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Stroke

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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Stroke

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  1. Stroke Issues & prevention

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

  3. 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

  4. 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

  5. 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

  6. Stroke Case Fatality Data from Oxford Community Stroke Project

  7. 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.

  8. 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

  9. Risk Factors for Stroke • Age • Blood Pressure • History of Stroke / TIA • Atrial Fibrillation • Smoking • Cholesterol • Alcohol • Homocysteine • Social Class • Birth Weight

  10. Incidence of Stroke by Age • By age of 85, 1 in 4 men and 1 in 5 women will have • experienced a stroke

  11. 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.

  12. 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

  13. History of Stroke / TIA Adapted from Stroke - A Practical Guide to Management - 2nd Edition, Edited by Warlow C et al, Blackwell 2001, P655

  14. 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

  15. Absolute risk stratification for patients with atrial fibrillation

  16. Management of stroke

  17. 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

  18. 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

  19. 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

  20. Guidelines for secondary prevention of stroke

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