The sudden death of former UK MP Tony Banks, and the recent hospitalisation of Israeli Prime Minister Ariel Sharon, have brought stroke into the public eye, but for the wrong reasons. Stroke is seen as an inevitable consequence of ageing, despite the fact that a quarter of stroke cases are in people under 65 years of age. The trouble is that few people know about stroke, what can be done to treat it, and what are its symptoms. The UK does not compare favourably to other countries around the world; it suffers from institutionalised ignorance and a lack of organisation. These are some of the criticisms highlighted at a recent conference on Preventing and Treating Stoke in the NHS.
The conference was hosted by Dr Ian Gibson MP, who is Chair of the Parliamentary Office of Science and Technology and of the Parliamentary and Scientific Committee. Gibson, who himself had a mini-stroke or transient ischaemic attack in September 2004 while visiting Palestine, said, “I realised, while talking about it afterwards with my constituents, that people just don’t know what a mild stroke is.” Therefore, part of the aim of the conference was to raise awareness. “But it’s not enough to have a lovely conference that allows us to all go home happy. I’m very keen for people to become interested in the political process,” he added. “We need to get the tectonic plates shifting.”
And there are some heavy plates indeed. First speaker was Professor Peter Rothwell, University of Oxford, who spoke about the current state of stroke care in the UK. “I’m afraid this will be a bit of a depressing rant,” he admitted. “We should have no illusions about where we’re starting from.” He said that statistically, during the course of his lecture, ten people would experience strokes in the UK. “According to the ‘rule of thirds’, three of the ten will die, three will be disabled, and three will make a full recovery.”
However, despite this high burden, few resources are being committed to stroke treatment and care. This is particularly stark when you compare stroke to coronary heart disease, he commented. There are seven research posts for stroke and 455 for heart disease; similarly there are six trainees in stroke and 430 in heart disease. Ninety-five percent of heart disease outpatients are seen within 14 days of having their attack, compared to 37% of stroke victims. “We’d think from this that heart disease is more common, but it isn’t,” Rothwell added. “They both occur around the same age, and stroke is actually more common than acute coronary syndromes in women. Stroke accounts for a fifth of acute hospital bed usage and a quarter of long-term care beds. It’s an enormous burden; much more than coronary heart disease.”
“Secondary care is where the major problems are,” he elaborated. “The way to improve the situation is to look after patients well.” Dedicated stroke units can help. Rothwell highlighted results from the Stroke Unit Triallists’ Collaboration (2001), which showed that at one year, dying from stroke was 17% less likely in a stroke unit than on a general medical ward, and that chances of either dying or being disabled to the point of dependence were reduced by 25% (p<0.0001). "But only 40% of patients spend more than half their time in a stroke unit." Furthermore, we are not taking sufficient advantage of high-tech advances. "The data on thrombolysis - or clot busters - are very convincing. If patients are treated within three hours there are enormous benefits, but most hospitals in the UK do not have the capacity to administer this treatment because they need to scan the patient to check that they have the right sort of stroke (ischaemic rather than haemorrhagic). In Australia, 5-10% of acute stroke patients get thrombolysis; in the UK it is 0.1%."
Country comparisons make unhappy reading. Rothwell observed that in the UK there is one neurologist for every 177,000 people; in Europe, the ratio ranges from 1:38,462 in France to 1:8,117 in Italy. The UK comes last in Europe behind Poland in terms of the percentage of patients who get a CT scan within 48 hours (about 50%) while Sweden and Norway are nearly at 100%. We are in danger of being left far behind: “CT scans are last century’s goals. Most countries now are using MRI, with the advantages of increased accuracy of diagnosis and the identification of microbleeds,” he lamented. “By not identifying patients with microbleeds, we are likely to be putting a significant proportion of patients at very high risk of intracerebral haemorrhage on combination antiplatelet treatment and warfarin.”
The bottom line is that delays are costing lives. “Carotid surgery is highly effective if the operation is carried out quickly.” This is particularly true for severe stenosis: operating on 100 patients within two weeks of the mini-stroke prevents more than 30 strokes, whereas the average current delay in the UK of 12 weeks reduces the number of strokes prevented to less than 10 and renders surgery for moderate stenosis harmful.
A lot of the impact of stroke can be reduced if the public recognise the signs and know how to act. However, only around 8% of people know what transient ischaemic attack is or can recognise early signs of stroke such as facial and arm weakness, speech problems and loss of balance. The problem is that stroke receives negligible media attention. A recent report by the National Audit Office that analysed the impact of stroke revealed damning conclusions. “I was stunned by how little attention the report got,” said Rothwell. “On the same day there was a paper in The Lancet about how stroke is more common than heart disease, but the media led with a story about how binge drinking might possibly lead to a small increase in risk of mouth cancer.”
