Editorials
Neurology Environmental health
Volume 171 - Issue 6

Preventing stroke: what is the real progress?

Author:  Graeme J Hankey

Med J Aust 1999; 171 (6): 285-286.
Published online: 20 September 1999
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Editorial

Preventing stroke: what is the real progress?

At last, stroke prevention is high on the political and public health agenda

MJA 1999; 171: 285-286

National Stroke Awareness Week (27 September - 3 October) is a pertinent time to review recent progress in stroke prevention and awareness in the past few years. In Australia, stroke continues to be a major public health issue.1 More than 40 000 Australians each year experience a stroke, nearly a third of which are fatal.1,2 Another third of stroke sufferers become disabled, and stroke victims make up nearly one in four of Australia's chronic disabled population.1 The annual total cost of caring for stroke victims is at least $1.67 billion,2 a figure which will continue to rise with ageing of Australia's population. It is estimated that there will be at least 70 000 new stroke patients each year by 2016.2

Nevertheless, real progress has been made in the past few years in several areas:

  • The emergence, and application in clinical practice, of sound evidence for the effectiveness of several stroke-prevention strategies in people at high risk;

  • A decline in stroke incidence due to effective prevention measures; and

  • A willingness of Federal, State and Territory governments to take a more active role in stroke prevention.

Strategies for reducing the social and economic burden of stroke are summarised in the Box. The effectiveness of primary stroke prevention in the entire population is difficult to ascertain. Mortality statistics are the only routinely collected data for measuring and monitoring the burden of stroke nationally, and between 1986 and 1997 the stroke mortality rate for Australian men and women fell by 3.2% and 3.5% per year, respectively. Since 1970 there has been a 68% overall reduction in stroke mortality.1,3

The recent Perth Community Stroke Study (PCSS)4 found that the decline in stroke mortality was due to a reduced incidence of stroke rather than an improvement in survival or a change in casemix (eg, a reduced proportion of lethal intracerebral haemorrhages). This fall in stroke incidence is likely to be due to a decline in the prevalence of important causal and modifiable risk factors. The PCSS identified several of these risk factors, many of which are well established, and some of which require confirmation in future studies.5 These include previous stroke or transient ischaemic attack, cigarette smoking, excess alcohol intake (> 60 g daily), a history of hypertension, diabetes mellitus, meat consumption (more than four times weekly), and adding salt to food. Over the past one to two decades, the Australian Institute of Health and Welfare (AIHW) has documented a significant decline in the population prevalence of many of these risk factors (ie, hypertension, smoking, total dietary fat intake, and saturated fat as a proportion of total energy intake).1

Although it is not possible to prove that health promotion programs, government legislation and the decline in prevalence and mean level of risk factors have been directly responsible for the reduction in stroke incidence in Australia, I believe the above data endorse the concept and power of the population approach to stroke prevention.

It might be argued that the population approach impinges on all for the benefit of relatively few.3 However, most of us are prepared to adopt lifestyle behaviours (eg, wearing of seatbelts, application of sunscreen lotion) which reduce harm to the population as a whole, and stroke prevention measures would be similar in principle. Moreover, given that the risk of stroke in the next 40 years for a 45-year-old is one in four for men and one in five for women,1 there is also a reasonable chance of individual benefit in adopting lifestyle changes aimed at reducing the risk of stroke.

The push for greater stroke awareness in our society has received a considerable boost in recent years from a greater involvement of governments in promoting awareness of stroke and facilitating educational programs aimed at reducing the risk of stroke. The involvement is exemplified by:

  • Establishment of the National Stroke Foundation, which published a National Stroke Strategy and Victorian Stroke Strategy in 1997;9

  • Establishment by the New South Wales Health Department of the NSW Stroke Project;10

  • Endorsement by Australian health ministers of heart, stroke and vascular disease as one of the five National Health Priority Areas (NHPAs).

The recent NHPA report, Cardiovascular Health 1998,11 highlights the strategies that are in place (and to be developed) to prevent stroke by improving awareness, lifestyle behaviours, and risk factor profiles of Australians, and improving outcomes for those with symptomatic disease through optimal diagnosis, management, rehabilitation, and community care.11 It also emphasises the ongoing role of the AIHW in operating a national system to monitor stroke incidence, pathology, risk factors, treatments, care, outcome (for patients and carers) and costs.

At last, stroke is high on the political and public health agenda, but it is crucial that the commitment be maintained to measuring, monitoring and reducing the burden of stroke by widespread adoption of evidence-based practices and other strategies outlined in the NHPA report.11 Otherwise, we will soon experience a needless epidemic of stroke, with its legacy of death, disability and mounting cost.

Graeme J Hankey
 Consultant Neurologist, and Head of Stroke Unit, Royal Perth Hospital
Clinical Associate Professor, Department of Medicine, University of Western Australia, Perth, WA
Email: gjhankeyATcyllene.uwa.edu.au

