it presents us with another challenge: As the population ages, risk factors increase. One example is in an area of medical science that we share — atrial fibrillation.

We know that the risk of developing atrial fibrillation increases with age. And both because of this and other factors, age also increases the likelihood of stroke, and of cognitive impairment and dementia.

However, we have found ways to reduce the risk of developing AFib – treating hypertension, heart failure, and even valvular heart disease. That has helped. And beyond that, even with an increasing incidence of AFib, we have developed better ways to reduce its risk for stroke. Because of that, the effects on cognitive decline in the United States – at least as documented in the Framingham Heart Study – show some improvement in the incidence of dementia. Of course, in Framingham there are very few African-Americans and Hispanics/Latinos.

Insight into one component of that improvement, better hypertension control, may be emerging from last week’s publication of data from SPRINT MIND This is the cognitive focus of this major trial of aggressive blood pressure control: aiming for less than 120 mmHg systolic, versus the standard of less than 140 mmHg. While the primary endpoint, an impact on dementia, was not significant, that result may have been limited by the early stopping of SPRINT for its positive effects on heart attack, heart failure, stroke and death.

A second concern we all share, and a major commitment of the Stroke Association, is understanding and effectively addressing health disparities. We are greatly concerned that the risk of stroke, and the age-adjusted rates of death from stroke in African-Americans, continue to show an enormous excess burden. We clearly need to do more to reduce stroke and cardiovascular risk and to improve treatment for all populations – in all neighborhoods and in all countries.

As you could tell from the new mission statement that Nancy [Brown, CEO of AHA/ASA] discussed, our patients – and, in fact, the public in general – not only want to live longer, but want to be healthy, productive and able to enjoy their lives. The work of all of you here at ISC has never been more important in that regard: stopping stroke and vascular dementia from shortening and burdening lives is critical. We have many opportunities to use what we already know to reduce these problems. And we can explore and explain better the unknown or less-understood contributors to these and other forms of cognitive decline and dementia, which often co-exist in our patients.

So, I propose that we think about our organization’s new mission statement with an emphasis specific to all of us here at ISC, and to others who may join us in these efforts. We must become a relentless force for a world with fewer strokes, and with healthier brains overall.

One of the things I’ve learned from my years of volunteering is that this organization isn’t just about supporting our careers. It’s a place where we can have an impact. And by we, I mean you, me and the AHA/ASA.

How do we do that? We start with the science, and you see a great example in this scientific statement we published in 2017 to define optimal brain health.

Our organization is establishing strategies based on this science to help consumers understand how important prevention is to maintaining cognitive ability throughout a long and healthy life. We’re continuing this work through updating of our prevention guidelines, including the latest on hypertension and cholesterol, and the U.S. government’s new physical activity guidelines that the AHA has adopted.

Of course, guidelines and statements like these are built upon discovery research, and our critical focus is to improve how that is funded.

As you know, the AHA/ASA itself is a significant funder of research related to stroke. We fund more cardiovascular and stroke research than any other nonprofit organization, including funding 13 Nobel Prize winners and numerous important breakthroughs. And for 2019, the board has recently approved an additional five percent for our research investment. While we are proud of our longstanding research commitment, we are dedicated to developing other sources of funding.

We are also a major supporter of research supported by the National Institutes of Health. Through our advocacy efforts, we continually push for more government research funding. And we work with many philanthropic supporters to expand the research funding footprint in new and innovative ways.

Nancy mentioned the AHA-Allen Initiative in Brain Health and Cognitive Impairment. Now I’d like to share a few more details about this groundbreaking work, of which I am thrilled to be part of the Joint Leadership Group.

Our goal is to prevent cognitive impairment by finding ways to treat its causes even before the earliest clinical signs appear. Current clinical trials for some forms of cognitive impairment and dementia — those marked by the presence of misfolded proteins such as amyloid beta deposits in the brain — have not to date had the impact we hoped for.

We have recognized that the type of cognitive impairment we call vascular dementia and the kind we call Alzheimer’s disease have many risk factors in common. Unfortunately, there remains a lack of ability to recognize problems early enough to have a preventive or therapeutic impact.

The AHA and the Allen Institute saw the value of discovery science focused on defining critical early steps in the development of cognitive impairment. These early steps might include stroke and TIAs, and also inflammatory processes, or proteostasis, affecting either cerebral blood vessels, neural or glial elements of the brain, or the neuro-vascular unit per se. A role for focal or more global cerebral hypoperfusion has also been suggested. And in addition, the mechanisms underlying the effects of aging and diabetes remain poorly defined. The investigators Nancy introduced are involved in examining these areas.

As we launch such partnerships, we can only hope they blossom into the long, powerful relationship we’ve been so fortunate to have with the Henrietta B. and Frederick H. Bugher Foundation. You know the Bugher Foundation and their Trustees for their longstanding investment in multiple areas of stroke research. Their most recent commitment will address hemorrhagic stroke via a strategically focused research network, with plans to release an RFA in 2020. Every Bugher research project has participated in caring for the future of science through an emphasis on early-career investigators. In fact, back in the earliest days of the Bugher Foundation’s funding of AHA research, the trustees invested in this then-much-younger investigator.

So as I stand before you as the first Bugher-funded fellow to become the organization’s president, I hope you will join me in appreciation of the Bugher Foundation and the Trustees we are privileged to have in the audience.

In addition to the discoveries that all this research will uncover, there is also great satisfaction in the outcomes of implementation research that demonstrates that our work in the field is helping to save and improve lives. I’m pleased to point out one shining example of science leading to better patient outcomes being presented this evening. I hope you can attend the Late-Breaking Science Abstract Poster Session to see a poster focused on the quality care initiative Target Stroke Phase Two. This is a prime example of evidence-based initiatives and improved systems of care.

In closing, I’d like to extend my gratitude to the Stroke Council and to everyone involved with our Stroke journal. Your leadership and commitment are greatly appreciated by your peers and everyone touched by stroke.