In the period from October 1990 to December 1991, 23 patients with acute ischemic stroke were treated with recombinant tissue plasminogen activator (rt-PA) at a median of 205 min (range 78-355 min) after symptom onset. In this open pilot study rt-PA was given intravenously after an acute CT scan had not shown acute changes. In 12 patients regional cerebral blood flow was measured intravenously using 99mTc-HMPAO before and within 24 h after thrombolytic therapy. Reperfusion of the ischemic area was obtained in 10 patients. In these patients clinical improvement was greater the shorter the delay from symptom onset to initiation of treatment. Three of the 23 patients died, one of a parenchymatous hematoma, one of a large middle cerebral artery infarct, and one of acute myocardial infarction.
Nonvalvular atrial fibrillation (NVAF) has a prevalence of about 1% in the 60- to 70-year age group, increasing to above 4% in persons older than 80 years. The yearly stroke incidence in NVAF patients is 3-8%, which is 5-7 times higher than that in age-matched persons in sinus rhythm. In five independent studies of stroke prevention in NVAF patients, anticoagulation therapy resulted in a risk reduction of stroke of about 65%. The risk of intracerebral hemorrhage was 0.3% per year during warfarin therapy compared with 0.1% in the placebo group. In one study aspirin reduced the risk of thromboembolic events by 42% while another study found a nonsignificant effect of aspirin. The following variables were identified as risk factors for stroke in the individual studies: prior myocardial infarction, increasing age, mitral annular calcification, history of hypertension, congestive heart failure and previous arterial thromboembolism. A pooled analysis of risk factors in the placebo-treated patients of the five studies is ongoing.
This review concerns the acute phase of stroke. It describes incidence, prevalence, etiology, diagnosis and treatment together with the possibilities for prevention. The incidence of stroke in the Danish population is about 2/1000 person years and has been largely unchanged during the last 20 years. About 85% of strokes are caused by cerebral infarcts, ten percent by intracerebral haemorrhages and about five percent by subarachnoid bleeding. The incidence increases with age. Up till age 65 years the ratio between men and women is two to one, while the ratio in the oldest age group approaches one to one. The most important risk factors for stroke are smoking, arterial hypertension, previous cerebrovascular disease, heart disease and diabetes mellitus. Till now, no treatment has been documented as effective in reducing the cerebral damage caused by acute stroke. Ongoing controlled clinical trials in the acute state of ischaemic stroke are testing the effect of thrombolytic therapy, treatment with calciumantagonists, aspirin and heparin. The general medical treatment including nursing and physiotherapy in the acute phase is described. Within recent years benefit of various strategies of stroke prevention has been documented.
Three hundred and seventy-four general practitioners (GPs) in Denmark filled in a questionnaire on attitudes to include information on gender and diet in the strategy for prevention of coronary heart disease, cancer, osteoporosis, and overweight/underweight. Risk factors for disease in general were ranked as follows: smoking, alcohol, stress, diet, physical exercise, heredity and hygiene. The patients' lack of motivation, insufficient time for each patient, and inadequate knowledge about nutrition were stated as barriers to dietary counselling. The GPs stated that the gender of the patient was important only to the counselling on osteoporosis. Lack of time and insufficient knowledge were perceived as barriers for including gender specific issues in prevention. It is concluded that GPs consider dietary counselling important but lack time and knowledge. The results point at a need for better pre- and postgraduate training in nutrition, and for a better reimbursement system for time spent on prevention.
