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Stroke—prevention is better than cure
Editorial
A favourite interview question put to aspiring doctors applying to be a Lancet editor is: “How many people do you think die each year?” For readers familiar with global burden of disease statistics, this might appear to be an easy question. But for many doctors, who perhaps have not been required to think globally before, it can prove to be a difficult one to answer. Most candidates know that there are around 6·5 billion people living on the planet, so those who guess that around 1% of the population dies each year are not far wrong—around 59 million people will die in 2007. But, perhaps surprisingly, one disease— stroke—will kill 10% of these and leave millions of others disabled. This issue of The Lancet and the February issue of The Lancet Neurology—both published to coincide with the International Stroke Conference that will be held in San Francisco early next month—contain articles describing recent advances in the genetics, prevention, diagnosis, and treatment of stroke. Unfortunately, despite years of research, alteplase is still the only approved treatment for ischaemic stroke. More than a decade has passed since the publication of the first trial showing that alteplase is efficacious in some patients if given within 3 h of stroke onset. But even now only a tiny proportion of patients who could benefit are given the drug. As the investigators of the Safe Implementation of Thrombolysis in StrokeMonitoring Study (SITS-MOST) show in an Article, substantial evidence now exists that intravenous alteplase is safe and effective, even when administered in hospitals with relatively little previous experience of thrombolytic therapy for stroke. However, most stroke researchers would agree that dedicated stroke centres are needed to deliver the best quality of care, a conclusion that is supported by research done by Italian investigators in an Article on page 299. Ideally, a stroke centre will have access to MRI, which, according to Julio Chalela and colleagues, is better than computed tomography for detection of acute ischaemia, and is also able to detect acute and chronic haemorrhage. This issue of The Lancet also includes a Review on established treatments for acute ischaemic stroke, as well as a Seminar on subarachnoid haemorrhage. A Review by Ralph Sacco and colleagues looks to the future and summarises the experimental treatments for ischaemic stroke that are currently being investigated. www.thelancet.com Vol 369 January 27, 2007
Combination therapies—eg, combining alteplase with antiplatelet agents—might prove to be of benefit, as could sonothrombolysis—the use of ultrasound waves to break up clots. New thrombolytics are also in development: desmotoplase, which was isolated from the saliva of vampire bats, and tenecteplase seem to be the most promising. By contrast, the outlook for neuroprotective strategies, which would help prevent damage to neurons and glia in close proximity to the blocked vessel, is bleak. The announcement at the end of last year that the SAINT II trial results were negative, leading to AstraZeneca dropping disufenton (NXY-059) from its development pipeline, was a major blow to the stroke community. Trials testing the efficacy of other compounds and neuroprotective strategies, such as hypothermia, are ongoing. However, these new interventions will not be given to the vast majority of future stroke patients. According to WHO, 87% of the 5·7 million people who die from stroke each year live in low-income or middle-income countries, which are unlikely to be able to afford stroke units or new drugs. Worryingly, because of changing demographics, 7·8 million people will die each year of stroke by 2030 unless national governments in poorer countries start to implement population-based primary prevention strategies that are proven to work. Kathleen Strong and colleagues from WHO, writing in the February issue of The Lancet Neurology, propose a worldwide goal for stroke: “a 2% reduction [in stroke death rates] each year over and above that which may happen as a result of better case management and treatment.” Achieving this worthy goal would result in 6·4 million fewer deaths from stroke between 2005 and 2015. But this target will only be possible if governments and international agencies realise that stroke is neither solely a disease of affluence nor does it selectively affect older people who are nearing the end of their lives. A third of all stroke deaths are in people younger than 70 years of age, with 94% of those deaths taking place in lowincome or middle-income countries. Implementation of interventions that reduce hypertension, poor diet, and tobacco use will save more lives than all the thrombolytics, antiplatelets, and neuroprotectants combined. There is little doubt that for stroke, prevention really is better than cure. ■ The Lancet
Andrew Foster/Central Illustration Agency
Stroke—prevention is better than cure
For more on SITS-MOST see Articles page 275 See Lancet Neurol 2007; 6: 182–187
For more on stroke centres see Articles page 299
For more on MRI vs CT see Articles page 293
For more on established treatments see Review page 319 For more on subarachnoid haemorrhage see Seminar page 306 For more on experimental treatments see Review page 331
