http://www.thelancet.com/journals/laneur/article/PIIS1474-4422%2811%2970292-7/fulltext?rss=yes
In February, 2012, researchers and clinicians will gather in New Orleans, LA, USA, for the International Stroke Conference organised by the American Stroke Association (ASA), a division of the American Heart Association (AHA), to share the latest advances in basic and clinical research on cerebrovascular disorders. Ultimately, the goal will be to use this knowledge to guide prevention and treatment strategies, an aim that crucially depends on high-quality evidence that can be translated into clinical practice and health policy. The pressing need for such progress is highlighted by several articles in this issue, all with a focus on stroke.
Over the past few decades, global increases in incidence of stroke have paralleled changes in lifestyle that urgently need to be tackled if we are to reduce the burden of stroke. Evidence linking one such lifestyle factor, nutrition, with stroke is the subject of a comprehensive Review by Graeme Hankey. There are clear relations between poor nutrition and increased stroke risk, and one potential example of a cost-effective stroke prevention strategy is that of population-wide salt reduction: a 3 g reduction in daily salt intake is projected to reduce the annual number of new cases of stroke by 32 000 to 66 000 in the USA. However, more robust evidence is needed to understand the specific effects of various nutrients, foods, and dietary patterns on risk of stroke, and its many subtypes, so that appropriate interventions can be designed.
Also on the theme of risk factors, but with a focus on those associated with specific populations, Lynda Lisabeth and Cheryl Bushnell review the effects of menopause and hormone therapy on stroke risk, which roughly doubles in the 10 years after menopause. They discuss epidemiological evidence and potential mechanisms for this link, noting that more research is needed to identify the women in midlife who are at greatest risk of stroke and the safest ways to prescribe hormone therapy. Marie-Germaine Bousser and colleagues review the complex relation between migraine and risk of ischaemic stroke, and its diagnostic and therapeutic implications. As the authors point out, whether migraine itself causes the increased risk of stroke or whether both migraine with aura and an increase in stroke risk result from a shared pathophysiological mechanism remains to be determined. Moving from risk factors to management, Joyce Balami and Alastair Buchan review management approaches for intracerebral haemorrhage—the most devastating type of stroke—which consist largely of strategies to minimise damage after stroke and to avoid complications such as elevated intracranial pressure, seizures, and infections. Many of the procedures or treatment strategies have not been tested in randomised controlled trials and more robust evidence is needed on which to base reliable recommendations.
These four Reviews cover many of the impressive achievements that have been made in stroke research in recent years. They also point to the need for more robust evidence from studies of basic mechanisms through to epidemiological research and clinical trials of therapeutic interventions. The heterogeneity of stroke, and the frequent occurrence of comorbidities and complications, can make such evidence hard to obtain. Nevertheless, large national or international epidemiological studies and randomised trials are becoming more common and are proving invaluable in pinning down risk factors for different types of stroke and defining best practice for treatment. As discussed by Peter Rothwell in his Round-up of 2011's highlights in stroke research, the past year has seen important advances in promising new therapeutics—eg, randomised trials showed reduced stroke risk in patients with atrial fibrillation treated with the new factor Xa inhibitors rivaroxaban or apixaban. Large, collaborative efforts such as these are needed to drive stroke research forward and the AHA/ASA and similar organisations should continue to facilitate these approaches.
Despite progress in indentifying effective treatments to reduce death and disability after stroke, one of the greatest challenges facing neurologists is the implementation of these findings into everyday clinical practice. Organisations such as the AHA/ASA need to continue to take the lead in generating and updating guidelines in light of the results of recent trials. Similarly, although the evidence base for risk factors for stroke is growing, the findings are yet to be translated into public policy.
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