Editor's choice

Stroke: physical and financial pathology

Most BMJ readers will have studied pathology but forgotten most of what they knew. You don't, however, need to be much of a pathologist to see the infarct that scars the brain on the cover (or on the homepage of bmj.com). Such a stroke is something to be avoided, and a trial on p 699 shows that the angiotensin converting enzyme inhibitor ramipril will reduce by a third the risk of stroke and transient ischaemic attacks in patients with high cardiovascular risk. Hypertension is the major risk factor for stroke, but, as an editorial discusses (p 687), ramipril reduces the risk of stroke even in patients with normal blood pressure. It may work through a protective effect on the vascular wall.

Another possible way to prevent the death of brain tissue in stroke may be to use thrombolytic therapy. We know that it works in myocardial infarction, and some believe that it works in acute stroke (p 727)while others are less sure (p 726). The American Heart Association recently upgraded its advice on the use of alteplase (tPA) from optional (class IIb) to definitely recommended (class I) (p 723). Various other bodies are, however, unconvinced by the evidence, and one member of the American Heart Association panel dissented from the advice.

These disagreements are inevitable and the stuff of scientific and clinical debate. Unfortunately the advice of the American Heart Association is tainted by undeclared conflicts of interest (p 723). The association itself has received $11m (£7.8m; 12.6m) from Genentech, the US manufacturers of alteplase, and six of the eight panellists had financial ties to the manufacturer. Might these conflicts of interest have influenced the advice from the association? We can't know. Even those who produced the advice can't knowbecause bias is largely unconscious.

Butlike it or notwe live in an age where what is not open may well be considered to be biased, corrupt, or incompetent. So those producing guidelines must declare all conflicts of interest. Problems rarely result from disclosure, but failure to disclose creates anxieties. The Association of British Neurologists is about to declare its own conflicts and of those who write its guidelines on its website, and Charles Warlow, professor of neurology in Edinburgh, suggests that such conflicts should be quantified (p 726). "Accepting a ham sandwich may not colour one's attitude, but what about a million pounds . . . readers can then judge how much it takes to make the professor spin a little this way or that."

Meanwhile, 3500 doctors in Germany are currently being investigated by the district attorney for having taken funds and excessive hospitality from SmithKline Beecham (p 693). Doctors were invited to conferences to hear about angiotensin converting enzyme inhibitors but then taken to the final of the world soccer championships or to formula one races. Corruption comes in a different form in Nigeria, where drugs for preventing stroke are often fake (p 698). Some are made locally, but others come from China, Pakistan, Indonesia, Egypt, and India.

Footnotes

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