Elsevier

The Lancet

Volume 392, Issue 10154, 6–12 October 2018, Pages 1269-1278
The Lancet

Series
Prevention of stroke: a global perspective

https://doi.org/10.1016/S0140-6736(18)31269-8Get rights and content

Summary

Along with the rising global burden of disability attributed to stroke, costs of stroke care are rising, providing the impetus to direct our research focus towards effective measures of stroke prevention. In this Series paper, we discuss strategies for reducing the risk of the emergence of disease (primordial prevention), preventing the onset of disease (primary prevention), and preventing the recurrence of disease (secondary prevention). Our focus includes global strategies and campaigns, and measurements of the effectiveness of worldwide preventive interventions, with an emphasis on low-income and middle-income countries. Our findings reveal that effective tobacco control, adequate nutrition, and development of healthy cities are important strategies for primordial prevention, whereas polypill strategies, use of mobile technology (mHealth), along with salt reduction and other dietary interventions, are effective in the primary prevention of stroke. An effective collaboration between various health-care sectors, government policies, and campaigns can successfully implement secondary prevention strategies, through surveillance and registries, such as the WHO's non-communicable diseases programmes, across high-income and low-income countries.

Introduction

Globally, there is a huge burden of stroke, with 10·3 million new strokes and 113 million disability-adjusted life years (DALYs) per year.1 The disparities in the burden of stroke between low-income and middle-income countries (LMICs) and high-income countries has been growing, with about 75% of deaths from stroke and more than 80% of DALYs now occurring in LMICs.2, 3 Disparities in the incidence of stroke are also growing, with a 42% decrease in stroke incidence in high-income countries and a 100% increase in LMICs in the past four decades.4 The increasing burden and costs associated with stroke care all point towards the pressing need for effective measures of stroke prevention.

According to the Global Burden of Disease (GBD) 2013 study, potentially modifiable risk factors cause more than 90% of the stroke burden,2 and more than 75% of this burden could be reduced by controlling metabolic and behavioural risk factors.1 In this Series paper, we review the major and emerging strategies for the prevention of stroke globally, including, first, activities that prevent the emergence of risk factors via the establishment of environmental, economic, sociobehavioural, and cultural patterns of living (primordial prevention); second, reducing the incidence of stroke (primary prevention); and third, preventing the recurrence of stroke (secondary prevention). Given the growing burden of stroke in LMICs, we have specifically emphasised strategies in these regions (figure 1).

Section snippets

Risk factors for stroke

Risk factors associated with stroke can be classified as either non-modifiable or potentially modifiable. With our overall aim of reviewing the evidence for prevention, herein we focus on potentially modifiable risk factors.

Assessing the risk of stroke

Risk assessment tools can be used to identify prevention strategies for stroke at the community, physician, health worker, and individual level. Many tools for the assessment of the risk of stroke are available for physicians and also for personal use (appendix).10, 11, 12, 13, 14, 15 The charts for predicting risk developed by WHO and the International Society of Hypertension for WHO epidemiological sub-regions are helping local governments frame their cardiovascular disease prevention

Prevention

New and effective approaches to stroke prevention include population-based approaches (eg, smoking bans, healthy cities), individual-based approaches (eg, polypills), and combinations of these approaches, such as the use of mobile technology (mHealth), task shifting (the process of transferring tasks from highly trained health professionals to health-care workers with less training, qualifications, and education), and salt reduction. Depending on the stage of epidemiological transition, some of

Primordial prevention

Primordial prevention strategies prevent the emergence of risk factors, ideally taking a life-course perspective that incorporates analysing and improving social and biological conditions throughout the life of individuals. We discuss various strategies in this Series paper.

Primary prevention

Primary prevention strategies are mainly targeted towards those who are at risk of stroke because of the presence of risk factors. These can be individual-based or population-based strategies.

Secondary prevention

Smoking cessation, antihypertensive therapy, glycaemia control, cholesterol reduction with statins, antiplatelet agents, treatment of atrial fibrillation with oral anticoagulants, and endarterectomy for symptomatic carotid stenosis are all examples of evidence-based secondary prevention interventions.84 The simple combination of the use of aspirin, smoking cessation, antihypertensive drugs, and statins reduces the risk of recurrence of ischaemic events by about 75%.84

WHO's non-communicable diseases campaign

WHO's non-communicable diseases campaign lists several targets, including a 25% RR reduction in the overall mortality from cardiovascular diseases, at least a 10% RR reduction in the harmful use of alcohol, a 10% RR reduction in prevalence of insufficient physical activity, a 30% RR reduction in mean population intake of salt or sodium, and a 30% RR)reduction in the prevalence of tobacco use among people aged over 15 years.92 WHO's Global Strategy on Diet, Physical Activity, and Health and its

Surveillance through registries

WHO's STEPwise approach to surveillance (STEPS) has been implemented in more than 40 countries, involving different socioeconomic settings.93 The method aims to provide flexible options for assessing the burden of existing chronic diseases and its risk factors, using indicators that vary according to the technical and financial capacity of each country. There are options for surveillance via hospitals alone or in conjunction with community-based surveillance. STEPS provides software for data

Conclusion

Effective implementation of tobacco control, adequate nutrition, development of healthy cities (with walkable neighbourhoods, access to healthy foods, and public transport), polypill strategies, use of mHealth programmes, along with salt reduction and dietary interventions, can substantially reduce the risk of stroke. These strategies require collaborations between various sectors of health care, government policies, and campaigns for dissemination of evidence-based strategies to enable

Search strategy and selection criteria

We searched various databases using the PRISMA guidelines, including PubMed, Medline, and Google Scholar. We used the following search terms: “diet”, “dietary patterns”, “nutrition”, “food”, “Mediterranean”, “DASH diet”, “avocados”, or “plant-based” in combination with “prevention”, “stroke”, “cerebrovascular disease”, and “cardiovascular disease”; “stroke” in combination with “prevention”, “guidelines”, and “low to middle income countries”; “smoking uptake” OR “smoking initiation” in

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