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Stroke. Issues & prevention. Agenda. Impact of Stroke Definitions Epidemiology Risk factors Management of Stroke Acute management Primary & Secondary Prevention Guidelines Future Directions. Definitions . Stroke

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Presentation Transcript
stroke

Stroke

Issues & prevention

agenda
Agenda
  • Impact of Stroke
    • Definitions
    • Epidemiology
    • Risk factors
  • Management of Stroke
    • Acute management
    • Primary & Secondary Prevention
    • Guidelines
  • Future Directions
definitions
Definitions
  • Stroke

‘a clinical syndrome characterised by an acute loss of focal cerebral function with symptoms lasting over 24 hours or leading to death, and which is thought to be due to either spontaneous haemorrhage into the brain or inadequate cerebral blood supply to a part of the brain as a result of low blood flow, thrombosis, or embolism associated with diseases of the blood vessels, heart, or blood’

Taken from Stroke - A Practical Guide to Management - 2nd Edition, Edited by Warlow C et al, Blackwell 2001

definitions4
Definitions
  • Transient Ischaemic Attack (TIA)

‘a clinical syndrome characterised by an acute loss of focal cerebral function with symptoms lasting less than 24 hours and which is thought to be due to inadequate cerebral or occular blood flow, arterial thrombosis, or embolism associated with disease of the arteries, heart or blood’

Taken from Stroke - A Practical Guide to Management - 2nd Edition, Edited by Warlow C et al, Blackwell 2001

incidence of stroke
Incidence of Stroke
  • 125,000 strokes / year in UK
  • 100,000 population (PCO average)
    • 240 strokes / year
    • 50 TIA / year*
    • 33% of strokes are secondary events
  • Average GP
    • 2-5 strokes/year
    • 20-40 stroke / TIA survivors

* that come to medical attention

stroke case fatality
Stroke Case Fatality

Data from Oxford Community Stroke Project

survival with first and recurrent strokes
Survival with first and recurrent strokes

Days since stroke

Proportion surviving

Survival first stroke

Survival

recurrent stroke

P<0.001

0

100

200

300

400

500

600

700

adapted from Samsa G et al. Stroke. 1999;30:338-349.

impact of stroke
Impact of stroke
  • Majority of strokes are not fatal
  • Real ‘burden’ of stroke is disability
    • Stroke is most common cause of disability
    • There are approximately 250,000 disabled stroke survivors in UK
    • Stroke is 2nd leading cause of dementia
    • Stroke is most common cause of epilepsy in the elderly
    • Stroke is a frequent cause of depression
risk factors for stroke
Risk Factors for Stroke
  • Age
  • Blood Pressure
  • History of Stroke / TIA
  • Atrial Fibrillation
  • Smoking
  • Cholesterol
  • Alcohol
  • Homocysteine
  • Social Class
  • Birth Weight
incidence of stroke by age
Incidence of Stroke by Age
  • By age of 85, 1 in 4 men and 1 in 5 women will have
  • experienced a stroke
bp and risk of first stroke

4.00

2.00

1.00

0.50

0.25

BP and risk of first stroke

7 prospective observational studies: 843 events, 405,500 individuals

RelativeRisk of Stroke

76

84

91

98

105

mm Hg

Approximate mean usual DBP

MacMahon S, Peto R, Cutler J, et al. Lancet. 1990;335:765-774.

bp and risk of recurrent stroke

4.00

4.00

2.00

2.00

1.00

1.00

0.50

0.50

0.25

0.25

75

80

85

90

95

120

130

140

150

160

170

BP and risk of recurrent stroke

Stroke and usual BP among 2435 individuals with a history of TIA or minor stroke

Relative

risk of

stroke

Relative

risk of

stroke

Usual Diastolic BP (mm Hg)

Usual Systolic BP (mm Hg)

Rogers A. et al. BMJ 1996;313:147

history of stroke tia
History of Stroke / TIA

Adapted from Stroke - A Practical Guide to Management - 2nd Edition, Edited by Warlow C et al, Blackwell 2001, P655

atrial fibrillation stroke
About 20% of patients with primary stroke are in atrial fibrillation

AF confers an approximate 5 fold increase in stroke risk

Absolute risk however can vary from <1% to >12% per annum depending on presence or absence of clinical / echocardiographic risk factors

Patients with atrial fibrillation should be stratified according to absolute risk of future CVA events prior to any clinical decision to prescribe anticoagulants or antiplatelet agents

Atrial Fibrillation & Stroke
stroke prevention
Stroke prevention
  • Key issues
    • Identification of patients
      • Stroke / vascular disease registers
    • Evidence for intervention
      • Blood pressure reduction
      • Antiplatelet agents
      • Anticoagulants
      • Cholesterol reduction
      • Carotid endartectomy
    • Effective management in practice
summary of secondary prevention
Summary of secondary prevention

Estimated effect of long term treatments for secondary prevention of stroke in the

12,000 patients with a history of previous stroke or TIA in a population of 1 million people

‡ in the 12,000 patients with history of stroke / TIA in an average 1 million population

* BP reduction may be equally relevant to all patients which would double the number of strokes avoided

† Number of extra events avoided compared to aspirin

Adapted from Hankey & Warlow Lancet 1999; 354:1457-1463

summary of secondary prevention19
Summary of secondary prevention

Estimated effect of long term treatments for secondary prevention of stroke in the

12,000 patients with a history of previous stroke or TIA in a population of 1 million people

‡ in the 12,000 patients with history of stroke / TIA in an average 1 million population

* BP reduction may be equally relevant to all patients which would double the number of strokes avoided

Adapted from Hankey & Warlow Lancet 1999; 354:1457-1463