Stroke epidemic in Pakistan Mohammad Wasay, MD, FRCP, FAAN Aga Khan University

Burden of neurological diseases

Stroke in Pakistan Pakistan has the world’s sixth largest population (165 million in 2007) with a growth rate of about 2% per year. A recent community based survey suggested an estimated 21.8% prevalence of stroke and/or TIA in an urban slum of Karachi. Stroke-specific fatality has been reported between 7% and 20% in various studies from Pakistan. One study from JPMC showed mortality up to 80%. Up to 63% of all stroke patients develop complications and up to 89% are dependent for activities of daily living.

Stroke risk factors in Pakistan 33% of Pakistani population above the age of 45 years are suffering from hypertension. About one-third of these hypertensives were unaware of their hypertension. in 2000 there were 5.2 million diabetics in the country and the number is estimated to rise to 13.9 million by the year 2020, raising Pakistan to the 4th most populous country for patients with diabetes mellitus. Prevalence of smoking has been reported to be 14-21% in adolescents and adults, being more common in men

Un-studied risk factors huqqa (water- pipe) smoking, orally chewed tobacco (naswar, pan, mishri, ghutka, bajjar, and ghundi) different forms of clarified butter and hydrogenated oils rheumatic heart disease high prevalence of hepatitis B and C

Pakistani stroke population Younger age at first stroke particularly among women higher prevalence of stroke among women higher proportion of hemorrhagic stroke High proportion of intracranial diseases and lesser proportion of extra cranial disease

Acute stroke care tPa – only 2 centers in country Stroke units- 6 in country Availability of CT/MRI- 300 in country

Stroke outcome At discharge mortality7-30% (both ICH and IS) NAISD data13% MRS 0-2 (NAISD)36% MRS (3-5)50%

Public awareness Only 51% of the responders in one survey identified brain as the organ affected in stroke. Around 13% of the study respondents did not know of any risk factor for stroke, while 11.6% of the study respondents didn't know about the alarming signs of stroke

Physicians awareness A survey of 588 family physicians from Pakistan showed that 88% of the physicians are aware of at least one of the 5 major symptoms of stroke, but only 46% are able to correctly identify all 5 symptoms. This study found that 63% use a cutoff of 140/90 mm Hg to start antihypertensive therapy in routine clinical practice; 75% do not routinely check cholesterol levels in their patients; 57% use intravenous or sublingual antihypertensive medications in patients with acute stroke with blood pressure 160/100 mm Hg.

Pakistan Stroke Society Pakistan Stroke Society was established more than ten years ago. It works in collaboration with Pakistan Society of Neurology. This society organizes public awareness programs, CME activities for internists and GPs and provide small funding for stroke research in Pakistan. Society organizes biennial stroke conference and is actively involved in advocacy activities including media campaigns and World stroke day activities.

Stroke guidelines

Stroke research NIH grant for training stroke specialists and researchers in Pakistan. Glove for stroke risk assesment Asian young women stroke registry and Asian CVT registry Collaborators in interact-II, INTERSTROKE

Acute stroke units Evidence based All neurology services All major teaching hospitals All district hospitals

Stroke rehabilitation In collaboration with neurology Neurology services should start or collaborate with rehab facilities All district hospitals should be equipped with stroke units and stroke rehabilitation programs.

National Task force Participation of all stake holders including government, physicians, professional organization, Non Governmental Organizations (NGO) s, patients’ support groups and media This task force should be commissioned to design stroke prevention strategies in Pakistan and must work with medical colleges, district hospitals and other governmental and private sector teaching institutes to improve education and training for stroke care at graduate and post graduate levels.

Advocacy Effective tobacco (all forms ) control BP screening and control Availability of tPa Stroke units Rehabilitation centers

LHW network More than NCD awareness, tobacco cessation, life style changes Need to train these LHWs for stroke prevention

Future research Prevalence, DALYs innovative, cost-effective strategies Implementation strategies network of research centers in Pakistan South Asian network for research

Conclusion Diagnosis of high blood pressure and its effective control, use of anti-platelet therapy and strategies to control smokeless tobacco (chewing tobacco) and smoking are most important areas of intervention.

Conclusion Public awareness, advocacy and training of GPs, ER doctors, nurses and medical students are key to success