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    • Eastern European countries have undergone many

    2019-06-11

    Eastern European countries have undergone many socioeconomic changes in the past two decades. In particular, in Russia, alcohol was strongly associated with adult mortality. More than half of deaths in Russian men are attributable to cardiovascular disease, with hypertension, hypercholesterolaemia, tobacco use, inadequate diet, obesity, insufficient physical activity, and alcohol being among the prevalent risk factors for death. The decline in incidence, mortality, DALYs, and mortality-to-incidence ratios in high-income countries is likely to be because of improved prevention, and acute and chronic treatment of stroke. High-income regions such as western Europe, North America, Australia, and New Zealand have increased efforts to prevent and diagnose stroke, which might be shown by the delay of stroke incidence to older age groups. Mortality-to-incidence ratios for ischaemic stroke in people younger than 40 years were significantly higher in low-income to middle-income countries than in high-income countries. This finding might show an increased prevalence of risk factors such as alcohol use; tobacco smoking, including second-hand exposure; and high blood pressure in this age group, or it might be due to chance. By contrast, the increased overall global burden of stroke in low-income and middle-income countries could be attributable to reduced levels of awareness of risk factors, low levels of primary and follow-up health care, and a scarcity of basic drugs and equipment for the prevention and treatment of stroke. To progress our understanding of the burden of ischaemic and haemorrhagic stroke, and to better inform large initiatives in health funding, further study is needed that is specific to low-income to middle-income countries in terms of improved identification of what subgroups of the AZD 6244 are at greatest risk (eg, by age, sex, and ethnic origin) and could be targeted for preventive efforts. High-quality community-based epidemiological studies in low-income and middle-income countries with early neuroimaging investigations to identify stroke types are needed across WHO regions because heterogeneity is likely to exist across large regions such as central Asia and sub-Saharan Africa. A systematic review recommended the establishment of sustainable systems to obtain stroke data shared by other non-communicable diseases, and a wide application of feasible and practical surveillance techniques (eg, WHO STEPS) particularly in low-income countries. Population-wide preventive strategies should be given priority because even modest changes in prevalence of risk factors (eg, reduction of blood pressure, smoking cessation, and reduction of salt intake) could contribute substantially to the cumulative population risk reduction. Interventions to reduce the burden of chronic disease in low-income to middle-income countries should be cost effective and financially feasible. Because of the overlap of risk factors related to ischaemic stroke and ischaemic heart disease, preventive efforts focused on these factors (eg, raised blood pressure, cholesterol, diabetes, smoking) would be a cost-effective way to target prevention in a wide population. Raised blood pressure is the strongest risk factor for both ischaemic and haemorrhagic stroke, and on the basis of the high burden of both types, prevention programmes should focus on control of blood pressure, including both individual screening and treatment but also population-wide lowering of blood pressure. Tobacco control (via increased taxes, reduced advertising, and banning of smoking in public places), strategies for salt reduction, and evidence-based multidrug strategies to treat those at high risk of cardiovascular disease, would be relevant for prevention of both haemorrhagic and ischaemic stroke. Several successful and cost-effective campaigns have already been identified and need to be adapted on a wider scale worldwide. Government initiatives to encourage and support healthy diets and increased physical activity are imperative in countries of all income types. Similarly, engaging of food manufacturers to achieve these goals by reduction of salt levels and fat content in processed foods would need to be implemented at government level.