Dr George Kassianos discusses two initiatives from the Action for Stroke Group designed to raise awareness of stroke and improve its management in primary care

Stroke is the third most common cause of death in the UK after all cancers and coronary heart disease (CHD), accounting for 10.5% of all deaths1 (see Table 1, below). Stroke is also the leading cause of disability in the UK. The costs to the NHS are enormous (see Table 2, below).

Table 1: Stroke morbidity and mortality data
  • Mortality from stroke has declined during the past 30 years in the UK and many other industrialised countries. The decline is probably due, in part, to improved awareness and treatment of risk factors (e.g. hypertension) for stroke.
  • Stroke killed 66400 people in 1997 (15664 were aged <75 years),1 making it the third most common cause of death in the UK after all cancers (156125) and CHD (140559). Adding together all vascular deaths makes cardiovascular disease the biggest killer in the UK, accounting for 40% (261315) of all deaths.1
  • Patients are at risk of stroke after MI, and at risk of MI after a stroke. Among stroke survivors, 10% suffer an MI in the first year (of which 40% are fatal)7and 10-16% suffer a recurrence;8 12% of transient ischaemic attacks lead to a stroke within one year.9
Table 2: The cost of stroke
  • Around 5% of NHS expenditure is for stroke-related illness.
  • Patients with stroke occupy 13% of NHS beds, costing the NHS £2.32 billion a year10 (cf. patients with CHD, who cost the NHS £1.63 billion).
  • Caring for a patient with stroke in the community is estimated to cost around £6600 per year (NHS and Social Services costs).11
  • Estimates suggest that 12% of stroke patients are in long-term care one year after their stroke.12

It is estimated that 110 000 first strokes and 30 000 recurrent strokes will occur during the course of a year and that there are approximately half a million stroke survivors living in the UK.2

One in four men and one in five women can expect to have a stroke if they live to 85 years of age, and the incidence of stroke is likely to increase in the future as a result of the ageing population.

Atherosclerosis is a common factor in myocardial infarction, peripheral vascular disease, and most ischaemic strokes. About a third of patients with ischaemic stroke already have clinical manifestations of CHD, such as angina or a past myocardial infarction.3

For these reasons, stroke has been identified as a key disease in the Government's White Paper Saving Lives: Our Healthier Nation which calls for a 'reduction in death rate from heart disease and related illnesses such as stroke in those aged under 75 by 40% by the year 2010'.4 The National Service Framework for Coronary Heart Disease5 is the Government's blueprint for delivering this objective. Preventing stroke, and atherosclerotic disease generally, is now a priority.

To help identify where the focus of any educational initiatives should lie, the Action for Stroke Group (ASG) conducted a national survey among 3000 GPs, between July and August 1998. The findings revealed that:

  • GPs' knowledge of the stroke services available locally was extremely variable.
  • Communication between primary and secondary care regarding patient management could be improved.
  • The preferred method of stroke education appeared to be via GP or consultant-led meetings, or practice-based team meetings.

A booklet of the survey results was compiled, which summarises and interprets the key results.6 It provides practical information for GPs on stroke management and services based on available clinical evidence and current thinking.

The booklet also suggests a number of initiatives that could be developed by primary care organisations (PCOs) to help improve local care and develop closer links with local hospitals.

In response to the findings of the GP survey, and to ensure that GP education is PCO-focused, the ASG developed a comprehensive and user-friendly educational resource pack, entitled How can we improve the outlook for stroke? A PCG-based initiative.

The pack aims to provide an educational platform, encouraging discussion between the primary healthcare team and the local hospital stroke team, on the optimum use of local services and key aspects of stroke management.

Specifically, it will encourage the primary healthcare team to exchange practical information on achieving current best practice.

It has been designed for use by the GP responsible for education or clinical governance within individual PCOs, when setting up a meeting on stroke management. The local secondary care stroke team should actively participate in and contribute to the meetings.

The pack provides a rationale for making stroke an educational priority for the primary healthcare team, and contains all the key elements for developing and organising an educational meeting on stroke.

