Mumbai stroke registry (2005-2006)--surveillance using WHO steps stroke instrument--challenges and opportunities.

BACKGROUND: India will face enormous socioeconomic burden because life expectancy is increasing placing larger numbers of older people at risk of stroke and other chronic diseases. In order to plan prevention strategies, reliable information on stroke epidemiology is required. For uniform data collection (population based), WHO recommends use of STEPS Stroke instrument. STUDY: A well-defined community (H-ward) with verifiable census data, and representative of population structure of Mumbai (Bombay), was selected. The manual on WHO STEPwise approach to stroke surveillance (STEPS; http://www.who.int/chp/steps/Manual.pdf) was the operational protocol. RESULTS: During the two year study period (Jan 2005 to Dec 2006), 521 new stroke (CVD) cases (males--275 and females--246) were identified; of which 456 (238 males and 218 females) had "first ever stroke"(FES) indicating an annual incidence of 145 per 100,000 persons (CI 95%: 120-170); age adjusted Segi rate: 152/100,000/year (CI 95% 132-172). Two thirds of the FES cases were admitted to health care facilities (Step I: "in-hospital" cases), the remaining 150 (32.8%) either died outside of hospital or were treated at home or nursing homes (Step II: Fatal events in community and Step III: Non-fatal events in community). CVD Diagnosis was supported by CT (Computed Tomography) in 407 (89%) of 456 FES cases: 366 (80.2%) had Ischaemic CVD, 81 (17.7%) had hemorrhagic CVD and 9 (1%) were of unspecified category. The mean age was 66 yrs SD +/- 13.60 and women were older compared with men (mean age 68.9 yrs SD +/- 13.12 versus 63.4 yrs SD +/- 13.53). Hypertension (BP more than 140/90 mm Hg) alone or in various combinations was present in 378 ( 82.8%) cases. Case fatality at 28 days after the FES stroke was 29.8%. Of 320 surviving patients 38.5% had moderate to severe disability. CONCLUSIONS: WHO STEPs stroke surveillance Instrument is simple to use and, practical for community surveys. The data are useful for planning stroke prevention campaigns on public awareness and education with regard to diet, exercise, blood pressure control and early symptoms of minor strokes.

Antithrombotic agents in cerebral ischaemia.

The current evidence suggests that aspirin is treatment of choice when compared to anticoagulants for patients with non-cardioembolic stroke. The usefulness of combination therapy (aspirin vs. with or without warfarin) is still debated. Likewise the combination of Aspirin with clopidogrel has no added advantage (MATCH Trial). However anticoagulant therapy significantly benefits high-risk patients with atrial fibrillation in the elderly subjects whereas aspirin may still be the drug of choice in stroke prevention in low risk group in the younger age. There is dire need for well planned randomized double blind controlled studies to define the role of Antithrombotic agents in "cryptogenic stroke" (PFO/ASD related) antiphospholipid antibody syndrome, arterial dissections and intraluminal clot syndromes. Evaluation and treatment of associated risk factors in all categories needs greater emphasis.