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Lifting the burden of stroke

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Lifting the burden of stroke

Around 152,000 people in the UK suffer a stroke each year, and unfortunately 50,000 people die because of it, yet there are many simple changes that people can make to reduce their risk of suffering from the condition

By the time you’ve read this article, someone, somewhere in the UK will have suffered a stroke. The Stroke Association says that about 152,000 people in the UK suffer a stroke each year – that's about one person every five minutes. What’s more, one in five strokes are fatal, while half the survivors are left permanently, and often severely, disabled. In the UK, deaths from stroke halved over the last 20 years. Yet the condition was still the fourth leading cause of death in the UK during 2010 and kills about seven per cent of men and 10 per cent of women. Only cancer, heart disease and respiratory diseases killed more people. Strokes usually strike people over 65 years of age. But anyone can suffer a stroke, even babies.

In fact, the Lancet noted recently that in high-income countries, such as the UK, one in every 200 strokes occurred in children (under the age of 20 years) and about a third in young and middle-aged adults (20–64 years). Fortunately, watching out for the symptoms (see box on opposite page), offering straightforward lifestyle advice and ensuring people take their medicines can help lift the burden imposed by stroke.

What are strokes?

There are, broadly, two types of stroke. About one in seven are haemorrhagic, which means a blood vessel bursts causing blood to flood into, and destroy, parts of the brain. And about 85 per cent of strokes are ischaemic, which means that an interruption or reduction in blood supply starves the brain of oxygen and nutrients, causing brain cells to die. Sometimes, the blood supply returns relatively rapidly. Symptoms of this ‘transient ischaemic attack’ (TIA) – also called a ‘mini stroke’ – are similar to a full-blown stroke, but most people return to normal within 24 hours. In contrast, the effects of a stroke often last for the rest of the person’s life.

Dr Alan Rees, consultant physician at the University Hospital of Wales and trustee of the cholesterol charity Heart UK, explains that ischaemic strokes arise from two main causes. Sometimes, part of a blood clot can clog an artery, blocking the supply of blood to the brain. Arrhythmias – changes in the heart’s rate or rhythm – cause many of these clots. In other ischaemic strokes, fatty plaques accumulate in the arteries – the same process that causes most heart attacks. Doctors call this accumulation atherosclerosis. ‘Sclerosis’ means hardening, and ‘athere’ is the Greek word for gruel or porridge, which gives you an idea of the consistency of these fatty deposits.

Rethinking risk

Dr Rees and other specialists want to redefine the way doctors estimate risk. Currently, doctors estimate risk based on an individual’s likelihood of suffering a heart attack or stroke over the next 10 years. “However, a 30-year or longer horizon may help save more lives,” he suggests. “Any individual at the age of 30 has a very low or negligible risk of a heart attack or a stroke over the ensuing 10 years. However, their long-term risk – for example, over 30 years – may be high enough to justify an intervention at the age of 30 rather than delaying treatment until their 10-year risk crosses the threshold. This threshold may not be reached until they are past the age of 50 years. Thus, an earlier intervention is justified in those individuals with an elevated 30-year risk.”

Reducing risk

The risk factors for ischaemic stroke are similar to those for a heart attack: smoking, raised levels of total and low-density lipoprotein (LDL) cholesterol, diabetes, and dangerously raised blood pressure (hypertension). Indeed, according to the Stroke Association, hypertension contributes to about half of all strokes. Dr Rees points out that people can reduce their risk of stroke by combining lifestyle changes and medicines.

Drug use and blood pressure “In young people under the age of 30, illicit drugs – such as cocaine – are the most common cause of strokes,” Dr Rees told Training Matters. “Cocaine and some other drugs can trigger a marked rise in intracranial blood pressure.”

Exercise and a healthy diet “We all know about – but usually studiously ignore – the lifestyle changes that reduce the risk of heart attacks and strokes, such as maintaining a healthy weight, which helps avoid type 2 diabetes and hypertension, getting plenty of exercise and eating a high-fibre diet low in saturated fat and calories,” says Dr Rees.

