ESJ Comment: Secondary prevention of stroke

Original research article: “Availability of secondary prevention services after stroke in Europe: An ESO/SAFE survey of national scientific societies and stroke experts” European Stroke Journal DOI: 10.1177/2396987318816136

Secondary prevention of stroke: never too late

Comment by Linxin Li

Stroke is the second most common cause of death and the leading cause of long-term disability in Europe.1 Recurrent stroke is associated with physical disability, cognitive decline, mood disturbances and poor quality of life. However, early recurrent stroke can be reduced in up to 80% of cases with the implementation of optimal secondary prevention of stroke.2 Although all countries across Europe agree that appropriate secondary preventive measures are important, information is lacking regarding the provision of secondary prevention services in different countries.

Acute stroke care in Europe

Following the recent publication of the ESO/SAFE/ESMINT/EAN survey on provision of Acute Stroke Care across Europe,3 in this issue of the ESJ, the ESO-SAFE Secondary Prevention Survey Steering Group reported their results of a survey on the availability of secondary prevention services after stroke in Europe.

Methodology of this survey is similar to the previous survey on acute stroke care, where consensus responses were sought from panels of three experts in each country, coordinated by national stroke society chairs, or an ESO-nominated expert where there was no national society. National or local stroke registries were identified where possible and in the absence of such information, the coordinator and experts were asked to perform best estimates by consensus.

Of all 50 countries, data were available from 46 countries. 71% countries reported access to some registry data and 54% identified national strategies including secondary stroke prevention. Overall provision of secondary prevention varied between countries of different GDPs, with gaps in care prevalent particularly in lower income countries. Highlights of the results are listed below

  • Acute assessment: more than 60% of patients with a TIA were assessed by stroke specialists in high income countries, whilst 4 countries in the lowest tertile of GDP assessed >60% of patients in general medical clinics, and 3 countries in the lower two tertiles still deferred assessment of >20% patients to primary care. Even in high income countries, less than one third of them had >60% of the patients assessed on the same day, one of which took more than one week to see most patients.
  • Investigation and interventions: prolonged cardiac monitoring was routinely performed for AF screening in only half of the countries. Blood pressure monitoring is standardly deferred to primary care with only a third of countries offering out-of-office monitoring. Significant delays until carotid intervention remain common across all countries, especially in lower income countries. 5 lower income countries reported that >60% of patients are not operated within one month.
  • Management of risk factors: The commonest follow-up method was primary care (51%) and only 10% of the countries offered specialist-led follow-up clinics for most patients. Combined lifestyle management programmes are commonly available only in half of the countries. In contrast, the majority of patients across all countries receive antiplatelet and antihypertensive treatment at initial assessment. Statins are however less commonly prescribed in lower income countries. Moreover excellent compliance to secondary prevention medication in >60% of patients is only achieved in less than 60% of countries.

The authors concluded that, “despite significant advances in secondary stroke prevention over the past decade, many gaps in the provision of routine, cost-effective, evidence-based interventions across Europe remain”. The gaps identified in this survey also echoed with the Action Plan for Stroke in Europe,4 which identified 4 targets for 2030 in the area of secondary prevention, including incorporating secondary prevention in national stroke plans, ensuring that at least 90% of the stroke population is seen by a stroke specialist, and ensuring access to key investigations as well as key preventative strategies.

So, for secondary prevention of stroke, there is still many to do but it is never too late!

The full paper can be found on the ESJ website.


  1. Feigin VL, Forouzanfar MH, Krishnamurthi R, et al. Global and regional burden of stroke during 1990–2010: findings from the Global Burden of Disease Study 2010. Lancet 2014; 383: 245–254.
  2. Rothwell PM, Giles MF, Chandratheva A, et al. Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison. Lancet 2007; 370: 1432–1442.
  3. Aguiar de Sousa D, von Martial R, Abilleira S, et al. Access to and delivery of acute ischaemic stroke treatments: A survey of national scientific societies and stroke experts in 44 European countries. Eur Stroke J 2018; DOI: 10.1177/2396987318786023
  4. Bo Norrving, Jon Barrick, Antoni Davalos, et al. Action Plan for Stroke in Europe 2018–2030. Eur Stroke J 2018; DOI: 10.1177/2396987318808719