Pragmatic Solutions to 'Catastrophic' Global Stroke Burden

Deaths and disability due to stroke are expected to rise alarmingly over the next 30 years, with almost 10 million stroke deaths forecast annually by 2050, according to a new report from the World Stroke Organization-Lancet Neurology Commission Stroke Collaboration Group.

"This highlights the need for urgent measures to reduce stroke burden worldwide, with an emphasis on low- and middle-income countries," the report states.

These measures include an increase in trained healthcare workers who can implement effective primary prevention strategies, including the early detection and adequate management of hypertension.

On the basis of a review of evidence-based guidelines, recent surveys, and in-depth interviews with stroke experts around the world, the World Stroke Organization-Lancet Neurology Commission makes evidence-based pragmatic recommendations to reduce the global burden of stroke, including measures to improve surveillance, prevention, acute care, and rehabilitation.

The Commission report was announced on October 10 by World Stroke Organization president, Sheila Martins, MD, at the World Stroke Conference in Toronto. The report was also published online in The Lancet Neurology on October 9.

"Stroke care has changed a lot in the last few years," Martins, who is chief of neurology and neurosurgery at Hospital Moinhos de Vento, Porto Alegre, Brazil, and founder and president of the Brazilian Stroke Network, told theheart.org | Medscape Cardiology.

"We know what we need to do to reduce the global burden of stroke, and high-income countries are making progress in that regard. But the situation in low- and middle- income countries is catastrophic, with mortality rates of up to 80% in individuals who have had a stroke in some countries. There is a very large gap between knowledge and implementation."

Martins said that the Commission is offering potential innovative suggestions on how to change this reality.

"While we have the knowledge on the strategies needed to reduce stroke burden, the mechanisms needed to implement this knowledge will be different in different countries and cultures. Our Commission includes several representatives from low- and middle-income countries, and we will be working with local stakeholders in these countries to try and implement our recommendations," Martins explained.

In the report, the Commission authors point out that the global burden of stroke is "huge." In 2020, stroke was the second leading cause of death (6.6 million deaths) and the third leading cause of disability — responsible for 143 million disability-adjusted life-years — after neonatal disorders and ischemic heart disease. Stroke is also a leading cause of depression and dementia.

The absolute number of people affected by stroke, which includes those who die or remain disabled, has almost doubled in the past 30 years, the report notes. Most of the contemporary stroke burden is in low-income and middle-income countries, and the burden of disability after a stroke is increasing at a faster pace in low- and middle-income countries than in high-income countries. Alarmingly, the incidence of stroke is increasing in young and middle-aged people globally.

The Commission forecasts the burden of stroke from 2020 to 2050, with projections estimating that stroke mortality will increase by 50% to 9.7 million and disability-adjusted life-years growing to over 189.3 million by 2050.

"Stroke exerts an enormous toll on the world's population, leading to the death and permanent disability of millions of people each year, and costing billions of dollars," said Professor Valery L. Feigin, of Auckland University of Technology, New Zealand, and Commission co-chair. "Precisely forecasting the health and economic impacts of stroke decades into the future is inherently challenging given the levels of uncertainty involved, but these estimates are indicative of the ever-increasing burden we will see in the years ahead unless urgent, effective action is taken."

The report explains that multiple factors contribute to the high burden of stroke in low- and middle-income countries, including undetected and uncontrolled hypertension; lack of easily accessible, high-quality health services; insufficient attention to and investment in prevention, air pollution; population growth; unhealthy lifestyles (eg, poor diet, smoking, sedentary lifestyle, obesity); an earlier age of stroke onset and greater proportion of hemorrhagic strokes than in high-income countries; and the burden of infectious diseases resulting in competition for limited healthcare resources.

The Enormous Financial Cost of Stroke

The total cost of stroke (both direct treatment and rehabilitation costs and indirect costs due to loss of income) is estimated to rise from US$891 billion per year in 2017 to as much as $2.31 trillion by 2050. "These substantial increases in the costs associated with stroke will cause distressing financial circumstances for many communities and national health systems," the authors say.

However, this increase can be avoided because stroke is highly preventable and treatable, they stress. "These unsustainable trends in burden and costs of stroke underline the importance of identifying interventions to prevent and manage stroke more effectively," they state.

