Editorial [Hot Topic: Stroke Prevention (Guest Editors: T. Tatlisumak, K. Rantanen and M. Fisher)]

Stroke is a worldwide major health problem being one of the most common killers and causes of disability in industrialized countries. Burden of stroke is likely to be similar in less developed countries as well, although precise epidemiological data lack. Approximately 80% of all strokes are ischemic. Stroke ranked as the sixth leading cause of disability-adjusted life years in 1990 and is estimated to rank fourth by the year 2020 [1]. About one-half of the stroke survivors are left with a permanent handicap. Stroke mortality has declined more than 50% among population aged 25 to 74 between 1971 and 1994 in the USA and prevalence increased by 30% during the same period in the same population [2]. The incidence of stroke is rising because life expectancy is increasing worldwide resulting in a higher proportion of elderly people and with the increasing wealth resulting in unhealthy life style changes. Approximately 700 000 strokes and 160 000 stroke-related deaths occur annually in the United States alone with over 4 million stroke survivors [3]. In addition to untimely deaths, disability, and personal suffering of the patients and their families, stroke stands for a sizable economic burden. The direct and indirect annual costs of stroke exceeded 50 billion USD in 2005. A recent population-based study showed [4] that cerebrovascular disease is already more prevalent than coronary heart disease, but this latter disease leads to more deaths than cerebrovascular disease.

Although the burden of stroke is already widely recognized and experts agree on the growth of this burden in the near future, stroke prevention is understudied and underused; stroke prevention research is unacceptably underfunded when compared with the funding addressed to diseases with similar global burden. Even some key issues remain unresolved, as reflected in the following reviews. A good example is carotid artery endarterectomy: although the first carotid endarterectomy was peerformed in the 1950's, its indications in symptomatic patients have been clarified only a decade ago and its use in patients with an asymptomatic carotid artery stenosis is still a matter of debate. We still lack evidence-based data addressing which patients should undergo carotid artery stenting or carotid artery angioplasty.

Currently we do not know in what extent we can reduce the risk of a forthcoming stroke in an individual who is in high risk and when all preventive measures are applied timely and appropriately. For example, antiplatelet therapies alone can reduce ischemic stroke risk by 20 to 30 %; but even inhibiting every single platelet would not end up complete ischemic stroke prevention, not to mention serious bleeding complications. Combining all potentially effective treatment strategies results in much larger protection. Although yet utopistic, stroke physicians should set their aim at “no recurrence” and should not be satisfied with anything less.

Primary prevention targets the whole population or selected high-risk subpopulations before a disease emerges and aims at inhibiting the development of disease whereas secondary prevention starts from the emergence of a disease and aims at preventing recurrence. The three mainstream targets in stroke prevention are 1) detection and modification of risk factors, 2) antiplatelet and anticoagulant medication for selected groups of ischemic stroke patients, and 3) surgical interventions including invasive procedures such as stenting of stenosed arteries or coiling aneurysms and vascular malformations.

Primary preventive measures include public health policies combating smoking, illicit drug use, and alcoholism. Policies tackling with obesity and food consuming habits, adding necessary exercise to routine life habits will not only reduce stroke incidence, but as well they will reduce the burden of several major diseases including coronary heart disease, hypertension, diabetes mellitus, and hyperlipidemia, just to name a few.

Stroke prevention is not only about developing high-tech therapies, but we recognize that a chain of health delivery for stroke patients should be constructed starting from primary prevention, delivering correct and timely secondary preventive measures, and incorporate measures which ensure that patients continue on these measures lifelong after discharge from hospitals. A major problem which has not yet been dealt with extensively, is the compliance of patients..............