Stroke is the second most common single cause of death in Europe and the leading cause of long-term disability.
1,2 Every year, up to 1.3 million persons in Europe suffer a first-ever stroke.
3 Consequently, the socioeconomic impact of stroke is considerable with an annual cost in Europe of up to €45 billion.
1
Projections show that the overall stroke burden in Europe will further
increase by 35% in 2050, mostly because of the aging population.
4
However, there is overwhelming evidence that an acute ischemic stroke
is no longer an unavoidable fate because strokes can be prevented and
treated(10% full recovery is not being treated successfully), dramatically reducing the burden of stroke and its long-term
consequences.
Endovascular
treatment (EVT) has recently become the standard of
care(NOT RECOVERY!) in stroke
patients with large vessel occlusions, and it is now, together with
stroke unit (SU) treatment and intravenous thrombolysis (IVT), a main
pillar of acute stroke management.
(But you never tell us its full success rate , so I call that a failure.) However, and despite much discussion
on the necessary overhaul of stroke systems of
care(NOT RECOVERY!), information on
access and delivery of these acute stroke treatment strategies in Europe
was lacking. In a recent publication in the European Stroke Journal,
Aguiar de Sousa et al
5 surveyed the status of acute stroke treatment in Europe.
Current Status of Acute Stroke Care(NOT RECOVERY!) in Europe
A
survey drafted by stroke professionals from the European Stroke
Organisation, the European Society of Minimally Invasive Neurological
Therapy, the European Academy of Neurology, and the patient organisation
Stroke Alliance for Europe
was sent to national stroke societies and
experts requesting best available national data on the number of SUs, as
well as IVT and EVT rates, per year. Experts from 44 of 51 European
countries provided data. Out of the 7 nonparticipating countries, 5 were
from Eastern Europe. The authors compared both pooled and individual
national data per 1 million inhabitants (United Nations data) and per
1000 annual incident ischemic strokes (Global Burden of Disease Report)
with the best-performing countries.
(Well fuck, you didn't request surveys from survivors asking how well they recovered because you didn't want to publicize your complete failure in getting them 100% recovered.)
The
estimated mean number of SUs was 2.9 per 1 million inhabitants and 1.5
per 1000 annual incident strokes; highest country rates were 9.2 and
5.8, respectively. Forty-two countries provided the annual number of
IVTs. The estimated mean annual number was 142 IVT per 1 million
inhabitants, whereas 4 countries had rates per million above 350.
Overall, 7.3% of all patients with an ischemic stroke in Europe received
IVT. However, 15 countries had IVT rates <5%, whereas 6 countries
reported that at least 15% of their patients received this treatment.
The annual number of EVT was provided in 39 countries and was mostly for
2016. The estimated mean annual number of EVTs was 37.1 per 1 million
inhabitants. Importantly, the annual number of treatments was estimated
to be <10 per 1 million inhabitants in 13 countries, whereas rates
for the 3 best-performing countries were 3× higher than the overall mean
(up to 111.5). Overall, only 1.9% of incident ischemic stroke patients
received EVT, whereas the top 3 countries reported rates above 5%.
These
data showed that for most countries access to and delivery of SU
care(NOT RECOVERY!) along with both IVT and EVT rates varied significantly, and in most
countries, rates were far below best performers. The discrepancy means
that 226 662 more patients could have been treated with IVT (339 929
instead of 113 267) and 67 347 with EVT (94 852 instead of 27 505), if
best practice would have been followed in all countries. Although these
are still rather conservative estimates, this means that two-thirds of
patients that would potentially be eligible for IVT and three-quarters
of candidates for EVT did not receive these treatments in Europe.
This
survey provides a comprehensive snapshot of acute stroke
care(NOT RECOVERY!) standards
in European countries. These results are valuable for all stakeholders
responsible for drawing up and implementing long-term strategies. The
major limitation of this investigation was that it relied on surveyed
data. Although it was requested that only best available information has
to be utilized to compile the survey, in countries lacking organized
nationwide registries, data came from variable sources, namely recent
health ministerial statistics, service reports, national stroke
registries, and estimates made by a consensus of coordinators and
experts. In addition, no audit could be performed to assess the quality
of the data. A larger prospective survey is planned for 2019.
Perspective of Acute Stroke Care in Europe
The
findings of this survey have implications for the future organization
of acute stroke
care(NOT RECOVERY!) standards throughout Europe. In 2006, the second
Helsingborg Declaration, cosponsored by the World Health Organization
Regional Office for Europe, set new targets for stroke management and
care(NOT RECOVERY!).
6
One specific goal for 2015 was that all patients with acute stroke who
were potentially eligible for acute specific treatment should be
transferred to hospitals with adequate capacity and expertise to
administer treatments—defined as an SU or stroke dedicated area. The
current survey suggests that this goal still is far from being reached.