BACKGROUND AND PURPOSE: We wished to test the validity of a stroke probability point system from the Framingham Study for a sample of the population of Copenhagen, Denmark. In the Framingham cohort, the regression model of Cox established the effect on stroke of the following factors: age, systolic blood pressure, the use of antihypertensive therapy, diabetes mellitus, cigarette smoking, prior cardiovascular disease, atrial fibrillation, and left ventricular hypertrophy. Derived from this model, stroke probabilities were computed for each sex based on a point system. The authors claimed that a physician can use this system for individual stroke prediction. METHODS: The Copenhagen City Heart Study is a prospective survey of 19,698 women and men aged 20 years or older invited to two cardiovascular examinations at 5-year intervals. The baseline examination included 3015 men and 3501 women aged 55 to 84 years; 474 stroke events occurred during 10 years of follow-up. In both cohorts initial cases of stroke and transient ischemic attack recorded during 10 years of follow-up were used. We used the statistical model from the Framingham Study to establish a corresponding stroke probability point system using data from the Copenhagen City Heart Study population. We then compared the effects of the relevant risk factors, their combinations, and the corresponding stroke probabilities. We also assessed stroke events during 10 years of follow-up in several subgroups of the Copenhagen population with different combinations of risk factors. RESULTS: For the Copenhagen City Heart Study population some of the risk factors (diabetes mellitus, cigarette smoking, atrial fibrillation, and left ventricular hypertrophy) had regression coefficients different from those of the Framingham Study population. Consequently, the probability of stroke for persons presenting these risk factors and their combinations varied between the two studies. For some other risk factors (age, blood pressure, and cardiovascular disease), no major differences were found. The recorded frequency of stroke events in subgroups of the Copenhagen population was compatible with the estimated probability intervals of stroke from the Copenhagen City Heart Study and with those from the Framingham Study, but these intervals were very large. CONCLUSIONS: The majority of risk factors for stroke identified by the Framingham Study also had a significant effect in the Copenhagen City Heart Study population. The differences found could be due partly to different definitions of these factors used by the two studies. Although estimated stroke probabilities based on point systems from the Copenhagen City Heart Study and the Framingham Study were similar, the points scored in the two systems did not always correspond to the same combination of risk factors. Such systems can be used for estimating stroke probability in a given population, provided that the statistical confidence limits are known and the definitions of risk factors are compatible. However, because of the large statistical uncertainty, a prognostic index should not be applied for individual prediction unless it is used as an indicator of high relative risk associated with the simultaneous presence of several risk factors.
OBJECTIVES: Knowledge of resource use and costs can be useful when evaluating existing services or planning new services. This study investigates the use of health care and social services during the first year after a stroke. Total costs are calculated, costs are compared across subgroups of patients, and resource items of major importance for the total costs are identified. METHODS: The study is based on a database comprising data on all stroke patients admitted to a university hospital in Copenhagen, Denmark, over a 1-year period, 1994-95. Patients were followed for 1 year after the stroke, and data on resource use during and after hospitalization were collected prospectively at interviews. This paper focuses on a subset of 385 patients who were admitted because of cerebral infarct or unspecified stroke. RESULTS: The mean cost, based on all patients, of health care and social services during the first year was 142,900 DKK (US $25,500). The hospital care until the first discharge, including acute care and rehabilitation, cost 101,600 Danish krones (DKK) (US $18,100), i.e., 71% of the total cost. Major resource items after discharge were nursing homes, readmissions, outpatient rehabilitation, and home help. The cost during the first year varied with a number of factors, with the most important being survival and degree of disability. Patients who survived the acute phase and who had severe disability (Barthel Activities of Daily Living [ADL] Index: 0-9) 7-10 days after admission had a total cost during the first year that was five times as high as patients with no disability (Barthel ADL Index: 20). CONCLUSION: Costs of health care and social services during the first year after a stroke vary considerably. Disability as measured with the Barthel ADL Index is a stronger predictor of costs than Scandinavian Stroke Scale scores and other clinical and demographic variables.
OBJECTIVES: Knowledge of resource use and associated costs of treatment, care and rehabilitation at hospitals and in the health care and social service sectors is limited. This study presents data on the total resource use during the first year after spontaneous intracerebral hemorrhage. METHODS: All patients hospitalized because of stroke at a university hospital in Copenhagen, Denmark, during a 1-year period 1994-1995 were included in a database. The patients were followed until 1 year after the stroke, and data on resource use during and after the hospital stay were collected prospectively. This study investigates a subgroup comprising 90 patients with intracerebral hemorrhage. Resource use is described and costs are calculated. RESULTS: The cost of the hospital stay including acute care and rehabilitation had a mean of 90200 DKK (US$16100). The total cost of health care and social services during the first year had a mean of 123200 DKK (US$22000). Costs decreased significantly with age, but when differences of 30 days case fatality between age groups were considered, the association between costs and age disappeared. CONCLUSIONS: The mean cost of treatment, care and rehabilitation during the first year after intracerebral hemorrhage was 123200 DKK, of which the primary hospital stay constituted 73%.
In order to obtain knowledge of costs of health care and social services for patients who have transient ischaemic attacks (TIA) all patients admitted to a university hospital in Copenhagen, Denmark, with TIA during 12 months in 1994-1995 were included in a database. The patients were followed until one year after admission and data on resource use during and after the hospital stay were collected prospectively at interviews. The cost of the hospital stay had a mean of 10,100 DKK (1,800 US$) and the cost of health care and social services after discharge had a mean of 8,800 DKK (1,600 US$) per person.