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 0100200300400500600700 Proportion surviving Survival first stroke Survival recurrent stroke P<0.001 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. MacMahon S, Peto R, Cutler J, et al. Lancet. 1990;335:765-774. 0.25 0.50 1.00 2.00 4.00 76849198105 mm Hg RelativeRisk of Stroke Approximate mean usual DBP 7 prospective observational studies: 843 events, 405,500 individuals BP and risk of first stroke

12. BP and risk of recurrent stroke Stroke and usual BP among 2435 individuals with a history of TIA or minor stroke Rogers A. et al. BMJ 1996;313:147 4.00 2.00 1.00 0.50 0.25 7580859095 Usual Diastolic BP (mm Hg) Relative risk of stroke 4.00 2.00 1.00 0.50 0.25 Relative risk of stroke Usual Systolic BP (mm Hg) 120130140150160170

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. 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 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

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

19. Summary of secondary prevention Adapted from Hankey & Warlow Lancet 1999; 354:1457-1463 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

20. Guidelines for secondary prevention of stroke