Secondary Prevention: A Cost-Effective Yet Underutilized Strategy for Reducing the Stroke Burden in Resource-Limited Settings
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BACKGROUND: Over two-thirds of global stroke occur in low- and middle-income countries (LMIC), where the populations are affected on average 15 years younger. Those who survive potentially lose their livelihood and are financially vulnerable to health care expenses. On a national level, stroke DALYs rob the developing economy of its workforce. Cost-effective prevention strategies and interventions could help reduce the stroke burden in LMIC. Primary prevention is considered the top priority, but it necessitates sufficient infrastructure and human resources for successful campaigns. In resource-limited health systems, the population at greatest risk for stroke are likely not receiving regular health maintenance. OBJECTIVE: Secondary prevention targets the cohort seeking medical attention for an incident stroke. It is hypothesized to be a more feasible strategy of improving stroke rates in LMIC by reducing recurrence in high-risk populations. The objectives of this study are to compare stroke risk and secondary prevention practices across four different countries of varying income level, and to determine which secondary prevention drug regimen would be optimal for resource-limited settings. METHODS: Current economic and health indicator data were collected from the World Bank and the World Health Organization (WHO) on the United States, France, Vietnam, and Peru. Death and disability-adjusted life-years (DALYs) rates along with risk factor prevalences for each country were accessed from the WHO. Literature reviews on secondary prevention of recurrent stroke and healthcare-utilization in the developing world were conducted on MEDLINE and Pubmed databases using the following key words: stroke, epidemiology, risk factors, stroke burden, secondary prevention, secondary prevention drugs, cost-effectiveness, healthcare-utilization, resource-limited settings, developing world, developing countries, and LMIC. Articles that addressed thesis objectives were selected for review. Additionally, the latest country-specific guidelines for secondary prevention of stroke were retrieved online from the relevant national stroke organizations. RESULTS: Vietnam experienced the highest death (109) and DALY (729) rates for both genders despite having a young population. Peru has the next highest incidence of death (45.8) and DALYs (385) from stroke. There was a trend of increasing stroke burden with decreasing country GNI per capita among the four countries. Each country had a signature risk factor profile; the United States with raised total cholesterol and obesity; France with hypertension, raised total cholesterol, and smoking; Vietnam with the greatest risk of hypertension and the highest prevalence of smoking among men; and Peru with risk of high BMI. Regarding clinical practice, both the United States and France have an established national guidelines on secondary prevention of stroke. Vietnam recently established its own quality standards based on the Royal College of Physicians' recommendations. Peru does not have its own clinical guidelines for secondary prevention, and adherence to evidence-based recommendations is likely variable among Peruvian neurologists. CONCLUSION: In the absence of a health system that can adequately screen and monitor common risk factors in its population, most susceptible patients will go untreated until a cerebrovascular event brings them to medical attention. The opportunity to intervene in the high-risk population is at the moment of incident stroke. Secondary prevention is a cost-effective strategy that can be implemented in the interim while sufficient healthcare capacity develops to maximize primary prevention in the future. LMIC must economize according to the constraints of their resources. Therefore, it would be practical to initiate secondary prevention drug therapy according to the top one or two risk factors in the population.