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 A New Three Step Program For National Stroke Prevention

George S Lavenson, Jr.^1,2
1Kaweah Delta District Hospital, Visalia, CA; ²Uniformed Services University for Health Sciences, Bethesda, MD.

OBJECTIVES: The three medical conditions that are the immediate cause of the majority of strokes; carotid occlusive disease (COD), atrial fibrillation (AF), and hypertension (HTN); are asymptomatic in 80% of cases prior to the stroke. Most strokes could be prevented by a three-step program of (1) screening all seniors to exclude the normals and detect any with a possible immediate cause of stroke, (2) thorough diagnostic evaluation of those positive to discover all with >60% COD with liberal selection for intervention, and (3) intervention with <2% major complications.

METHODS: (1) For screening, a protocol was developed that employs an ultrasound quick carotid scan (QCS) for COD, a lead II rhythm strip for AF, and blood pressure determination for HTN. The QCS relies primarily on imaging to indicate the presence of possible >60% COD without need for velocity determinations, is performed in < 1 minute, and had a sensitivity of 97% when tested at NYU. (2) For diagnostic evaluation of those positive for possible significant COD on screening, a full carotid duplex ultrasound (CDU) examination is employed with liberal use of a CTA or MRA for those with indeterminate examinations to ensure not missing a >60% lesion. Seniors with >60% stenosing COD are selected for intervention (per ACAS). (3) Intervention is only performed by physicians and centers with a <2% and preferably <1% stroke/death rate.

RESULTS: Screening 22,000 seniors in Central California, Madigan Army Medical Center, NYU, and the American Vascular Association yielded 7.5% with possible >60% COD, 4% with AF, and 25% with HTN. Full diagnosis of COD required a CTA or MRA in addition to CDU in 20% of cases. Approximately 66% of those with possible >60% COD on screening had the diagnosis confirmed and were selected for CEA. The author’s stroke/death rate with CEA was 0.8%. It is estimated that the COD portion of this program alone would prevent >200,000 strokes nationally and save >13 billion dollars.

CONCLUSIONS: A three-step program of (1) screening all seniors to detect the possible immediate causes of stroke, (2) thorough evaluation of those positive on screening to diagnose all with a stroke potential condition with intervention for >60% COD, and (3) intervention with a <2% and preferably <1% stroke/death rate can reduce stroke nationally on an epidemiological scale.