Challenges and solutions of secondary prevention of stroke in low- and middle-income countries

• DOI: 10.4103/jncd.jncd_24_24
• Publication Date: 2024-03-30T07:00:06Z
• Authors: P. N. Sylaja; Veena Babu
• Keywords: Stroke; Secondary Prevention; Middle income

Globally, stroke remains the second leading cause of death and third disability.[1] Over years, burden increased drastically, i.e., 70% increase in incident strokes, 102% prevalent 43% deaths with higher lower income low- middle-income countries.[2] About 85% are registered countries.[3] The recurrence remained unchanged during last 20 years despite use secondary prevention measures it ranges from 3.1% at 30 days to 39.2% 10 after initial stroke.[4] Approximately one six survivors will have another within 1 year which increases three by 3 years.[5] Furthermore, out every is recurrent.[3] Medication adherence important varies Low-and middle-Income Countries (LMICs) poor developing countries such as India Africa[6,7] good developed around 90%.[8] Being key prevention, medication can lead recurrence, disability, or even countries.[9] risk factors include high systolic blood pressure (contributing 55.5% total disability-adjusted life [DALYs]), body mass index (24.3% DALYs), fasting plasma glucose (20.2% stroke), ambient particulate matter pollution (20.1% smoking (17.6% estimate). 90.5% global was attributable these modifiable factors,[1] control an integral factor prevent sub-optimal LMICs.[10] In general, focus vascular hypertension, diabetes, dyslipidaemia, cessation, lifestyle behavioral modification. Lifestyle healthy diet physical activity essential for prevention.[11] SAMMPRIS trial has shown that aggressive medical treatment coaching on behavior more effective preventing compared angioplasty intracranial stenting.[12] A modeling study showed combination five proven strategies, namely dietary modification, exercise, aspirin, a statin, antihypertensive agent appropriate patients predicted 80% reduction risk.[13] Intracranial atherosclerotic disease most common etiologies ischemic Asian population associated recurrence.[14] Anticoagulation therapy cardioembolic due atrial fibrillation, mechanical valves, cardiac thrombus if patient no contraindications. symptomatic extracranial carotid stenosis (>50%), revascularization 2 weeks index-event recommended[11] but delayed LMIC guideline recommended timings.[15] majority undergo endarterectomy (CEA) transient attack,[16] while countries, CEA done often stroke.[15] half some degree cognitive impairment.[3] disability huge still increasing faster pace than high-income countries. need support daily activities directly influences quality patients. not being treated unit recurrence.[17] Human-resource scarcity LMICs also creates additional challenge prevention. There inequity accessing health services among rural areas limited geographic access financial barriers poststroke short-term mortality.[18] Addressing challenges making clinician aware face managing role they play providing tailored education hour. Establishing routines, periodic reminders, buy medicines, expected improve LMICs.[6] Implementing integrated population-level individual-level strategies people any cerebrovascular disease, promotion interdisciplinary care services, reducing caregivers all dire necessity.[19] delay timing be improved creating awareness early recognition symptoms patients, educating seek care, physician referring neurologist surgeon recurrence. Increasing number units certification comprehensive management discharge planning. existing resources monitoring community settings help burden.[20] To address resource constraints areas, worker-based intervention based task-shifting skill delegation proved feasible.[21] Moreover, their families receptive information technology thereby promoting communication between pharmacists addition, get advice through mobile follow-ups adherence. Currently, World Organization targeted level primary over time. conclusion, mitigated strategies. An overwhelming prevented strict adherence, along modifications, physicians importance Both promoted care. Capacity building task shifting human nonhuman reduce community.