Abstract Body

Theoretically, up to 90% of all strokes could prevented if all individual risk factors could be set at the theoretical minimum risk exposure level, e.g., zero level of exposure to smoking, alcohol intake, or systolic blood pressure of 110-115 mmHg across the whole population, etc. However, in practice this level of reduction of exposure to risk factors across the world is hardly achievable, at least for the near future. Therefore, in practice realistic goals for primary stroke prevention should be informed by results of reliable randomised controlled trials (RCTs) and modelling, including meta-analysis and systematic reviews. It is also important to consider primary prevention goals that are achievable via population-wide prevention strategies, individual prevention strategies, and both strategies combined. In my presentation, I would like to give an overview of currently available primary stroke prevention strategies, outline evidence from RCTs, difficulties and opportunities for effective primary stroke prevention, realistic medical and economic benefits of stroke prevention, and the most promising ways to improve the situation.

Abstract Body

The 2-3-fold increase in stroke burden across the globe clearly indicates that primary stroke prevention strategies are either not used widely enough or not effective. There are also major between-country gaps in the proportion of recurrent strokes, with some countries (even some developed countries, such as New Zealand) not showing a trend towards improvement at all or very little improvement over the last 30 years. This is suggestive of insufficient implementation of proven effective secondary stroke prevention strategies across the globe, with developing countries suffering the most. This unsatisfactory situation requires analysis of causes of failing primary and secondary stroke prevention strategies and outlining directions and action plans for improving the situation.

In my presentation I will discuss the current trends in stroke burden and risk factors in the world and focus on promising, validated and affordable primary stroke prevention strategies that could be applied across the globe, using strategies outlined in the recent World Stroke Organization Declaration on primary stroke and dementia prevention. These include population-wide and mass individual motivational prevention strategies via widely available and free to use eHealth technologies, such as the Stroke Riskometer app, community interventions by nurses and health volunteers and polypill for people at risk of stroke. I argue that the best way for implementing these strategies is through the support of the WHO and other major international health organisations for these strategies, followed by their inclusion into national and international stroke prevention guidelines endorsed by the national Ministries of Health.

Background and Aims

Initiatives at non-urban hospitals in New Zealand have improved access to reperfusion therapies for patients with stroke. We aimed to investigate if any additional costs are offset by improved outcomes and costs savings after discharge.

Methods

REGIONS Care involved consecutive patients admitted with stroke to all 28 acute stroke hospitals in New Zealand (12 urban) between May and October 2018. Costs from a societal perspective at 12 months after stroke were estimated using standardised data collected on the hospital stay and a follow-up survey. Estimated costs were assigned to the initial hospital patients presented to. Quality adjusted life years (QALYs) were estimated using outcomes at discharge from hospital, vital status and responses to the EuroQol-5D questionnaire at 12 months follow-up. Multiple imputation and multivariable regression analyses were used to assess differences between groups.

Results

There were 946 patients from non-urban and 1419 from urban hospitals. Costs of acute care for patients presenting to urban hospitals were $1786 greater on average than those presenting to non-urban hospitals (p<0.001). Estimated costs until 12 months were no different between groups (urban $26137 vs non-urban $25067, p=0.396). The average QALYs per person was greater in the urban cohort than the non-urban cohort (0.58 vs 0.53, p=0.001).

Conclusions

Despite greater costs of acute care, patients who presented to urban hospitals had similar costs at 12 months compared to non-urban counterparts. Further research is required to investigate if additional funding to non-urban hospitals can reduce downstream costs and improve outcomes.

Background and Aims

Stroke care in Brazil has improved with the organization of acute stroke care. But it was not enough to reduce the 400,000 cases that occur each year. We present a strategy of modifying the primary prevention for stroke in Brazil with the restructuring of primary care.

Methods

The strategy is a task force, uniting the Pan American Health Organization, the Brazilian Ministry of Health, the Medical Societies acting to plan, train and implement the restructuring of primary care, based on the HEARTS program of the World Health Organization and Cut Stroke in Half of the World Stroke Organization. It is a gradual and monitored change in the way of care in primary care, adapting the programs through flowcharts and simplification of processes through protocols.

