Stroke is one of the diseases of the arteries – these are known collectively as cardiovascular disease (CVD). A stroke is a type of brain injury which usually occurs without warning, cutting off the blood supply to part of the brain, depriving brain cells of oxygen. Stroke can occur in two ways:
1. Ischaemic stroke – The most common cause of stroke which accounts for 85% of all strokes, caused by the blockage of an artery cutting off the supply of oxygen to parts of the brain (Royal College of Physicians, 2012).
2. Haemorrhagic stroke - caused when a blood vessel in the brain bursts, producing bleeding into the brain which causes damage to the brain cells.
A Transient Ischemic Attack (TIA) or ‘mini stroke’ is caused by a brief interruption to the blood supply to a particular area of the brain. A TIA does not last as long as a stroke, with effects lasting minutes for hours. The term TIA is defined as having effects lasting less than 24 hours. A TIA is an important warning sign of a more serious stroke, heart attack or other vascular event.
Stroke is the fourth biggest cause of death in England after cancer, heart disease and respiratory disease causing almost 50,000 deaths (British Heart Foundation, BHF,2012) and the largest single cause of severe disability (DH, 2007):
- There are an estimated 152,000 strokes in the UK every year (BHF, 2012).
- Stroke causes a greater range of disabilities than any other condition, of those who survive, approximately:
- 42% will be independent
- 22% will have a mild disability
- 14% will have a moderate disability
- 12% will have a severe disability
(Royal College of Physicians, 2011)
- It is estimated that stroke costs the UK economy around £8.2 billion per year (Stroke Association, 2013)
- Production losses due to mortality and morbidity associated with stroke cost the UK almost £1 billion. The cost of informal care for people with stroke was £1 billion in 2009 (BHF, 2012).
- Stroke costs the health care system in the UK around £1.8 billion; this represents a cost per capita of £29 (BHF 2012).
- Nationally 86.1% of patients admitted with a stroke spent 90% of their time on a stroke unit.
- For TIA nationally 74.5% of those patients with a higher risk of stroke presenting in an outpatient setting were treated within 24 hours.
- The death rate from stroke for men is 2.9 times higher in routine and manual socioeconomic status than in the higher managerial socioeconomic status (BHF, 2012).
This chapter considers the epidemiology, diagnosis and treatment of stroke. Cardiovascular Disease as a whole and lifestyle risk factors are considered in separate chapters: Smoking, Physical Activity, Diet and nutrition, Alcohol, Adult obesity. Also relevant to stroke care, are the chapters on End of Life, and Carers.
Unmet needs and gaps
In addition to the eight priority areas identified within the 2010 Nottingham City Stroke Strategy (see Recommendations for consideration by commissioners) local data analysis has identified the following priority issues for Nottingham City:
- Nottingham’s mortality rates from stroke have fallen and the male death rate is now similar to females and both rates are similar to the England averages. Admission rates are now also similar to the England average and our ONS cluster group (Cardiovascular Disease profiles, PHE).
- It appears services may be under-utilised by people from Asian and African-Caribbean groups.
- In 2015/16, 74,834 people were eligible (not already diagnosed as having a cardiovascular condition and aged 40-74 years) for a Health Check. The Health Check programme aims to invite all of those eligible over a five-year period. Two years into the programme, 25,196 people (33.7%) had been invited to take part, short of the intended 40%. Of those invited, 12,412 (49.3% of those invited and just over 16.6% of the entire eligible population) took up the invitation (NHS Health Check, 2015/16, PHE http://fingertips.phe.org.uk/profile/nhs-health-check-detailed/data#page/1/gid/1938132726/pat/6/par/E12000004/ati/102/are/E06000018).
The Care Quality Commission (CQC) national review of services for people who have had a stroke and their carers published in January 2011, identified the following priority areas for development:
- Provision of services for carers;
- The provision of information for stroke patients and their carers;
Recommendations for consideration by commissioners
Key strategic issues the CCG should consider are:
- Support practices to increase the detection, diagnosis and effective treatment of high blood pressure and atrial fibrillation in the community, to prevent cardiovascular and other disease generally, and stroke in particular.
- There appears to be a case for increased access to atrial ablation procedures for the population of Derbyshire and Nottinghamshire.
- Continuous improvement of the management of transient ischaemic attack and acute stroke to improve outcomes for patients.
- The provision of rehabilitation services for all patients with residual problems following stroke. Particular current issues are: access to psychological support for patients and carers, speech and language therapy, and the rehabilitation of complex stroke cases.
- Pending the completion of the research, consider making use of the findings of the Interim Report Increasing the uptake of primary and community long-term conditions services in Black and Minority Ethnic (BME) communities in Nottingham - an exploratory research study, to improve access to long-term conditions services for people from BME communities.
- Implement the recommendations of NICE IPG548 on mechanical clot retrieval in acute stroke.
- Providers should make a full contribution to the Sentinel Stroke National Audit Programme.
- Providers of care should record the ethnicity more completely and systematically so that equity of access to services can be assessed robustly.