The patient population
The State of the Nation: Stroke statistics guide was published by the Stroke Association in 2016. This provides a helpful summary of data about stroke epidemiology, risk factors, prevention and treatment, and is the source of the statistics below.
The reported incidence of stroke in the UK ranges from 115 to 150 per 100,000 population, depending on the region. Eighty five per cent of strokes are due to cerebral infarction and 15% are due to haemorrhage. Someone has a stroke in the UK every 3.5 minutes, equating to 152,000 people per year. The 30-day case fatality from stroke is 1 in 8. By the age of 75, 1 in 5 women and 1 in 6 men will have had a stroke. Although the risk of stroke doubles every decade for people over the age of 55, stroke can affect people of any age – 26% of stroke patients are under 65 and 400 children have a stroke each year. Black and south Asian people are at higher risk of stroke and strokes occur at a younger age in people from these ethnic groups. Stroke incidence and mortality are strongly linked to social deprivation with the incidence being twice as high and mortality three times as high in the most economically deprived areas of the UK compared with the more affluent areas.
There are over 1.2 million stroke survivors in the UK, where stroke is one of the largest causes of disability – half of all stroke survivors are disabled. Thirty per cent of people who have had a stroke go on to have a second stroke. Stroke costs the UK economy £9 billion per year (£4.53 billion health and social care costs). Approximately 15% of ischaemic strokes are preceded by a transient ischaemic attack (TIA) and the risk of stroke is greatest in the days following TIA. Although stroke incidence and case fatality rates are falling due to improvements in prevention and care, stroke will continue to be a major health problem due to our ageing population.
Prevention of disease
The approach to primary prevention of ischaemic and haemorrhagic stroke is similar to the prevention of other vascular disease. At a population level the most important modifiable risk factors for stroke are hypertension and smoking. High blood pressure is a contributory factor to 54% of strokes in the UK. The risk of stroke increases fivefold for people with atrial fibrillation and atrial fibrillation is a contributing factor to 20% of strokes (Source: State of the Nation: Stroke statistics). Other important risk factors are:
- high cholesterol
- sickle cell disease
- high alcohol intake
- illegal drugs eg cocaine and amphetamines.
Optimising primary prevention could significantly reduce the incidence of stroke and other vascular diseases.
As with primary prevention, there is a strong evidence base for the secondary prevention of stroke. The National Clinical Guideline for Stroke 2016 gives clear guidance on secondary prevention. People who have had a stroke or TIA should receive a comprehensive and personalised strategy for vascular prevention including medication and lifestyle factors. Risk factor modification should begin as soon as possible and be reviewed and monitored regularly. For patients with ischaemic stroke, secondary prevention includes:
- anti-thrombotic treatment (usually clopidogrel)
- lipid modification
- blood pressure reduction
- anticoagulation for patients in atrial fibrillation
- surgery for severe symptomatic carotid stenosis
- treatment of haematological or cardiac structural abnormalities.
Secondary prevention of intracerebral haemorrhage involves: blood pressure reduction, and identification and treatment of vascular or haematological abnormalities. As with primary prevention, diet, exercise, smoking, alcohol consumption should be addressed.
Planning effective services
There is a National Clinical Director for Stroke in NHS England who is actively involved with service development nationally.
The fifth edition of the National Clinical Guideline for Stroke was published in October 2016. This comprehensive document covers:
- organisation of stroke services
- acute care
- recovery and rehabilitation
- long-term management
- commissioning of services.
The Sentinel Stroke National Audit Programme (SSNAP) based at King’s College London has been integral to improving stroke care. All hospitals that admit stroke patients in England, Wales and Northern Ireland contribute data about all stroke patients to this prospective audit. SNNAP produces detailed reports every 3 months and annually which describe the overall quality of stroke care in each trust/service (grade A–E). Performance in ten domains is also reported on. There are also regular reports about the organisation of acute services and post-acute care. SSNAP reports are available at hospital level, regionally, nationally or by CCG/LHB/LCG. There are also public reports and easy access versions.
NICE guidance is available for:
- the diagnosis and initial management of stroke and TIA
- the use of alteplase in the treatment of acute ischaemic stroke
- stroke rehabilitation in adults.
The British Association of Stroke Physicians has developed standards for providing safe acute ischaemic stroke thrombectomy services (opens PDF, 348.66KB).
The Department of Health 10-year National Stroke Strategy (opens PDF, 1.04MB) runs until 2017 but unfortunately has already been archived. The Stroke Association is actively campaigning for a new national stroke strategy.
The RCP Stroke Programme has a Stroke Peer Review Scheme to assist trusts, CCGs, and regions to plan and develop their services.