The Commission points out that population-wide primary prevention across the lifespan is extremely cost-effective. It has been estimated that for every $1 spent on the prevention of stroke and cardiovascular disease, there is a more than $10 return on investment.

Additionally, primary prevention efforts directed at stroke would probably yield large gains because of the secondary effects of reducing the risk for heart disease, type 2 diabetes, dementia, and some types of cancer that share common risk factors, the authors note.

"One of the most common problems in implementing stroke prevention and care recommendations is the lack of funding. Our Commission recommends introducing legislative regulations and taxations of unhealthy products (such as salt, alcohol, sugary drinks, trans-fats) by each and every government in the world," Feigin said.

"Such taxation would not only reduce consumption of these products — and therefore lead to the reduction of burden from stroke and major other non-communicable diseases — but also generate a large revenue sufficient to fund not only prevention programmes and services for stroke and other major disorders, but also reduce poverty, inequality in health service provision, and improve wellbeing of the population," he added.

Recommendations

The Commission authors make the following recommendations for key priorities to reduce the burden of stroke:

Surveillance and Prevention

Incorporate stroke events and risk factor surveillance into national stroke action plans.
Establish a system for population-wide primary and secondary stroke prevention, with emphasis on lifestyle modification for people at any level of risk of stroke and cardiovascular disease.
Primary and secondary stroke prevention services should be freely accessible and supported by universal health coverage, with access to affordable drugs for management of hypertension, dyslipidemia, diabetes, and clotting disorders.
Governments must allocate a fixed proportion of their annual healthcare funding for prevention of stroke and related noncommunicable diseases. This funding could come from taxation of tobacco, salt, alcohol, and sugar.
Raise public awareness and take action to encourage a healthy lifestyle and prevent stroke via population-wide deployment of digital technologies with simple, inexpensive screening for cardiovascular disease and modifiable risk factors.
Establish protocol-based shifting of tasks from highly trained healthcare professionals to supervised paramedical healthcare workers, to facilitate population-wide primary stroke prevention interventions across rural and urban settings.

Acute Care

Prioritize effective planning of acute stroke care services; capacity building, training, and certification of a multidisciplinary workforce; provision of evidence-based equipment and affordable medicines; and adequate resource allocation at national and regional levels.
Establish regional networks and protocol-driven services, including community-wide awareness campaigns for early recognition of a stroke, regionally coordinated pre-hospital services, telemedicine networks, and stroke centers that can triage and treat all cases of acute stroke, and facilitate timely access to reperfusion therapy.
Integrate acute care networks into the four pillars of the stroke "quadrangle" of resources, including surveillance, prevention, and rehabilitation services, by involving all relevant stakeholders (ie, communities, policymakers, nongovernmental organizations, national and regional stroke organizations, and public and private healthcare providers) in the stroke care continuum.

Rehabilitation

Establish multidisciplinary rehabilitation services and adapt evidence-based recommendations to the local context, including the training, support, and supervision of community healthcare workers and caregivers to assist in long-term care.
Invest in research to generate innovative low-cost interventions, in public awareness to improve demand for rehabilitation services, and in advocacy to mobilize resources for multidisciplinary rehabilitation.
Promote the training of stroke rehabilitation professionals. Use digital portals to improve training and to extend the use of assessment tools — such as the Modified Rankin Scale and the US National Institutes of Health Stroke Scale — and quality-of-life measures to assess functional impairment and monitor recovery.

The Commission concludes that "Overall, if the recommendations of this Commission are implemented, the burden of stroke will be reduced substantially…which will improve brain health and overall wellbeing worldwide."

Martins said that the World Stroke Organization is committed to supporting and accelerating the implementation of these recommendations globally through the WSO Implementation Task Force, with stroke experts to advise the establishment of stroke prevention and care and to contribute with educational programs, and through Global Stroke Alliance meetings facilitating the discussions between stroke experts and policymakers, giving technical support to governments to elaborate national plans for stroke and to include stroke care in universal health coverage packages.

The Commission received funding from the World Stroke Organization, Bill and Melinda Gates Foundation, Health Research Council of New Zealand, and National Health & Medical Research Council of Australia and was supported by the US National Institutes of Health.

15th World Stroke Conference. Presented October 10, 2023.

Lancet Neurol. Published online October 9. 2023. Full text

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