ReviewTreatment and secondary prevention of stroke: evidence, costs, and effects on individuals and populations*
Section snippets
Identification and selection of studies
We searched the Cochrane Library and the US National Library of Medicine's Medline for up-to-date systematic reviews and RCTs of acute stroke treatment and secondary stroke prevention. The latest reviews from the Cochrane Library were selected but if they did not include recently published RCTs we added data from those RCTs to data in the review. In the absence of a systematic review, we pooled data from RCTs. If no RCTs had been done we relied on observational cohort and case-control studies.
Acute stroke interventions
Interventions for which there is reasonable evidence are stroke units, aspirin, thrombolysis, and heparin; the evidence for all other medical therapies, and surgery for primary intracerebral haemorrhage (PICH) is inadequate. We shall give full details of RRR, ARR, deaths/dependents avoided per 1000 treated, and NNT for stroke units but table 1 summarises these calculations for all three effective acute stroke interventions.
Secondary prevention
The secondary prevention strategies for which there is reasonable evidence of effectiveness are control of vascular risk factors, antiplatelet drugs, anticoagulants, and carotid endarterectomy. The effectiveness indices are summarised in table 2.
Discussion
We have attempted to find and then apply the best available evidence of acute stroke treatments and secondary prevention strategies to a hypothetical population of 1 million people to determine the relative cost of each strategy, and the impact on the burden of stroke in the population.
References (56)
- et al.
European Stroke Prevention Study 2: dipyridamole and acetylsalicyclic acid in the secondary prevention of stroke
J Neurol Sci
(1996) - et al.
Prevalence of atrial fibrillation and eligibility for anticoagulants in the community
Lancet
(1998) - et al.
Prediction of benefit from carotid endarterectomy in individual patients: a risk-modelling study
Lancet
(1999) - et al.
Practical management of stroke
(1996) - et al.
Assessment of clinical outcomes in acute stroke trials
Stroke
(1998) - et al.
The American Heart Association Stroke Outcome Classification
Stroke
(1998) Cochrane Library [database on disk and CD ROM]. Cochrane Collaboraton; 1999, Issue 1
(1999)- et al.
Finding information on clinical effectiveness
BMJ
(1998) Stroke: how large a public health problem, and how can the neurologist help?
Arch Neurol
(1999)Confidence intervals for the number needed to treat
BMJ
(1998)
Schedule of pharmaceutical benefits for approved pharmacists and medical practitioners (Nov 1, 1998)
A prospective study of acute cerebrovascular disease in the community: the Oxfordshire Community Stroke Project—1981–1986: methodology, demography and incident cases of first-ever stroke
J Neurol Neurosurg Psychiatry
Stroke incidence and case fatality in Australia: a comparison of the Auckland and Perth population-based stroke registers
Stroke
Stroke incidence, case fatality, and mortality in the WHO MONICA project
Stroke
Transient ischaemic attacks of the brain and eye
Incidence of transient ischemic attack in Rochester, Minnesota, 1985–1989
Stroke
A prospective study of acute cerebrovascular disease in the community: the Oxfordshire Community Stroke Project—1981–1986: II: Incidence, case fatality rates and overall outcome at one year of cerebral infarction, primary intracerebral and subarachnoid haemorrhage
J Neurol Neurosurg Psychiatry
Predicting survival for one year among different subtypes of strokes: results from the Perth Community Stroke Study
Stroke
Prevalence of stroke and stroke-related disability: estimates from the Auckland Stroke Studies
Stroke
Long-term risk of recurrent stroke in the Perth Community Stroke Study
Stroke
Organised in-patient (stroke unit) care after stroke (Cochrane review). In: The Cochrane Library
Comparable studies of the incidence of stroke and its pathological subtypes: results from an International Collaboration
Stroke
Practical management of stroke
Costs of medical care after first-ever stroke in the Netherlands
Stroke
Indications for early aspirin use in acute ischaemic stroke: a combined analysis of over 40,000 randomised patients
Stroke
A systematic audit of IV tPA in Cleveland Area Hospitals
Stroke
Predicted impact of intravenous thrombolysis on prognosis of general population of stroke patients: simulation model
BMJ
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Based on a talk given by G J H at The Lancet's conference The Challenge of Stroke, held in Montreal, Canada, In October, 1998.