Results

The steps for implementation: 1)Organization of a committee with neurologists, cardiologists and family doctors; 2)Choice of 8 health units to implement a pilot; 3)Preparation and adaptation of technical protocols for screening and treatment of hypertension and diabetes (based on the HEARTS program); 4)Implementation of a protocol for atrial fibrilation screening with a point-of-care mobile ECG recording; 5)Preparation of printed material for lifestyle modification; 6)Implementation of Stroke Riskometer App; 6)Preparation of an educacion course for primary care professionals including community health works; 7)Implementation of decision, data collection and monitoring software enriched with artificial intelligence.

The implementation starts on June 2021 and will be expanded to 60 Units of Health in the whole country in 2022.

Conclusions

The success of implementation in the country has potential to decrease in 50% the incidence of stroke.

Background and Aims

The increase burden of stroke and dementia provides strong evidence that currently used primary prevention strategies are not enough and 80% of strokes occur in people with low to moderate risk. The purpose is to test whether a polypill used alone or in combination with lifestyle modification will reduce the incidence of stroke and cognitive impairment in a population of individuals with low to moderate risk of stroke.

Methods

Phase III Randomized Clinical Trial, prospective, factorial 2x2, of 12,268 subjects followed by 3 years. 60 Health Units will be randomized (clusters) to use or not the approach of community health workers with the Stroke Riskometer. After a run-in phase (30 days, all participants with active drug), patients will be randomized to receive the polypill (valsartan 80 mg, anlodipina 5 mg e rosuvastatina 10 mg) or placebo (dose adjustment of amlodipine 2,5 for patients with adverse events). It will be included: (1)adults aged 50-75 years; (2) no previous history of stroke, TIA or cardiovascular disease; (3)systolic blood pressure (BP) 120-139 mmHg; (4) one or more lifestyle risk factors (smoking, overweight, physical inactivity or inadequate diet. It will be excluded patients with hypercholesterolemia or diabetes or take other antihypertensive drugs or open label statins. Subjects will be randomized under a minimization process using age, sex, BP, education level, total cholesterol.

Results

We expect to reduce in 50% the risk of stroke and cognitive decline in 3 years.

Conclusions

With the trial results we expect to change the public prevention policies in primary care.

Abstract Body

Theoretically, up to 90% of all strokes could prevented if all individual risk factors could be set at the theoretical minimum risk exposure level, e.g., zero level of exposure to smoking, alcohol intake, or systolic blood pressure of 110-115 mmHg across the whole population, etc. However, in practice this level of reduction of exposure to risk factors across the world is hardly achievable, at least for the near future. Therefore, in practice realistic goals for primary stroke prevention should be informed by results of reliable randomised controlled trials (RCTs) and modelling, including meta-analysis and systematic reviews. It is also important to consider primary prevention goals that are achievable via population-wide prevention strategies, individual prevention strategies, and both strategies combined. In my presentation, I would like to give an overview of currently available primary stroke prevention strategies, outline evidence from RCTs, difficulties and opportunities for effective primary stroke prevention, realistic medical and economic benefits of stroke prevention, and the most promising ways to improve the situation.

Abstract Body

The 2-3-fold increase in stroke burden across the globe clearly indicates that primary stroke prevention strategies are either not used widely enough or not effective. There are also major between-country gaps in the proportion of recurrent strokes, with some countries (even some developed countries, such as New Zealand) not showing a trend towards improvement at all or very little improvement over the last 30 years. This is suggestive of insufficient implementation of proven effective secondary stroke prevention strategies across the globe, with developing countries suffering the most. This unsatisfactory situation requires analysis of causes of failing primary and secondary stroke prevention strategies and outlining directions and action plans for improving the situation.

In my presentation I will discuss the current trends in stroke burden and risk factors in the world and focus on promising, validated and affordable primary stroke prevention strategies that could be applied across the globe, using strategies outlined in the recent World Stroke Organization Declaration on primary stroke and dementia prevention. These include population-wide and mass individual motivational prevention strategies via widely available and free to use eHealth technologies, such as the Stroke Riskometer app, community interventions by nurses and health volunteers and polypill for people at risk of stroke. I argue that the best way for implementing these strategies is through the support of the WHO and other major international health organisations for these strategies, followed by their inclusion into national and international stroke prevention guidelines endorsed by the national Ministries of Health.