Treatment to reduce the number of people suffering a stroke can help the NHS balance the books, writes Victoria Fletcher
Having a stroke is among the conditions people in the UK fear most, with one in twenty admitting it scares them more than cancer, dementia and motor neurone disease. However, 70 per cent of strokes could be avoided through changes in lifestyle and better preventive medicine.
High blood pressure, raised cholesterol, diabetes and a heart condition called atrial fibrillation (AF) all dramatically increase the risk of stroke and yet each one can be managed with the correct drugs.
Over the last ten years there has been a major drive to improve the emergency care provided to stroke patients resulting in an impressive 37 per cent fall in stroke deaths.
Now experts are turning their focus to prevention and asking if enough is being done to stop strokes from happening in the first place, through eating well, stopping smoking and also ensuring those at high risk are being treated effectively.
They also want to see high standards of treatment to be available across the UK with no postcode lottery of services.
The tide against strokes has turned although there are vagaries in the prescribing of anticoagulants and the availability of healthcare. The dominant message is that levels of stroke can be reduced, but there is plenty of room for improvement from GPs, members of the public and health policy-makers.
In Bradford, for example, there has been an astonishing 11 per cent drop in strokes among patients with atrial fibrillation in only one year, thanks to a local initiative to ensure GPs gave these patients anticoagulation drugs rather than aspirin or no treatment at all.
But in other areas this does not always happen, resulting in avoidable stroke deaths and disability. The cost of implementing the Bradford programme was just £50,000. Yet each stroke victim would have cost the NHS £15,000 in care over five years.
High blood pressure is the biggest cause of stroke and is responsible for at least 50 per cent of cases.
According to guidelines from the National Institute of Health and Care Excellence (NICE), every incremental 2mmHg rise in systolic blood pressure can increase stroke risk by 10 per cent. Once a patient has a reading above 140/90 mmHg, they may need treatment.
Graham MacGregor, professor of cardiovascular medicine at the Wolfson Institute of Preventive Medicine, says: “Preventing high blood pressure is the single most cost-effective strategy for preventing death and disability. Despite this, only around half of the eight million patients being treated for hypertension, a stroke risk factor, have the condition under control.”
Guidelines are in place to ensure patients with hypertension are treated with a range of drugs, but there is concern that high blood pressure is not being taken seriously enough.
Professor Tony Rudd, national clinical director for stroke and chairman of the intercollegiate stroke working party for the Royal College of Physicians, adds: “Sometimes doctors are reluctant to treat someone with high blood pressure aggressively in case the reading is caused by the ‘white coat’ effect of seeing the doctor. But we now know that hypertension is something that needs to be brought down rapidly with medication.”
Later this year, new targets within the Quality Outcomes Framework (QOF), through which GPs are paid, will tell family doctors to be more ambitious in how far they reduce hypertension in patients who have already suffered a stroke.
However, some patients may have themselves to blame. A study, published last month in the journal Heart, of just over 200 patients, used urine tests to reveal that one in four hypertension patients did not take their medication properly, one in ten didn’t take any of their medication and one in seven took it occasionally, often due to side effects.
Preventing high blood pressure is the single most cost-effective strategy for preventing death and disability
Professor MacGregor believes a good doctor should be able to prevent side effects by switching patients on to different dosages of pills or a combination of different pills.
Figures from the Stroke Association show that statins can reduce stroke risk by 25 per cent. A 1mmol/L drop in cholesterol reduces the risk by 21 per cent.
The benefits of taking statins are particularly key for anyone who has already had a stroke. New figures from the Sentinel Stroke National Audit Programme show that 80 per cent of patients are now put on a statin within six months of suffering a stroke to prevent further stroke and a similar focus is now needed on all patients with high cholesterol to prevent stroke.
But perhaps one of the most easily preventable causes of stroke is AF, which causes an uneven or fast heartbeat that puts patients at higher risk of blood clots.
Figures from the QOF reveal there are more than a million patients in England and Wales with AF. This figure has risen by 20 per cent in only six years, due in part to better detection, but also because AF is more common in an ageing population. By 2050, the figure is expected to double.
AF patients are five to six times more likely to have a stroke because blood pools in the heart, leading to clots.
Estimates suggest that 12,500 strokes a year are caused by AF, and 7,100 strokes and 2,100 deaths could be prevented if these patients were on the correct medication.
Anticoagulation drugs, such as warfarin, stop the blood from clotting and can reduce the risk of AF stroke by 70 per cent. Yet according to an analysis, published last year in Heart, more than one in three AF patients, who should have been on anticoagulants such as warfarin, were not.
Dr Matthew Fay, a GP in Bradford, says: “Many GPs and hospital doctors are afraid of using warfarin because they worry they won’t get the dose right and patients will suffer a dangerous bleed. Instead, they prescribe aspirin, especially to elderly patients, because they think it’s safer, but we now know this is wrong.”
Recent studies have shown aspirin can still cause bleeding while being far less effective than warfarin at preventing stroke.
The current guidelines set out by NICE are that aspirin can be used for AF patients when warfarin is ‘not appropriate’. GPs also still get paid if they give these patients aspirin.
Later this year, however, new NICE guidelines will alter this emphasis and instead call for patients to be given warfarin or a new range of medicines called novel oral anticoagulants (NOAC).
Patients on NOACs do not need regular blood tests and the medication provides an alternative for those who do not fare well on warfarin.
Bradford’s success at reducing AF-related strokes by 11 per cent was achieved by encouraging GPs with a league table showing their results. “GPs are competitive and reviewed their AF patients, and many who were not on anticoagulants were switched. The results were astonishing,” says Greg Fell, a former consultant in public health at Bradford and Airedale Teaching Primary Care Trust, who worked on the programme.
But data from Oberoi Consulting show that, while the best ten performing clinical commissioning groups in England anticoagulate between 70 and 97 per cent of AF patients, this falls to between 55 and 58 per cent for the ten worst. The figures suggest the cost of stroke in AF patients, who could have been anticoagulated, is almost £200 million a year.
“Many doctors worry about the patient who bleeds to death on warfarin and no one thinks of the patient who never suffers a stroke because they are effectively treated. We have to change this view among doctors as it will save many, many lives,” says Mr Fell.