_ RCGP Learning

May marks Action on Stroke Month, which is organised by the Stroke Association.

In 2011, Public Health England launched the ‘FAST – Face-Arm-Speech-Time’ campaign to increase awareness of the signs of a stroke and fast access to treatment. Treating at 90 minutes will result in 10% more patients being independent at three months post-stroke than if treatment is given at three hours. Stroke is often thought of as an illness of old age but 10-15% of ischaemic strokes occur in young adults¹. ‘Young adults’ are broadly defined as aged between 18-50 years of age².

The worldwide incidence of ischaemic stroke in those aged 18-50 has increased up to 40% in recent decades, with around 2 million people suffering ischaemic stroke each year². In England, approximately 57,000 people had a stroke for the first time in 2016, 3% of whom were aged under 40³.

Strokes in younger adults have a more significant economic impact due to patients being left disabled during their most productive years¹. The prevalence of vascular risk factors for stroke in younger adults can differ from those in older adults and may not be as routinely screened for. The primary stroke prevention strategy is to reduce potential risk factors such as:

Atrial fibrillation (AF)                  

There are around 1.4 million people with AF in the UK⁴. It is the most common cardiac arrhythmia contributing to significant morbidity and mortality⁵. A 2015 study found that around 10% of young stroke patients (≥50) had AF⁶. The risk of stroke increases five-fold for people with AF and it contributes to around one in five strokes. AF related strokes are often more severe and have higher mortality and disability rates⁷. However, a quarter of people with AF remain undiagnosed. Our RCGP eLearning course on AF contains more information on its management, anticoagulation and risk assessment.

Elevated Lipids

Hyperlipidaemia contributes to the development of atherosclerotic plaques, so statins are indicated for primary prevention when the 10 year risk of cardiovascular events is high. In secondary prevention of ischaemic stroke, a high intensity statin (such as atorvastatin 20-80mg daily) is used, with the aim of reducing non-HDL cholesterol by more than 40%⁸.

Hypertension

Hypertension affects around 9.5 million people in the UK and can triple the risk of stroke and heart disease⁹. Worldwide it is a contributing factor to approximately half of stroke episodes¹. Lifestyle modifications, such as exercise, weight loss and reduced alcohol consumption, should be advised, but depending on an individual’s risk assessment, antihypertensives may be necessary.

Lifestyle

Factors such as obesity, smoking, drinking alcohol and using recreational drugs can increase the risk of stroke. Drugs such as cocaine can acutely and markedly increase blood pressure. This can then lead to both ischaemic or haemorrhagic strokes. It’s estimated that around 6 out of 10 young adults were regularly engaging in smoking, alcohol abuse or recreational drug use at the time of their stroke⁹.

GPs can play a key role in preventing a stroke in a young adult by detecting, treating and monitoring AF. The Stroke Association’s ‘Detect, Protect and Perfect’ AF toolkit details the ways that CCGs can implement policies to identify those with AF and reduce their stroke risk. The data in this document focuses on London CCGs but the methodologies and resources can be applied throughout the UK. Examples of other CCGs that have used ‘Detect Protect and Perfect’ can be found here. The Stroke Association’s ‘AF: How can we do better?’ document, which was produced in partnership with the RCGP and other health organisations, looks at data in England but includes key messages that can be applied in all four countries. Regular reviews are vital for patients with AF, and any patient aged under 50 who has a stroke or TIA should be tested for antiphospholipid syndrome (APS). Patients with thromboembolic events and women who have recurrent miscarriages should also be considered for a test for APS.

For more information on stroke risks and contributing factors, you can access the following RCGP resources for free:

Atrial Fibrillation – 1 CPD point

Antiphospholipid syndrome (APS) – 0.5 CPD points

Alcohol: Identification and Brief Advice – 2 CPD points

Behaviour change and cancer prevention – 0.5 CPD points

Essentials of smoking cessation – 0.5 CPD points

Management of Obesity in General Practice – 5 minute screencast

RCGP members can also benefit from free access to the following resources:

EKU 4: Management of Patients with Stroke or TIA

EKU 15: Atrial fibrillation & New Oral Anticoagulants in Patients with Atrial Fibrillation

References

¹ Smajlović D. 2015. Strokes in young adults: epidemiology and prevention. Vascular health and risk management, 11, 157–164. DOI:10.2147/VHRM.S53203

² Cited in: Ekker MS et al. 2018. Epidemiology, aetiology, and management of ischaemic stroke in young adults. The Lancet. Volume 17, issue 9, p790-801, 01 September 2018. DOI: https://doi.org/10.1016/S1474-4422(18)30233-3

³ Public Health England. 2018. Briefing document: First incidence of stroke. Estimates for England 2007 to 2016. [Online] Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/678444/Stroke_incidence_briefing_document_2018.pdf

⁴ Stroke Association. 2018. AF: How can we do better? [Online] Available at: https://www.stroke.org.uk/sites/default/files/af-data_2018_england_eng_2.pdf

⁵ Aggarwal, N., Selvendran, S., Raphael, C. E., & Vassiliou, V. 2015. Atrial Fibrillation in the Young: A Neurologist's Nightmare. Neurology research international, 2015, 374352. doi:10.1155/2015/374352

⁶ Sanak D., Hutyra M., Kral M., et al. 2015. Atrial fibrillation in young ischemic stroke patients: an underestimated cause. European Neurology. 2015;73(3-4):158–163.

⁷ NICE. 2018. Atrial fibrillation. Scenario: First or new presentation of AF. [Online] Available at: https://cks.nice.org.uk/atrial-fibrillation#!scenarioRecommendation:4

⁸ NICE. 2017. Clinical knowledge summary. Stroke and TIA. [Online] Available at: https://cks.nice.org.uk/stroke-and-tia#!scenario:2

⁹ Cited in: Stroke Association, 2018. State of the nation. [Online] Available at: https://www.stroke.org.uk/system/files/sotn_2018.pdf