Decreasing the Morbidity, Mortality, and Cost of Stroke Through Awareness and Prevention
Am Fam Physician. 2003 Dec 15;68(12):2335-2340.
Stroke is a significant medical problem that affects more than 700,000 Americans annually.1 In the United States, it is the third leading cause of death, the major cause of disability, and the primary reason for nursing home admissions.1,2 Because of the aging of the U.S. population and the increasing incidence of chronic illnesses, the rate of stroke and its associated costs will continue to escalate. Unfortunately, public awareness of the warning signs of stroke and its early treatment remain limited.3,4
In this issue of American Family Physician, Ezekowitz and associates5 review strategies that have been shown to be effective in stroke prevention. It is clear that preventive measures and early interventions can reduce the morbidity, mortality, and cost of stroke. Thus, physicians need to recognize which patients are at risk for stroke and design systematic approaches to these patients.6 In addition, medical education needs to focus on stroke prevention and the care of patients who experience a stroke.7
Primary prevention of stroke includes the treatment of hypertension and hyperlipidemia, the use of angiotensin-converting enzyme inhibitors and glucose control in patients with diabetes, the use of warfarin (Coumadin) in patients with atrial fibrillation, and smoking cessation. Weight reduction in obese patients and increased physical activity also should be encouraged. Low-dose aspirin has not been shown to be effective in preventing a first stroke and, in fact, can increase the risk of hemorrhagic stroke.8 Secondary prevention of stroke may include the use of antiplatelet agents, aspirin, warfarin, statins (3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors), and carotid surgery. Treatment of chronic diseases such as hypertension and diabetes should follow accepted evidence-based guidelines.9,10
The media (particularly television) and community-based education in settings such as schools and churches can help to increase public awareness of the warning signs and early treatment of stroke.11,12 In addition, medical office personnel must be able to provide proper advice when a patient or family member calls to report signs suggestive of stroke. If there is a possibility that a patient could be having a stroke, “9-1-1” should be called immediately. Delay in treatment because the signs of stroke were not recognized results in a poorer outcome.13 The patient with a possible stroke must be a top priority and should be transported to an appropriate facility by an emergency medical service, rather than by private car.14
Hospital emergency departments should develop triage systems to care for patients who have signs consistent with stroke.14 Triage should be similar to that in patients with chest pain who may have cardiac disease. Fever, blood glucose levels, and blood pressure must be managed, and consideration should be given to immediate administration of aspirin.
Good evidence shows that patients with an ischemic stroke who meet specific criteria benefit from the administration of tissue-type plasminogen activator (tPA) if the tPA is given within three hours of the onset of symptoms.14 Strict adherence to the protocol for tPA administration increases efficacy and safety.15 Hospitals that provide emergency stroke care should have a protocol in place for tPA administration or be prepared to transfer patients to a better equipped facility.
Not all hospitals have 24-hour radiology, laboratory, and neurosurgery services. Hence, the staff and administrators of each hospital must determine the level of stroke care their institution can provide. The community then must determine the best use of local resources to accommodate its residents.16
As family physicians, we can do much to increase awareness of stroke, promote its prevention, and provide education about its treatment. We can implement office systems to enhance prevention, and we can establish awareness campaigns in our offices, in emergency responders, in hospitals, and within our communities. By helping to create these systems, family physicians can work with their communities to decrease the morbidity, mortality, and cost of this devastating illness.
1. Minino AM, Arias E, Kochanek KD, Murphy SI, Smith BL. Deaths: final data for 2000. Natl Vital Stat Rep. 2002;50(15):1–119.
2. American Heart Association. Heart disease and stroke statistics—2003 update. Dallas: American Heart Association, 2002. Accessed October 10, 2003, at: http://www.americanheart.org/downloadable/heart/10590179711482003HDSStatsBookREV7–03.pdf.
3. Goldstein LB, Gradison M. Stroke-related knowledge among patients with access to medical care in the stroke belt. J Stroke Cerebrovasc Dis. 1999;8:349–52.
4. Pancioli AM, Broderick J, Kothari R, Brott T, Tuchfarber A, Miller R, et al. Public perception of stroke warning signs and knowledge of potential risk factors. JAMA. 1998;279:1288–92.
5. Ezekowitz JA, Straus SE, Majumdar SR, McAlister FA. Stroke: strategies for primary prevention. Am Fam Physician. 2003;68:2379–86,2389–90.
6. Solberg LI. The KISS principle in family practice: keep it simple and systematic. Fam Pract Manag. 2003;10:63–6.
7. Alberts MJ. Undergraduate and postgraduate medical education for cerebrovascular disease. Stroke. 1995;26:1849–51.
8. Hart RG, Halperin JL, McBride R, Benavente O, Man-Son-Hing M, Kronmal RA. Aspirin for the primary prevention of stroke and other major vascular events: meta-analysis and hypotheses. Arch Neurol. 2000;57:326–32.
9. Straus SE, Majumdar SR, McAlister FA. New evidence for stroke prevention: scientific review. JAMA. 2002;288:1388–95.
10. Gorelick PB, Sacco RL, Smith DB, Alberts M, Mustone-Alexander L, Rader D, et al. Prevention of a first stroke: a review of guidelines and a multidisciplinary consensus statement from the National Stroke Association. JAMA. 1999;281:1112–20.
11. Becker K, Fruin M, Gooding T, Tirschwell D, Love P, Mankowski T. Community-based education improves stroke knowledge. Cerebrovasc Dis. 2001;11:34–43.
12. Alberts MJ, Perry A, Dawson DV, Bertels C. Effects of public and professional education on reducing the delay in presentation and referral of stroke patients. Stroke. 1992;23:352–6.
13. Brice JH, Griswell JK, Delbridge TR, Key CB. Stroke: from recognition by the public to management by emergency medical services. Prehosp Emerg Care. 2002;6:99–106.
14. Alberts MJ, Hademenos G, Latchaw RE, Jagoda A, Marler JR, Mayberg MR, et al. Recommendations for the establishment of primary stroke centers. Brain Attack Coalition. JAMA. 2000;283:3102–9.
15. Albers GW, Bates VE, Clark WM, Bell P, Verro P, Hamilton SA. Intravenous tissue-type plasminogen activator for treatment of acute stroke: the Standard Treatment with Alteplase to Reverse Stroke (STARS) study. JAMA. 2000;283:1145–50.
16. Improving the chain of recovery for acute stroke in your community. Task force reports (NIH publication no. 03-5348). Bethesda, Md.: National Institute of Neurological Disorders and Stroke (In press).
Copyright © 2003 by the American Academy of Family Physicians.
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