247
A favourite interview question put to aspiring doctors applying to be a Lancet editor is: “How many people do you think die each year?” For readers familiar with global burden of disease statistics, this might appear to be an easy question. But for many doctors, who perhaps have not been required to think globally before, it can prove to be a difficult one to answer. Most candidates know that there are around 6·5 billion people living on the planet, so those who guess that around 1% of the population dies each year are not far wrong—around 59 million people will die in 2007. But, perhaps surprisingly, one disease— stroke—will kill 10% of these and leave millions of others disabled. This issue of The Lancet and the February issue of The Lancet Neurology—both published to coincide with the International Stroke Conference that will be held in San Francisco early next month—contain articles describing recent advances in the genetics, prevention, diagnosis, and treatment of stroke. Unfortunately, despite years of research, alteplase is still the only approved treatment for ischaemic stroke. More than a decade has passed since the publication of the first trial showing that alteplase is efficacious in some patients if given within 3 h of stroke onset. But even now only a tiny proportion of patients who could benefit are given the drug. As the investigators of the Safe Implementation of Thrombolysis in StrokeMonitoring Study (SITS-MOST) show in an Article, substantial evidence now exists that intravenous alteplase is safe and effective, even when administered in hospitals with relatively little previous experience of thrombolytic therapy for stroke. However, most stroke researchers would agree that dedicated stroke centres are needed to deliver the best quality of care, a conclusion that is supported by research done by Italian investigators in an Article on page 299. Ideally, a stroke centre will have access to MRI, which, according to Julio Chalela and colleagues, is better than computed tomography for detection of acute ischaemia, and is also able to detect acute and chronic haemorrhage. This issue of The Lancet also includes a Review on established treatments for acute ischaemic stroke, as well as a Seminar on subarachnoid haemorrhage. A Review by Ralph Sacco and colleagues looks to the future and summarises the experimental treatments for ischaemic stroke that are currently being investigated. www.thelancet.com Vol 369 January 27, 2007
Combination therapies—eg, combining alteplase with antiplatelet agents—might prove to be of benefit, as could sonothrombolysis—the use of ultrasound waves to break up clots. New thrombolytics are also in development: desmotoplase, which was isolated from the saliva of vampire bats, and tenecteplase seem to be the most promising. By contrast, the outlook for neuroprotective strategies, which would help prevent damage to neurons and glia in close proximity to the blocked vessel, is bleak. The announcement at the end of last year that the SAINT II trial results were negative, leading to AstraZeneca dropping disufenton (NXY-059) from its development pipeline, was a major blow to the stroke community. Trials testing the efficacy of other compounds and neuroprotective strategies, such as hypothermia, are ongoing. However, these new interventions will not be given to the vast majority of future stroke patients. According to WHO, 87% of the 5·7 million people who die from stroke each year live in low-income or middle-income countries, which are unlikely to be able to afford stroke units or new drugs. Worryingly, because of changing demographics, 7·8 million people will die each year of stroke by 2030 unless national governments in poorer countries start to implement population-based primary prevention strategies that are proven to work. Kathleen Strong and colleagues from WHO, writing in the February issue of The Lancet Neurology, propose a worldwide goal for stroke: “a 2% reduction [in stroke death rates] each year over and above that which may happen as a result of better case management and treatment.” Achieving this worthy goal would result in 6·4 million fewer deaths from stroke between 2005 and 2015. But this target will only be possible if governments and international agencies realise that stroke is neither solely a disease of affluence nor does it selectively affect older people who are nearing the end of their lives. A third of all stroke deaths are in people younger than 70 years of age, with 94% of those deaths taking place in lowincome or middle-income countries. Implementation of interventions that reduce hypertension, poor diet, and tobacco use will save more lives than all the thrombolytics, antiplatelets, and neuroprotectants combined. There is little doubt that for stroke, prevention really is better than cure. ■ The Lancet
Andrew Foster/Central Illustration Agency
Stroke—prevention is better than cure
For more on SITS-MOST see Articles page 275 See Lancet Neurol 2007; 6: 182–187
For more on stroke centres see Articles page 299
For more on MRI vs CT see Articles page 293
For more on established treatments see Review page 319 For more on subarachnoid haemorrhage see Seminar page 306 For more on experimental treatments see Review page 331
247