Care and Connect Research Project - S Donnelly

Driving Assessment following Stroke - T Stapleton

Family mediated Exercise for Stroke Survivors - R Galvin

Global Epidemiology of Stroke - M O'Donnell

Stroke Advocacy - C Macey

The Clots Trial - C Williams

The Role of Cerebral Cortex Plasticity - D Smithard

EHN Meeting 2010 - Dr Brian Maurer

ABSTRACT:              
Advances in our knowledge of the aetiology and pathogenesis of atherosclerosis have led to effective treatment strategies for many of the serious illnesses caused by this disorder. As a result mortality from many diseases such as the acute coronary syndromes and cerebrovascular accidents has declined steadily over the last forty years. Beginning around 1980 and accelerating until very recently this fall can be associated with the adoption of life style and preventive strategies and improved pharmacological and interventional therapies. It has been suggested that about half of this improvement is due to prevention and half to therapy.

The need for primary and secondary preventive strategies is widely accepted. Controversy persists about how to deliver effective primary prevention but there is a general consensus that aggressive secondary prevention measures are advisable for all with known atherosclerotic disease. There is also a broad acceptance that aggressive management of the acute ischaemic syndromes and especially of myocardial infarction is best practice and securely rooted in a good and growing evidence base. The dramatic fall in early hospital mortality from over 40% in the 1960s to around 8% today can be attributed to the development of acute coronary units and to the introduction of new and ever more effective interventions in the decades which followed. The more recent introduction of acute stroke care and thrombolysis where indicated appears to be equally effective  in reducing mortality and morbidity.

Many problems remain. The fall in acute mortality has led to an increase in the prevalence of chronic ischaemic heart disease. Identification of high risk individuals and asymptomatic patients by screening for primary prevention, secondary preventive strategies and particularly the treatment of associated and often asymptomatic disorders like hypertension and hyperlipidaemias means that many of these patients are taking a large number of drugs often of dubious benefit to the individual. Most patients discharged following an infarction will be taking 5 to 8 powerful agents.

New drugs effective in relieving symptoms and improving quality of life are continue to become available and are a welcome addition to the therapeutic armamentarium. In recent years the have included rate regulators and sodium channel inhibitors.  They offer relief to the minority of patients who have persistent significant limitation due to symptoms despite intervention or treatment with older agents. Their judicious deployment is an essential component of treatment and should result in a clear benefit to the individual. Treating to ever lower targets of blood pressure and cholesterol cannot be regarded in the same way particularly in an asymptomatic primary prevention population where Individual benefit is likely to be very small but individual harm is frequent as the incidence of side effects increases with every drug used. Many of these are low grade and unrecognised.
                           
The management of any chronic disease requires considerable experience and expertise. Nowhere is this more apparent than in ischaemic heart disease. Because the course of stable ischaemia is often benign, and the prognosis improved by alteration in life style and preventive measures as well as the judicious use of drugs it is important not to fall into the trap of polypharmacy. Treatment must be individualised, not delivered by cook-book recipe and requires the supervision of an experienced physician capable of changing the therapeutic strategy as the disease progresses.

Early recognition of the warning signs of developing instability coupled with an awareness of the importance of quality of life and its possible diminution by marginally relevant drugs is the key to the successful management of these diseases. The physician, supported by the interventionist, the cardiac surgeon, the rehabilitation team and all other disciplines involved in the management of the different stages of an illness which evolves over half a life time, must continue to be the individual on whose experience and knowledge the patient and the family doctor can rely over the years and decades.