One of the benefits of the pack is that it allows the meeting to be tailored to an individual PCO's needs, and is available on disk as well as hard copy.

A second initiative of the ASG is the publication of its checklist Preventing further events – a stroke management checklist, which is designed to help primary healthcare teams meet the Government's target. It was developed in conjunction with three practice nurse advisers.

The checklist has been produced as an A4 laminated card,which is ideal for use both in the surgery and during home visits (see Figures 1 & 2, below).

Figure 1: Front of the ASG stroke management checklist
action for stroke group checklist - front
Figure 2: Reverse of the ASG stroke management checklist
action for stroke group checklist - back

It outlines the risk factors that should be checked regularly and provides a summary of current national recommendations for the management of stroke patients.

The suggested management steps are also applicable to patients with other manifestations of vascular disease, such as myocardial infarction, angina, and peripheral vascular disease.

The ASG checklist gives advice on the management of risk factors in stroke patients. It summarises key existing information, aiming to raise awareness of the risk factors and how to manage them among the primary healthcare team.

We need to be more 'aggressive' in our management of atherosclerotic disease if we are to reduce cardiovascular morbidity and mortality rates in our patients.

The checklist, which is supported by the Stroke Association, gives advice on the management of hypertension, diabetes, lipid-lowering therapy, and antiplatelet and anticoagulation therapy in stroke patients.

Stroke is not just a cerebrovascular accident: it occurs secondary to disease of the blood vessels. It is not a single disease but a consequence of a number of diseases that cause occlusion of cerebral arteries or predispose to bleeding into the brain.

There have been many advances in the prevention and treatment of myocardial infarction and, as a result, a significant reduction in its incidence and improvement in survival. However, a strategy for the prevention and treatment of stroke is less defined.

Management of patients with stroke is still a long way behind that of patients with CHD, as highlighted by the greater number of coronary care units in the UK compared with stroke units.

The issue of stroke and the allocation of resources by PCOs should be at the top of the cardiovascular agenda, since stroke prevention is one of the most cost-effective interventions in primary care. We need to deliver on all fronts of atherosclerosis.

  • Copies of the ASG resource pack and checklist can be obtained free from the Action for Stroke Group, PO Box 31412, London W4 1FJ (Tel: 020 8747 4400).

  1. Petersen S, Mockford C, Rayner M. Coronary heart disease statistics. British Heart Foundation Statistics Database, 1999.
  2. Dunbabin D. Cost-effective intervention in stroke. Pharmacoeconomics 1992; 2: 468-99.
  3. Sandercock PAG, Warlow CP, Jones LN, Starkey I. Predisposing factors for cerebral infarction: the Oxfordshire Community Stroke Project. Br Med J 1989; 298: 75-80.
  4. DoH. Saving Lives: Our Healthier Nation. London: The Stationery Office, 1999.
  5. DoH. National Service Framework for Coronary Heart Disease. London: March, 2000.
  6. Fowler G, Farmer A, Mant J et al. Results of a GP Survey on the Management of Stroke. London: Action for Stroke Group, 1998. Copies available from: ASG, PO Box 31412, London W4 1FJ.
  7. Vitanen M, Eriksson S, Asplund K. Risk of recurrent stroke, myocardial infarction, and epilepsy during long-term follow-up after stroke. Eur Neurol 1988; 28: 227-31.
  8. Warlow CP 1998. Stroke: A Practical Guide to Management. Blackwell Science.
  9. Dennis M et al. Prognosis of transient ischaemic attacks in the Oxfordshire Community Stroke Project. Stroke 1990; 21: 848-53.
  10. Stroke Care: Reducing the Burden of Disease. London: The Stroke Association, 1998.
  11. Phillips C. The evidence for stroke prevention. Evidence Based Medicine in Practice. Newmarket:Hayward Medical Communications, 1997: 3-9.
  12. Legh-Smith J, Wade DT, Langton-Hewer R. Services for stroke patients one year after stroke. J Epidemiol Commun Health 1986; 40: 161-5.

Guidelines in Practice, December 2000, Volume 3
© 2000 MGP Ltd
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