2 decades of stroke

A Cardiology Today Editorial Board member discusses progress in stroke prevention and treatment.

Issue: June 2017

Editor’s Note: Cardiology Today is celebrating its 20th anniversary in 2017. We are reaching out to experts in cardiology for their take on changes in CV medicine since the publication launched in 1997. In this issue, Larry B. Goldstein, MD, FAAN, FANA, FAHA, focuses on stroke.

It appears the prevalence of stroke is essentially unchanged from 20 years ago. These data are very difficult to obtain because the United States does not have an active stroke surveillance system. According to the National Health Interview Survey, the prevalence of stroke in the U.S. was 2.3% in 1997; based on the Behavioral Risk Factor Surveillance System, the prevalence increased to 2.7% in 2014 — the latest data available. This may, to some extent, be related to the aging of the population.

On a more positive note, between 2004 and 2013, there was a 41% reduction in stroke mortality in the U.S., largely related to better prevention. The stroke mortality rates between 2013 and 2015, however, showed an increase, particularly among younger adults. The reasons are not entirely clear, but may in part be related to increased prevalence of obesity and diabetes.

It does not appear there has been a major shift in knowledge related to stroke risk factors. A study published in 1999 found that only 50% of patients interviewed named hypertension as a stroke risk factor, while 37% named smoking, 27% named obesity, 22% named poor diet, and 10% named lack of exercise. A study published in 2006 found that only 43% of patients interviewed named hypertension, 39% named smoking, 34% named obesity, 14% named poor diet and 20% named lack of exercise. In addition, there are major areas for improvement of CV and brain health. The latest data indicate that 16% of individuals older than 50 years smoke compared with 24% of those aged 20 to 49 years; 40% older than 50 years are obese, 55% do not get adequate exercise, 70% do not follow recommendations for a healthy diet and 25% have poorly controlled hypertension. There is increasing recognition of the importance of lifestyle as a means of preventing a first stroke — those who follow a healthy lifestyle are 80% less likely to have a stroke compared with those who don’t. Effecting lifestyle change, however, is not trivial.

There have also been advances in medical therapy for stroke prevention in appropriate populations. These include the use of platelet anti-aggregates, the more widespread use of statins and the availability of the non-vitamin K antagonist oral anticoagulants as an alternative to warfarin to prevent stroke and systemic embolization in high-risk patients with atrial fibrillation.

Over the past 2 decades, there also has been a revolution in acute stroke care, initiated by the advent of treatment with IV tissue plasminogen activator beginning in 1995. This led to the development of stroke systems of care, organizing pre-hospital care bring patients as quickly as possible to designated primary or comprehensive stroke centers, including care in stroke units. More recently, it was shown that selected patients with large vessel occlusions benefit from endovascular clot retrieval. I consider all of these things to be most significant advances related to stroke in the past 20 years.

– Larry B. Goldstein, MD, FAAN, FANA, FAHA

Cardiology Today Editorial Board Member

University of Kentucky

References:
Benjamin EJ, et al. Circulation. 2017;doi:10.1161/CIR.0000000000000485.
Chiuve SE, et al. Circulation. 2008;doi:10.1161/CIRCULATIONAHA.108.781062.
Goldstein LB, Gradison M. J Stroke Cerebrovasc Dis. 1999;doi:10.1016/S1052-3057(99)80010-X.
Muller-Nordhorn J, et al. Stroke. 2006;doi:10.1161/01.STR.0000209332.96513.82.
National Center for Health Statistics. Health, United States, 2010, With Special Feature on Death and Dying. DHHS Pub No. 2011-1232; February 2011.

Disclosure: Goldstein reports serving on the steering committee for the SPARCL trial sponsored by Pfizer, speaking at Pfizer-sponsored meetings, and serving as an investigator in numerous stroke-related trials and clinical studies.