  1. Australian Institute of Health and Welfare (AIHW). Heart, stroke and vascular diseases, Australian facts. Canberra: AIHW/Heart Foundation of Australia, 1999. (AIHW Catalogue No. CVD 7; Cardiovascular Disease Series No. 10.)
  2. National Health and Medical Reseach Council (NHMRC). Clinical Practice Guidelines. Prevention of stroke: the role of anticoagulants, antiplatelet agents and carotid endarterectomy. Canberra: NHMRC/Australian Government Publishing Service, 1997: 3-4.
  3. Rose G. The strategy of preventive medicine. Oxford: Oxford University Press, 1992: 29-52, 64-106.
  4. Jamrozik K, Broadhurst R, Lai N, et al. Trends in the incidence, severity and short-term outcome of stroke in Perth, Western Australia. Stroke 1999. In press.
  5. Jamrozik K, Broadhurst RJ, Anderson CS, Stewart-Wynne EG. The role of lifestyle factors in the etiology of stroke. A population-based case-control study in Perth, Western Australia. Stroke 1994; 25: 51-59.
  6. Hankey GJ. Stroke: how large a public health problem, and how can the neurologist help? Arch Neurol 1999; 56: 748-754.
  7. Hankey GJ, Warlow CP. Treatment and secondary prevention of stroke: evidence, cost, and effects on individuals and populations. Lancet 1999. In press.
  8. Gorelick PB, Sacco RL, Smith DB, et al. Prevention of a first stroke. A review of guidelines and a multidisciplinary consensus statement from the National Stroke Association. JAMA 1999; 281: 1112-1120.
  9. National Stroke Strategy. Melbourne: National Stroke Foundation, 1997.
  10. Stroke in NSW. Priorities and strategies for better care. Sydney: NSW Health Department, 1997.
  11. Commonwealth Department of Health and Aged Care and Australian Institute of Health and Welfare. National Health Priority Area Report: Cardiovascular Health 1998. Canberra: Australian Institute of Health and Welfare, 1999. (Catalogue No. PHE9.)





Strategies for reducing the burden of stroke and stroke recurrence (in increasing order of potential impact)6,7

Effective treatment of acute stroke6,7

  • Organised care in a stroke unit by a multidisciplinary team
  • Aspirin 300 mg for acute ischaemic stroke
  • tPA (may be effective, but possibly hazardous, and therefore is not currently registered in Australia or Europe for stroke treatment6)

Secondary prevention of recurrent stroke in patients with transient ischaemic attacks (TIAs) and stroke (in decreasing order of cost-effectiveness)7*

  • Treatment of high blood pressure with a diuretic or β-blocker
  • Aspirin, aspirin + dipyridamole, or clopidogrel for patients in sinus rhythm
  • Anticoagulation with warfarin for patients with atrial fibrillation
  • Carotid endarterectomy for patients with severe stenosis of the internal carotid artery on the symptomatic side

Primary prevention of stroke among people at high risk of stroke (eg, those with severe hypertension or atrial fibrillation)3,8

  • Treatment of high blood pressure with a diuretic or β-blocker
  • "Statins" to lower serum cholesterol levels in patients with symptomatic coronary artery disease or hypercholesterolaemia
  • Anticoagulation with warfarin for patients with atrial fibrillation and specific risk factors (age > 65 years, diabetes, hypertension, TIA or stroke), or patients with recent myocardial infarction who have atrial fibrillation, decreased left ventricular ejection fraction, or left ventricular thrombus Primary prevention of stroke in the general population by reducing risk factors3,6
  • Reducing consumption of meat, salt, saturated fat and alcohol
  • Reducing prevalence of smoking
  • Reducing prevalence of obesity
  • Increasing physical activity
  • Controlling hypertension and hypercholesterolaemia
  • Controlling diabetes mellitus


*Randomised trials of the effect of smoking cessation, other antihypertensive agents, and 3-hydroxy-3-methylglutaryl coenzyme A (HMGCoA) reductase inhibitors ("statins") in secondary stroke prevention are either still in progress or yet to be undertaken.
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Author

  • Graeme J Hankey

References

  1. Australian Institute of Health and Welfare (AIHW). Heart, stroke and vascular diseases, Australian facts. Canberra: AIHW/Heart Foundation of Australia, 1999. (AIHW Catalogue No. CVD 7; Cardiovascular Disease Series No. 10.)
  2. National Health and Medical Reseach Council (NHMRC). Clinical Practice Guidelines. Prevention of stroke: the role of anticoagulants, antiplatelet agents and carotid endarterectomy. Canberra: NHMRC/Australian Government Publishing Service, 1997: 3-4.
  3. Rose G. The strategy of preventive medicine. Oxford: Oxford University Press, 1992: 29-52, 64-106.
  4. Jamrozik K, Broadhurst R, Lai N, et al. Trends in the incidence, severity and short-term outcome of stroke in Perth, Western Australia. Stroke 1999. In press.
  5. Jamrozik K, Broadhurst RJ, Anderson CS, Stewart-Wynne EG. The role of lifestyle factors in the etiology of stroke. A population-based case-control study in Perth, Western Australia. Stroke 1994; 25: 51-59.
  6. Hankey GJ. Stroke: how large a public health problem, and how can the neurologist help? Arch Neurol 1999; 56: 748-754.
  7. Hankey GJ, Warlow CP. Treatment and secondary prevention of stroke: evidence, cost, and effects on individuals and populations. Lancet 1999. In press.
  8. Gorelick PB, Sacco RL, Smith DB, et al. Prevention of a first stroke. A review of guidelines and a multidisciplinary consensus statement from the National Stroke Association. JAMA 1999; 281: 1112-1120.
  9. National Stroke Strategy. Melbourne: National Stroke Foundation, 1997.
  10. Stroke in NSW. Priorities and strategies for better care. Sydney: NSW Health Department, 1997.
  11. Commonwealth Department of Health and Aged Care and Australian Institute of Health and Welfare. National Health Priority Area Report: Cardiovascular Health 1998. Canberra: Australian Institute of Health and Welfare, 1999. (Catalogue No. PHE9.)