The
European Stroke Organisation has therefore prepared a European Stroke
Action Plan (ESAP) for the years 2018 to 2030, in cooperation with the
European patient organisation Stroke Alliance for Europe.
7
The ESAP adheres to the format of the Helsingborg Declarations,
presenting a review of the state of the art, the state of current
services, research and development priorities, and targets for a series
of domains in stroke
care(NOT RECOVERY!) (organization of stroke services, management
of acute stroke, prevention, rehabilitation, evaluation of stroke
outcome, and quality assessment). The ESAP includes 2 additional
domains, on primary prevention and life after stroke, along with
research and development priorities for translational stroke research.
The ESAP was prepared in an open, transparent process that involved
>100 scientists and patient organization representatives from almost
all of the European countries. A live-streamed consensus workshop was
held in Munich, March 22 to 23, 2018. The ESAP was launched at the
European Stroke Organisation Congress in Gothenburg in May 2018, and the
publication of the document is currently being finalized.
ESAP provides 32 specific targets for 7 domains. Four overarching targets were identified:
To reduce the absolute number of strokes in Europe by 10%.
To treat 90% or more of all patients with stroke in Europe in a dedicated SU as the first level of care(NOT RECOVERY!).
To have national plans for stroke encompassing the entire chain of care(NOT RECOVERY!) from primary prevention to life after stroke.
To
fully implement national strategies for multisector public health
interventions to promote and facilitate a healthy lifestyle, and reduce
environmental (including air pollution), socioeconomic, and educational
factors that increase the risk of stroke.
Where the fuck is the goal for 100% recovery for all survivors? Leaders would tackle such a goal.
An
ESAP implementation plan will be prepared by European Stroke
Organisation after having assessed an updated epidemiological report on
stroke incidence, prevalence, and mortality and receiving detailed and
reliable data from quality registries from national stroke and patient
societies. Progress toward the targets and research and development
priorities laid out in the ESAP will be reviewed in 2021 and 2024, with a
midterm review scheduled for 2024. The extent to which the targets have
been achieved will be reviewed in 2030.
Clearly,
the implementation of the ESAP is a big challenge, which involves
financial factors, as well as policy issues. Preventing and treating
stroke should be seen as an investment for the society that has a
favorable return, both social and economical, rather than just a cost to
the healthcare sector. Governmental bodies need to substantially
upscale efforts for stroke, along with other noncommunicable diseases,
requiring a change of strategy in many of the European countries.
National stroke and neurological societies will have a key role in the
implementation of the targets. Role models of stroke management have
been identified (ie, Austrian Stroke Network, Code Stroke System of
Catalonia), as well as national quality registers currently set up in
several European countries.
The
ESAP is likely the most comprehensive and detailed plan for improvement
of prevention and
care(NOT RECOVERY!) of stroke in any large geographical region of
the world, emphasizing the need to invest in stroke proportionally to
the public health impact of the disease. Hopefully, this plan could also
become an inspiration for other areas in the world. As Larry Elder
said, “A goal without a plan is just a wish”.
8
Disclosures
Dr
Fischer is a Consultant for Medtronic, Stryker, and Commonwealth Serum
Laboratories Behring. He is a principal investigator of the SWITCH
(Swiss Trial of Decompressive Craniectomy Versus Best Medical Treatment
of Spontaneous Supratentorial Intracerebral Hemorrhage (SWITCH): A
Randomized Controlled Trial), ELAN (Early Versus Late Initiation of
Direct Oral Anticoagulants in Post-Ischaemic Stroke Patients With Atrial
Fibrillation: An International Multicenter, Randomized-Controlled,
Two-Arm, Assessor-Blinded Trial), and SWIFT DIRECT trial (Solitaire With
the Intention for Thrombectomy Plus Intravenous t-PA Versus DIRECT
Solitaire Stent-Retriever Thrombectomy in Acute Anterior Circulation
Stroke). Dr Norrving receives Honoraria for Data and Safety Monitoring
Board work for Astra Zeneca and Bayer. Dr Caso receives Advisory boards
and speaker fees for Bayer, Boehringer Ingelheim, BMS-Pfizer,
Ever-Neuropharma. She also participated in a trial for Brainsgate and in
the NAVIGATE-ESUS (New Approach Rivaroxaban Inhibition of Factor Xa in a
Global Trial Versus ASA to Prevent Embolism in Embolic Stroke of
Undetermined Source), RESPECT-ESUS (Dabigatran Etexilate for Secondary
Stroke Prevention in Patients With Embolic Stroke of Undetermined
Source), and SOCRATES trial (Acute Stroke or Transient Ischemic Attack
Treated With Aspirin or Ticagrelor and Patient Outcomes). The other
author reports no conflicts.
Footnotes
The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.
Correspondence
to Urs Fischer, MD, MSc, Department of Neurology, University Hospital
Bern, Inselspital, University of Bern, Freiburgstrasse 10, 3010 Bern,
Switzerland. Email
urs.fischer@insel.ch
