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Since stroke is the third leading cause of death in the United States and the major cause of disability in older individuals, prevention deserves greater and more dedicated efforts by medical practitioners and health policy planners. As the population continues to age, successful implementation of stroke prevention strategies should produce tangible benefits for large segments of society.
The Prevention of Stroke focuses on the stroke risk factors that are amenable to modification and describes ongoing strategies for their amelioration. It emphasizes primary prevention of risk factors because intervention before a stroke risk factor appears clinically is likely to yield the highest benefits. It also recognizes secondary prevention measures as important in reducing the chance of a stroke. A strength of this book is its reliance on well-founded, scientifically derived evidence interpreted by clinically experienced stroke experts. The authors assess the state of our current knowledge of successful stroke prevention measures while pointing out areas where there is a need to develop new and better prevention techniques. With a fund of bibliographic references and comprehensive index, this is an essential clinical reference on the successful prevention of stroke.
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Through its initiative called "Healthy People 2010," the Department of Health and Human Services aims to reduce the incidence of stroke by 20 percent, from 60 cases per 100,000 population in 1998 to 48 cases per 100,000 population in 2010. This is an ambitious goal, given that reductions in mortality due to stroke slowed down between 1990 and 2000, the rate of smoking by teenagers continues to exceed 25 percent, undiagnosed hypertension is rampant, and many insurance carriers do not pay for office visits for preventive care. In the fight against cerebrovascular disease, The Prevention of Stroke is an outstanding resource for clinicians and policymakers. In particular, clinicians will find here a guide to clinical care and a sobering message that effective stroke prevention requires as much attention to health systems as to office-based efforts. The book consists of three sections, covering epidemiology and pathophysiology, approaches to prevention, and management of risk factors. The first section begins with a concise chapter that establishes the public and private burden of stroke. With uncluttered illustrations, it lays out the evidence that stroke kills 160,000 people in the United States each year. It then makes many important points about stroke, including the prediction that the situation is going to get worse. As the number of older Americans increases, the number of deaths from stroke will triple by 2050. The epidemiology of impairment, disability, and handicap is not described in this chapter, nor is this theme taken up elsewhere in the book. It is generally believed, however, that 30 percent of survivors of stroke are dependent on others for at least one activity of daily living, and 20 percent are dependent on others for more than one such activity. Completing the first section on epidemiology are chapters on specific risk factors (e.g., the use of oral contraceptives, sickle cell anemia, and cardiac disease), atherosclerosis, and genetics. Critical features of the epidemiology of stroke emerge in high relief, including the exceptionally high mortality from stroke among young black persons and persons with sickle cell disease. The chapter on sickle cell disease is particularly well written and lays out the argument for risk stratification and selective use of exchange transfusion. One might argue that a book on stroke prevention should have a single comprehensive section on pathophysiology. Instead, this book disperses information on pathophysiology, presenting it in the context of issues pertinent to prevention (e.g., cardiac disease and sickle cell disease), and the strategy is generally successful. The one chapter devoted to pathophysiology, however, is exceptionally effective in summarizing the emerging role of vascular inflammation in the development and promotion of atherosclerosis and plaque rupture. This chapter successfully supports subsequent sections on treatment. Office-based preventive interventions will never conquer stroke. Even if we set aside the criticism that physicians do not follow guidelines for the prevention of common vascular risk factors (e.g., hypertension, dyslipidemia, smoking, and atrial fibrillation), it is clear that many patients at increased risk for stroke never see a physician in time to modify their risk. So what are the alternatives? A remarkable achievement of this book is its juxtaposition of the alternative approaches to prevention (in section 2) and clinical guidelines for office-based care (in section 3). Section 2, "Approaches to Stroke Prevention," presents an honest appraisal of community-based strategies and quality-improvement efforts. The conclusions are sobering: we have the knowledge and technology to prevent stroke in persons who are at increased risk, but we are not identifying these persons or delivering them adequate care. In her chapter on stroke and public policy, Shwayder correctly indicates one reason, which is that public advocacy for patients with stroke lags behind advocacy for patients with other chronic disorders and infectious diseases. Elsewhere in this section, authors describe government programs and models of community intervention that are effective or have the potential to modify health behavior and the risk of stroke. The chapter on quality assurance is highly optimistic but describes a field that has not yet realized its promise. The editors, both clinicians, have used this book wisely to promote a multilevel discussion of prevention and to highlight the enormous potential of population-based and health-system-based efforts. The final section of the book is about treatment of risk factors. Each chapter briefly summarizes the evidence that treatment reduces risk. The chapters on hypertension, smoking, alcohol, and exercise provide general guidelines for the implementation of treatment strategies, but they are not intended to include the detail one might find in a clinical handbook. For example, the chapter on smoking cessation does not say how to prescribe nicotine-replacement therapy or bupropion. The chapter on antiplatelet therapy is an exception; it is 15 pages long, and the author surprisingly recommends a combination of aspirin and extended-release dipyridamole as initial therapy for the secondary prevention of stroke. Gorelick, Alter, and their colleagues have successfully placed stroke prevention within the wider context of health care systems, where it must be accomplished jointly by public health officials, health care administrators, and clinicians. The good news is that there are clinical strategies and specific therapies available to enable these groups to make massive reductions in the burden of stroke. The unanswered question is whether they will succeed and reach even the moderate stroke-reduction goals set by Healthy People 2010. Walter N. Kernan, M.D.
Copyright © 2003 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
"an outstanding resource for clinicians and policymakers. A remarkable achievement of this book is its juxtaposition of the alternative approaches to prevention (in section 2) and clinical guidelines for office-based care (in section 3). Section 2, 'Approaches to Stroke Prevention, ' presents an honest appraisal of community-based strategies and quality improvement efforts." - The New England Journal of Medicine, January 23, 2003 "Provides a road map to guide physicians and other health professionals in ways to overcome barriers to stroke prevention practices." - from the Foreword by Martha N. Hill, R.N., Ph.D., FAAN and Daniel F. Hanley, MD
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