Population-based approaches for reducing stroke risk

Abstract

The global burden of stroke is particularly substantial in low- and middle-income countries. There are several risk factors or determinants of stroke and other cardiovascular diseases that are modifiable and have been shown to reduce the risk of stroke in at-risk persons. The high-risk or individual approach to prevention uses screening to identify such persons and medication is then usually required; however, to affect change in risk in a community, a population or mass approach is required to shift the community population to a lower risk profile. The community approach is usually accomplished through legislation, health education and wider economic means. In this review, the authors discuss the population approach to primary stroke prevention.

Keywords:

• high-risk approach
• population health
• population or mass approach
• stroke
• stroke prevention

Financial & competing interests disclosure

PB Gorelick is a steering committee member for the Bayer ARRIVE trial, is a consultant to Novartis for development of a cognitive vitality study with a novel blood pressure lowering agent, LCZ 696, is a speaker for stroke prevention in atrial fibrillation for Pfizer and Boehringer Ingelheim, and is a consultant to Boehringer Ingelheim on antiplatelet therapy. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the article apart from those disclosed.

Key issues

• Worldwide, stroke is a leading cause of morbidity and mortality, especially in low- and middle-income countries.

• The financial cost of stroke is projected to increase over the subsequent decades.

• Stroke is well-suited for prevention because it has a high prevalence and cost, well-documented risk factors, and evidence-based preventions.

• Most persons, especially those in developed countries are at high risk of having modifiable or potentially modifiable risks for stroke and cardiovascular disease, such as hypertension, diabetes, hypercholesterolemia and overweight or obesity.

• Complementary approaches to prevention include the population (mass) or high-risk (individual) approach.

• The population approach to prevention aims to shift a risk within a community such that many will benefit, although the improvement in risk may be modest. This is accomplished through economic, legislative and health education means.

• The high-risk approach to prevention advocates actively screening to detect those at high risk for a target disease and who will likely need medication therapy to reduce risk adequately.

• International calls to action and priority setting agendas are advocating use of the population approach to apply cost advantageous and cost–effective strategies to reduce stroke and cardiovascular risk.

Notes

Relative risk or odds ratio for select factors in parenthesis.

^†From the 5D Health Improvement Model.

^†Carried out in 42 US states and sponsored by the National Heart Disease and Stroke Prevention Program.