Prevention or cure of acute stroke: the clock is ticking away

Abstract

To the Editor: Stroke is a major cause of death and disability and its incidence increases linearly with age and the level of systolic and diastolic blood pressure (BP) (1). Professor Davis et al. (2), in their comprehensive review, highlight an important deficit in the early management of patients with acute stroke, especially in this era with emerging novel therapies. However, the missed opportunities for the prevention of stroke (approximately 21,400 stroke deaths and 42,800 strokes each year in the UK) remain and are an issue yet to be resolved (3). A recent study evaluating antihypertensive therapy within UK general practices in this select group of patients provides more insights into this aspect (4). Mant et al. (4) reported that despite the fact that the practices selected were active in research and the BP control may have been better than in the UK as a whole, for 80% of the patients, systolic BP was above the targets set by the British Hypertension Society. There were also notable paucities in aggressive combination therapy. They suggested that patients in the community were 12 years older in comparison with participants of the Perindopril Protection Against Recurrent Stroke Study (PROGRESS) trial (5), on the basis of which many national guidelines are based and called urgently for more research in appropriate populations before the international guidelines are implemented in primary care, an opinion which was endorsed by some (6). Nonetheless, the ethical implications of conducting a randomised controlled trial and thereby denying antihypertensive treatment in patients over the age of 80 years were surprisingly not referred to, which has particular inference from a practical outlook. Hypertension and diabetes mellitus (DM) are significant risk factors for stroke (1, 7). More recently, disorders of glucose metabolism in acute stroke patients have been demonstrated to be an under-recognised problem, and DM has been shown to worsen the outcome of acute stroke (8). Of note, the prothrombotic risk of DM (9) in the setting of commonly perceived complications of uncontrolled BP such as atrial fibrillation and congestive heart failure has to be reiterated. One can only estimate the future perspective (10) and magnitude of the situation given the global prevalence of DM and projections for 2030 (11), as well as the global challenge of hypertension over the next couple of decades (12). Perhaps, using tools that health departments would have otherwise used to prevent and control communicable diseases (13) should be applied to raise the awareness amongst both patients [as issues associated with treatment compliance are increasingly being recognised as a problem (14)] and healthcare personnel. Indeed, this may serve as a good role model to expedite the concept of ‘time is brain’. The need for a concerted approach across primary and secondary care should be acknowledged by all concerned healthcare professionals to act swiftly and bridge the gap to address deficiencies in the immediate intervention and management of acute stroke. GIV and AAG are involved with the management of patients with acute stroke during acute non-selective general medical takes. No conflict of interest among authors.