Avoidable factors in stroke

BMJ 1994; 308 doi: https://doi.org/10.1136/bmj.308.6929.657b (Published 05 March 1994) Cite this as: BMJ 1994;308:657
  1. G F Mead,
  2. P A O'Neill,
  3. C N McCollum
  1. Department of Surgery, University of Manchester, University Hospital of South Manchester, Manchester M20 8LR.

    EDITOR, - Mr Adiseshiah has pointed out the role of carotid endarterectomy in symptomatic patients with >70% stenosis of the ipsilateral internal carotid artery.1 The annual incidence of transient ischaemic attacks has been estimated to be 0.4/1000. Of the patients affected, between 5000 and 10000 would be suitable for carotid endarterectomy each year, which would reduce the number of strokes by between 500 and 1000.2 The role of carotid endarterectomy in symptomatic patients with moderate stenosis of the carotid artery and in asymptomatic patients with severe stenosis is currently being evaluated by international trials.

    Thus the benefit of carotid endarterectomy has been proved in a relatively small subset of patients. Recent research has identified other effective measures to prevent strokes, which may have a greater impact. The Antiplatelet Trialists' Collaboration showed that low dose aspirin reduces the risk of major stroke and reduces mortality in symptomatic patients.3 Several large trials have shown that treating hypertension in elderly patients reduces the risk of stroke by between 25% and 47% and that treating isolated systolic hypertension is also beneficial.1 Finally, primary prevention of stroke by giving anticoagulant treatment to asymptomatic patients with atrial fibrillation reduces the risk by two thirds.5

    It is not fair to imply that general practitioners alone are at fault for failing to refer the small number of patients who we currently know will benefit from carotid endarterectomy. Effective prevention of stroke requires close cooperation among general practitioners, general physicians, geriatricians, neurologists, and vascular surgeons. Funding for collaborative research is required to evaluate methods of implementing these research findings so that we can avoid the confusion that has existed about the value of carotid surgery. Is this what health services research is all about?


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