Advances in Primary Prevention and Health Services Delivery

T he American Heart Association's goal of reducing deaths from coronary heart disease and stroke in the United States by 25% between 1999 and 2010 was achieved in 2008 -a remarkable accomplishment associated with advances in stroke prevention and treatment.Yet, much work remains to be done.Stroke is still the third most common cause of death in the United States and other developed nations, and is the leading cause of death in middle-income countries.1,2 From 19791,2 From to 2005, the number of inpatient discharges from short-stay hospitals in the United States with stroke as the first listed diagnosis increased 20% to 895 000. 1 Prevention remains the cornerstone of efforts to reduce the burden of stroke on populations throughout the world, with much to be gained through better adherence to proven stroke prevention measures.3 Primordial prevention refers to societal and other efforts aimed at reducing the likelihood that persons will develop the risk factors that can lead to disease.In Scotland, a ban on tobacco smoking in public indoor spaces was enacted into law in March 2006.Although data for an effect on stroke risk is not available, a study focused on hospital admissions for acute coronary syndromes demonstrated the potential impact of such legislative efforts.4 Information on smoking status and exposure to secondhand smoke was collected prospectively based on questionnaires and biochemical findings from all patients admitted with acute coronary syndromes to 9 Scottish hospitals during the 10-month period preceding the passage of the legislation and during the same period the following year.The numbers of admissions for acute coronary syndromes decreased by 17% (95% CI, 16% to 18%) as compared to a 4% reduction in England (which has no smoking ban) over the same period.Persons who had never smoked reported a decrease in the weekly duration of exposure to secondhand smoke and had a 20% (95% CI, 18% to 22%) reduction in admissions.A second study evaluated changes in the frequency of acute coronary events in Rome, Italy, after the introduction of legislation that banned smoking in all indoor public places in January 2005.5 After adjustment for a series of confounders, there were reductions after the smoking ban in acute coronary events in 35-to 64-year-olds (11.2%; 95% CI, 6.9% to 15.3%) and in 65-to 74-year-olds (7.9%; 95% CI, 3.4% to 12.2%).Further work will be needed to determine whether reductions in exposure to environmental tobacco smoke also lead to lower risks of stroke.Stroke prevention guidelines developed and endorsed by voluntary health organizations and governmental agencies provide a variety of lifestyle and behavioral recommendations aimed at reducing stroke risk.6,7 People who adhere to these lifestyle recommendations have dramatically lower stroke risks as compared to those who do not.A prospective cohort study evaluated the impact on stroke risk of following a healthy lifestyle among 43 685 men from the Health Professionals Follow-up Study and 71 243 women from the Nurses' Health Study.8 Diet and other lifestyle factors were obtained from self-reported questionnaires.A low-risk profile was defined as not smoking, having a body mass index Ͻ25 kg/m 2 , engaging in at least 30 minutes per day of moderate physical activity, consuming modest amounts of alcohol (men, 5 to 30 g/d; women, 5 to 15 g/d), and scoring within the top 40% in a measure of a healthy diet.The diet score was based on the Alternate Health Eating Index (higher intakes of vegetables, fruit, nuts, soy, and cereal fiber; high ratio of chicken plus fish to red meat and polyunsaturated to saturated fat; low intake of trans fat; and multivitamin use for at least 5 years).Adherence to the low-sodium Dietary Approaches to Stop Hypertension (DASH) diet and a 6-nutrient diet score were also assessed.There were 1559 strokes (853 ischemic, 278 hemorrhagic) among women and 994 strokes (600 ischemic, 161 hemorrhagic) among men during follow-up.Women with all 5 low-risk factors had a 79% reduction in the risk of all strokes (relative risk, RRϭ0.21; 95% CI, 0.12 to 0.36) and an 81% reduction in the risk of ischemic stroke (RRϭ0.19;95% CI, 0.09 to 0.40) with a graded reduction related to level of adherence.Among men, there was a 69% reduction in all strokes (RRϭ0.31;95% CI, 0.19 to 0.53) and an 80% reduction in ischemic strokes (RRϭ0.80;95% CI, 0.10 to 0.42).Among the women, 47% (95% CI, 18 to 69) of all strokes and 54% (95% CI, 15% to 78%) of ischemic strokes were attributable to lack of adherence to a low-risk lifestyle; among the men, the corresponding risks were 35% (95% CI, 7% to 58%) and 52% (95% CI, 19% to 75%).The data