A lot of this ignorance is due to the historic vision of stroke as being an inevitable consequence of growing older, which is an increasingly out-dated view given advances in technology over the last few decades. Another cause is the fact that, unlike heart disease or cancer, there is no ‘stroke tsar’; no-one to create rules about stroke treatment, put pressure on Trusts and raise patient understanding. “The Stroke Association does a lot of good work, but their £2.5 million funding (1998-1999 figures) is small beer compared to that received for heart disease (£56 million) and cancer (£120 million). It’s the same story in the US,” observed Rothwell. Stroke, directly and indirectly, costs the NHS £7 billion a year, but receives only £7 million in research funding – a thousandth of the amount. “It’s pitiful,” he commented. “We should be spending at least 1% of the costs.”
Scrutinising surgery
Speaking next, Professor Ross Naylor, Leicester Royal Infirmary, backed up many of Rothwell’s points with facts of his own, supported by National Audit Office statistics. “Stroke is the third commonest cause of death in the UK and the principal cause of permanent neurological disability. There are 110,000 new cases of stroke each year and there are currently around 300,000 disabled survivors; 5% of the NHS budget is spent on treating this condition.”
The surgical intervention to prevent ischaemic stroke is carotid endarterectomy. “Carotid endarterectomy is the most scientifically scrutinised operation in the history of medicine,” Naylor observed. “And there is level 1 evidence of its benefits in selected patients.” Simple clinical predictors for identifying patients at highest risk of suffering a stroke include: being male, having hemispheric (as opposed to retinal) symptoms, and having displayed recurrent symptoms for longer than six months or having had a mini-stroke within the last month. Risk also increases with the number of co-morbidities and age. “However, the popular view is that carotid endarterectomy for elderly, symptomatic patients with increasing co-morbidity is inappropriate because the operative risks probably outweigh any long-term benefits. However, that is simply wrong.” In fact, stated Naylor, elderly symptomatic patients have the most to gain from surgical intervention, even for less-severe degrees of stenosis (50-69%).
He emphasised that it is the time to intervention (from presentation) that is crucial in determining theoverall benefit. “We know from Marshall’s work in the 1970s that within weeks of presenting with a transient ischaemic attack, thrombus overlying the stenosis is spontaneously lysed and that it becomes a smooth (lower risk) lesion. The time to target intervention should be when the thrombus is still present, i.e. when the patient is at greatest risk of embolic stroke.” Quoting NASCET data (1991), Naylor showed that while the risk of stroke in medically treated patients rose with increasing co-morbidity, the number of risk factors had no effect on surgically treated patients. “Contralateral occlusion and plaque ulceration remain two of the biggest imaging predictors of risk (of stroke) in medically treated, symptomatic patients,” he added.
“Surgeons too have a responsibility to minimise the operative risk.” Naylor reviewed experience observed at Leicester Royal Infirmary. Prior to 1991 the 30-day death/stroke rate after carotid endarterectomy was 6.0%. “In 1992, we introduced a sequential programme of research and audit, evaluating an integrated monitoring and quality control programme. Over the last 1,200 carotid endarterectomies since 1995, the operative risk has been reduced to 2.4%. Such a strategy may not be applicable to all units but it does serve to show that risks can be reduced and the long-term benefit of surgery increased.”
Naylor concluded with a wishlist for promoting stroke prevention and treatment for the future: more political support, more research funding, a higher public profile, better education, walk-in stroke clinics and, last but not least, rapid access to surgery and carotid artery stenting treatment.
Minimal invasion
Following Naylor, Dr Trevor Cleveland, The Sheffield Vascular Institute, discussed both angioplasty and stenting procedures. He noted that, specific to stenting, there is the risk of dislodging material from the occlusion that could end up damaging the brain. Therefore, cerebral protection devices are gaining in popularity. Research carried out between 1990 and 2002 shows that the risk of all stroke and death is reduced from 5.5 to 1.8 (p<0.001) if protection devices are used. Similarly, the risk of minor stroke is reduced from 3.7 to 0.5 (p<0.001) and major stroke from 1.1 to 0.3 (p<0.05). "And with stenting the patient can go home the next day," he added.
Comparisons of carotid endarterectomy and stenting show that the two procedures are “approximately the same” in terms of success rates. However, stenting is a relatively new procedure, and is rapidly evolving, and the National Institute of Clinical Excellence has yet to make a final recommendation. “It has completed its consultancy phase and made provisional recommendations,” Cleveland said. These are that carotid artery stenting is “efficacious in the short term”, but that a full audit and review is needed. The National Institute of Clinical Excellence also notes that adequate training is essential, “and a multidisciplinary team is important”, he added. There is still uncertainty about the role of cerebral protection devices. “Almost inevitably new techniques are treated with care and scepticism, and it takes time to do the required training. The UK is relatively conservative in this way, but it’s important to be reasonably certain that such advances will confer benefit, not harm. Nevertheless, stenting fits into the range of treatment options available for stroke that are tailored to the patients’ needs,” Cleveland concluded.
