Stroke : Silent Epidemic in India, 10 Million Cases per Year !

Stroke is a major public health problem in India, where it is the second leading cause of death and the third leading cause of disability. According to a recent report, India recorded the highest number of strokes among countries from the southeast Asian region in 2019, with nearly 1.3 million people getting it every year and 9.6 million people living with the consequences. The report also projected that stroke will claim over 10 million lives a year by 2050, a rise of 50% in 30 years, and lead to losses worth $2.3 trillion. The southeast Asian region already accounts for more than 40% of the global stroke mortality. About 185,000 strokes occur every year in India, with nearly one stroke every 40 seconds and one stroke death every 4 minutes.

What is Stroke ?

Stroke is a serious and life-threatening condition that occurs when the blood supply to a part of the brain is interrupted, causing brain cells to die. Stroke can cause permanent disability or death, depending on the severity and location of the damage. 

Reason behind surge in Stroke cases

The high burden of stroke in India is largely attributable to the high prevalence and poor control of the main risk factors for stroke, such as high blood pressure, diabetes, smoking, obesity, and air pollution. These risk factors are influenced by the rapid urbanization, industrialization, and lifestyle changes that have occurred in India in the past few decades. Moreover, the health system in India is ill-equipped to provide adequate and timely care for stroke patients, due to the lack of stroke units, trained personnel, equipment, and protocols. Most stroke patients in India do not receive evidence-based interventions, such as thrombolysis, thrombectomy, or rehabilitation, that can improve their outcomes and reduce their disability.

Therefore, there is an urgent need to prevent stroke in India, by addressing the modifiable risk factors and improving the quality and accessibility of stroke care. In this article, we will review the latest evidence from The Lancet, a leading medical journal, on the prevention of stroke in India, and provide some practical recommendations for policy makers, health professionals, and the general public.

Research Studies that are Alarming

The Lancet has published several articles and reports on stroke in India, covering various aspects of the epidemiology, risk factors, prevention, treatment, and outcomes of stroke. Some of the most relevant and recent publications are:

• The Global Burden of Disease Study 2019, which estimated the incidence, prevalence, mortality, and disability-adjusted life-years (DALYs) of stroke and other diseases in India and other countries, using data from multiple sources and statistical methods. The study found that stroke was the second leading cause of death and the third leading cause of DALYs in India in 2019, accounting for 10.2% of total deaths and 6.4% of total DALYs. The study also identified the main risk factors for stroke in India, such as high systolic blood pressure, high fasting plasma glucose, high body-mass index, dietary risks, tobacco use, and ambient particulate matter pollution. The study highlighted the need to implement effective and equitable interventions to reduce the exposure and impact of these risk factors on stroke and other non-communicable diseases.
• The SPRINT INDIA trial, which assessed the effect of a structured semi-interactive stroke prevention package in patients with subacute stroke to reduce recurrent strokes, myocardial infarction, and death. The trial randomly assigned 4298 patients with first stroke and access to a mobile cellular device to receive either the intervention or the control group. The intervention group received regular short SMS messages and videos that promoted risk factor control and medication adherence and an educational workbook, in one of 12 languages, and the control group received standard care. The trial found no significant difference between the two groups in the primary outcome, which was a composite of recurrent stroke, high-risk transient ischaemic attack, acute coronary syndrome, and death at 1 year. The trial also found low acknowledgment of receipt of the SMS messages and videos by the intervention group patients (17%). The trial concluded that the intervention was not effective in reducing the risk of vascular events or death in patients with subacute stroke in India.
• The ATTEND trial, which evaluated the effect of family-led rehabilitation after stroke in India on death and dependency. The trial randomly assigned 1250 patients with stroke and their caregivers to receive either the intervention or the control group. The intervention group received a family-led rehabilitation programme, which involved training the caregivers to provide physical, psychological, and social support to the patients, and the control group received usual care. The trial found no significant difference between the two groups in the primary outcome, which was a composite of death or dependency at 6 months. The trial also found no significant difference between the two groups in the secondary outcomes, such as quality of life, mood, and caregiver strain. The trial suggested that family-led rehabilitation after stroke in India did not improve the outcomes of stroke patients or their caregivers.

How to handle this Stroke Epidemic

Based on these publications and other sources, we can derive some key messages and recommendations for the prevention of stroke in India, as follows:

• Stroke is a major public health challenge in India, and requires a comprehensive and coordinated response from the government, the health system, the civil society, and the individuals.
• The prevention of stroke in India should focus on the primary prevention of the modifiable risk factors, such as high blood pressure, diabetes, smoking, obesity, and air pollution, by implementing population-wide and individual-level interventions, such as health education, taxation, regulation, screening, counselling, and treatment.
• The prevention of stroke in India should also include the secondary prevention of the recurrence of stroke and other vascular events, by ensuring the optimal management of the risk factors and the adherence to the evidence-based medications, such as antiplatelets, anticoagulants, antihypertensives, statins, and antidiabetics, in patients with stroke or transient ischaemic attack .
• The prevention of stroke in India should be supported by the improvement of the quality and accessibility of stroke care, by establishing more stroke units, training more stroke specialists, providing more equipment and protocols, and increasing the availability and affordability of the effective interventions, such as thrombolysis, thrombectomy, and rehabilitation, for stroke patients .
• The prevention of stroke in India should be informed by the generation and dissemination of more high-quality research on the epidemiology, risk factors, prevention, treatment, and outcomes of stroke, by investing more resources, building more capacity, and fostering more collaboration among the researchers, clinicians, policy makers, and the public.

In conclusion, stroke is a silent epidemic in India, that poses a huge threat to the health and well-being of millions of people. However, stroke can be prevented, by addressing the modifiable risk factors and improving the quality and accessibility of stroke care. The Lancet has provided valuable evidence and insights on the prevention of stroke in India, and we hope that this article will help raise awareness and inspire action among the stakeholders and the public. Together, we can prevent stroke and save lives in India.

Reference:

• https://www.thelancet.com/pdfs/journals/langlo/PIIS2214-109X%2822%2900544-7.pdf
• https://www.thelancet.com/pdfs/journals/laneur/PIIS1474-4422%2822%2900138-7.pdf
• https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736%2817%2931447-2.pdf
• https://www.thelancet.com/pdfs/journals/langlo/PIIS2214-109X%2818%2930448-0.pdf