Dr Rees stresses that exercise doesn’t necessarily mean joining a gym. “It’s about going up the stairs rather than taking a lift, walking to the shops rather than driving, and so on. The aggregation of small changes can make a big difference,” he says. And Dr Rees warns against exaggerating the benefits of exercise for weight control, which will help prevent people becoming disillusioned. “I’ve run a couple of marathons,” Dr Rees says, “and I only started losing weight once I was running more than 20 to 30 miles a week.”

A healthy diet helps reduce stroke risk, which means, for example, suggesting that people watch their intake of alcohol and salt. “Alcohol is essentially sugar dissolved in water, which is partially metabolised,” Dr Rees remarks. “People do not appreciate how many calories alcoholic drinks contain, and beers and wines are becoming stronger. Excessive alcohol consumption can contribute to obesity and, therefore, type 2 diabetes. Teasing out alcohol’s contribution to stroke is difficult. However, a moderate amount of alcohol may protect against cardiovascular disease, while higher amounts and binge drinking may increase the risk of stroke.” So, advise people to stick within the recommended limits:

Men should not regularly (every day or most days) drink more than three to four units of alcohol a day. Women should not regularly drink more than two to three units of alcohol a day.

Salt also contributes to strokes by increasing blood pressure. Unfortunately, according to the NHS, on average, adults eat around 8.1g of salt a day – about two teaspoons, yet the recommended intake is 6g. “We’re eating much more processed food than in the past. We’re often unaware of the hidden salt added to many processed foods, which makes a big contribution to hypertension,” Dr Rees comments. Fortunately, reducing salt is relatively straightforward – such as banishing salt from the table, not adding salt during cooking, and choosing low-salt foods (less than 0.3g of salt or 0.1g of sodium per 100g).

Medication

Patients can also reduce their risk of stroke by sticking to treatments suggested by their doctor, such as antihypertensives and statins and other lipidlowering medications. “An extremely rigorous evidence base shows almost unequivocally – we’re 99.9 per cent sure – that statins reduce the risk of cardiovascular disease when used as primary or secondary prevention,” Dr Rees says.

Primary prevention means treating to prevent a first stroke or heart attack. Secondary prevention aims to avoid a further stroke or heart attack. However, every drug has side effects. Statins, for example, can damage muscles (myopathy). “Statin-related myopathy is a continuum from a slight ache to a severe destruction of the muscle, called rhabdomyolysis,” Dr Rees explains. “Clinical trials suggest that about one or two per cent of patients taking statins develop myopathy. However, the rates are higher in clinical practice and statin-related myopathy is most common in frail, thin, elderly women.”

Nevertheless, Dr Rees points out, working out the cause of aches and pains can prove difficult. Patients may take several medications – some of which can also cause aches and pains in joints and muscles – have concurrent arthritis or other conditions, or may simply pull a muscle. Fortunately, doctors can measure levels of an enzyme called creatine kinase, released by damaged muscle, which helps them ascertain whether a statin was responsible.

The pattern of aches and pains offers another clue. Dr Rees suggests that people who have symmetrical aches and pains all over the body – which may be especially intense in the shoulders and hips – should see their GP to test for myopathy. The muscle aches and pains tend to emerge soon after the start of statin treatment and decrease once it’s stopped.

Dr Rees suggests restarting statins once the pain resolves to see if the discomfort re-emerges before definitively blaming the drugs. So, in summary, a combination of lifestyle changes, watching for symptoms and adherence to medication could have prevented many of the 50,000 deaths in the UK each year from stroke. By suggesting that patients follow these simple rules, pharmacy assistants can help lift the burden imposed by this distressing, disabling and deadly disease.

Know the symptoms

Call 999 if a person fails any one of these tests:

  • Facial weakness: Can the person smile? Has their mouth or eye drooped?
  • Arm weakness: Can the person raise both arms?
  • Speech problems: Can the person speak clearly? Can the person understand what you say?

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