Official response
Although roundly ignored in most of the public press, the National Audit Office report cannot be ignored by the Government. Giving the Department of Health response was Professor Roger Boyle, a cardiologist who, as one delegate remarked, has “been parachuted in to stroke” from the National Taskforce for Coronary Heart Disease, where he is the Heart Tsar. “Ten years ago I was hearing the same sentiments about heart disease that I am hearing about stroke today,” he recalled. “We achieved success by harnessing medical enthusiasm. It took some money, but was mostly because we started doing things better.” Heart disease, he commented, is at the crest of its wave, while stroke is in the trough. “But that means there’s only one way to go,” he added.
He assured delegates that the stroke issue “is being taken seriously”. The Government has issued a mandate for Boyle’s team to produce a strategy document for England, and that there will be a Public Accounts Committee hearing on 8th February. “There is no better way to raise political awareness than that,” said Boyle.
Boyle presented figures concerning mortality from all types of circulatory disease. “Since 1996 there has been a 31.4% fall in mortality.” However, he admitted that the rate for stroke is not declining as fast as heart disease. The cause of the reduction is two-fold: partly there is more and better drug-use, but around 60% of the reduction comes from lifestyle modification on the part of the public – in the main smoking cessation. The drive to cut smoking was aided by a public awareness campaign including TV adverts in 2004. These won numerous awards for impact, he noted, but at a cost: £67 million. “It shows though that you can influence public opinion,” Boyle observed.
For stroke, Boyle noted that the UK suffers from variable standards of care, including too few centres offering the latest treatments. “One lesson I’ve learnt is that to improve it takes the joining of all energies: we need to get patients into the same room as [hospital] commissioners. We need to engage the whole of the NHS, including walk-in centres, the NHS Direct, GPs, ambulance services, hospitals, nurses and rehabilitation centres. And these need to be linked with intermediate and social care.” He particularly emphasised the need for local involvement. “It would be foolish to try to direct all activities from the central Department of Health.” What can be developed centrally is a framework for what a good stroke service should look like, he added.
Boyle’s wishlist for stroke includes better prevention, early access to specialist care, treating stroke as a medical emergency, rapid diagnosis, expanding the workforce and improving training, smoothing the transition from hospital to home, better rehabilitation and access to support, and more joined up working between health and social care. “The challenge now for stroke is not what we need to do, but how quickly we can do it,” Boyle said.
The slough of despond
It is easy to become disheartened by the statistics. However, Joe Korner from the Stroke Association, told delegates, “We’re not despondent. There is a lot to achieve, but we want to be at the crest of that wave.” The charity is working to make stroke more of a public issue, including getting stroke-related storylines into soap operas. “We are also demanding that the Department of Health fund a public awareness campaign.”
So while there is a lot to be concerned about, hopes are high. Gibson, who also founded the All-Party Group on Cancer, commented that when they started the cancer campaign “cancer equalled death”, but that things had changed. Jess Hudson, senior analyst and author of the National Audit Office report, told Vascular News, “[The NHS is] doing a proportion of the out-patient scans, it’s just doing them too late; the money is being spent, but after the time when it would have been useful, which is wasteful. It’s a matter of better organisation… and attitudes.” Hudson added that the National Audit Office report says there is capacity within the system to do scans within the required timeframe, but that stroke is not a high-enough priority. But how much capacity is enough? Rothwell challenged Hudson: “Strokes are like buses, we need extra capacity to deal with those times when several come along at once.” It is also important to understand the organisational differences between the UK and other countries: “We’ve never had a stroke speciality, unlike cancer or cardiology,” said Rothwell, “it’s been dealt with either by neurologists, gerontologists or general physicians.” Hudson added that other medical professionals, such as nurses, are very important but are hard to recruit in the UK. “Stroke patients are seen as ‘heavy’ patients who are difficult to treat and rarely get better. It’s very depressing for [the nurses] to work in an environment like that. They need hope that they can make a difference.”
One idea to raise public awareness is to ‘rebrand’ stroke; the current name is non-descriptive, masking the condition’s severity, and has a legacy attached to it. Could ‘brain attack’ capture the public’s attention, and is starting from scratch with a new term better? Some mental health conditions have shaken off old views by renaming and redefining themselves. While this is one option, it is clear that ‘sexing stroke up’ will not solve all problems. However attitudes do need to change, and not just the public’s. “There is a fashionable cynicism in medicine that there’s nothing we can do about stroke… There is a slightly nihilistic view,” Rothwell commented to Vascular News. “This goes back to the old days when it wasn’t possible to help most patients.”
How much this would all cost was a bone of contention. On the whole everyone agreed that money spent up front would result in substantial savings elsewhere in the NHS. The problem is, that will be from “two different pots of money”. Rothwell dismissed those who claimed that investing money in stroke would be ‘cost-neutral’ in the short-term. “Heart disease took a lot of money to turn around; cancer took more.”
Clearly there are many points of view to incorporate in the stroke debate. Throughout the process though we must not lose sight of the goal. Other countries throughout the world have shown that stroke can be successfully tackled. So what is the message for the health profession? “They need to speak with one voice,” Korner told Vascular News. “We need to maintain pressure in a unified way. Local pressure is vital if we are to deliver on these national goals.”
