Prevention and Treatment of Strokes

Dr. Frank Silver Director, Stroke Program, University Health Network, Toronto Western Hospital PREVENTION AND TREATMENT OF STROKES Chairman: Robert J. Dechert President, The Empire Club of Canada

Head Table Guests

Catherine Steele, Vice-President (Toronto) and Partner, GGA Communications and Third Vice-President, The Empire Club of Canada; The Reverend Canon Paul Feheley, St. George's Anglican Church, Oshawa; Timothy Turk, Grade 12 and OAC Student, Western Technical-Commercial School; Diane Black, Vice-President, External Relations, Heart and Stroke Foundation of Ontario; Rick Gallop, President, Heart and Stroke Foundation of Ontario; Phil B. Lind, Vice-Chairman, Rogers Communications Inc.; George L. Cooke, President and CEO, the Dominion of Canada General Insurance Company and Immediate Past President, The Empire Club of Canada; Robert L. Brooks, Chair of the Board, Heart and Stroke Foundation, Executive Vice-President and Group Treasurer, Bank of Nova Scotia and a Past President, The Empire Club of Canada; Yvon Bastien, President and General Manager, Sanofi-Synthelabo Canada Inc.; and Ian Scott, Former Attorney General, Province of Ontario and Former Partner, Gowling Strathy & Henderson.

Introduction by Robert J. Dechert The following are the grim statistics:

- Approximately 50,000 new strokes are reported each year in Canada. Stroke is the fourth-leading cause. of death.

- Currently as many as 300,000 Canadians are stroke survivors living with an increased risk of a subsequent stroke.

- One-third of all stroke victims are under the age of 65.

- The cost to the Canadian economy of treating and caring for stroke victims is estimated at $2.5 billion annually.

Dr. Frank Silver has been one of the Heart and Stroke Foundation's most active and accomplished volunteers in the fight against stroke over the last five years.

Dr. Silver is a recognised expert in the prevention and treatment of stroke. He is the Foundation's driving force on the development of a co-ordinated stroke strategy to enhance stroke care across Ontario and Canada.

Dr. Silver graduated from the University of Toronto with the Degree of Doctor of Medicine in 1978. He has been a Professor in the Department of Medicine of the University of Toronto since 1985. Since 1993, Dr. Silver has been the Director of the Stroke Program of the University Health Network.

Dr. Silver is the recipient of numerous awards and honours including the 1998 Aikins/University of Toronto Teaching Award for undergraduate medicine and the 1999 distinguished Service Award from the Heart and Stroke Foundation of Ontario.

Dr. Silver is the author of dozens of noted publications on the subject of the prevention and treatment of stroke. He has been VicePresident of the Canadian Stroke Society since 1998.

Ladies and gentlemen, please welcome Dr. Frank Silver to the podium of The Empire Club of Canada.

Frank Silver

In 1945 the three most powerful leaders in the world met at Yalta to determine the boundaries of the New World order that would prevail after the Second World WarFranklin Delano Roosevelt, Winston Churchill and Josef Stalin.

Their doctors were worried with good reason. Each of the world leaders was suffering from high blood pressure. Roosevelt, Stalin and Churchill would all die from a stroke. No medical treatment then available could have saved them. The most powerful leaders in the world were no match for stroke.

Times have changed. There has been a profound shift in our approach to stroke. We have come from an extended period of helplessness, where medicine surrendered to the casualties left in the wake of stroke. We have now entered an era in which there is a new realisation that we can "beat" stroke. Our understanding of stroke has been reshaped and redefined. Today, we know that stroke is both treatable and preventable. People can and do recover from stroke.

Today, I'd like to share with you some of the exciting new developments that have revolutionised stroke care. Since February last year we have a powerful, clot-busting drug called TPA-tissue plasminogen activator. TPA has the ability to stop a stroke in its tracks. Eighty per cent of strokes are caused by blood clots and TPA can effectively dissolve clots. Given intravenously to the right patients, TPA has the potential to open up a clogged brain artery, rapidly restoring blow flow to the brain, completely reversing the process or significantly limiting the extent of brain damage. TPA can increase the proportion of stroke patients making a near or complete recovery by 32 per cent or looking at it another way, TPA results in a 42per-cent reduction in odds of being dead or dependent at three months.

The statistics are impressive but it is nothing compared to seeing patients brought into the emergency department lying on a stretcher unable to speak, one side of their body paralysed, start to move their paralysed limbs shortly after you inject this drug; then to see patients, normally destined to spend the rest of their life in a nursing home, able to walk out of hospital unaided.

But the use of tPA brings a challenge. The drug must be administered within three hours from the onset of symptoms. In that short interval, a patient must recognise the symptoms of stroke and react by calling 911. The emergency services have to deliver the patient rapidly to an appropriate emergency department. Once in the emergency, the patient has to be assessed, blood tests completed, and a CT scan performed and interpreted all BEFORE the final decision is made to proceed with clotbusting therapy; all of this in less than an hour from the patient's arrival to hospital. The consequences of wrong treatment can be fatal.

To achieve an optimal "door-to-needle" time for stroke requires that emergency health-care services are geared up and primed to respond rapidly-in much the same way that they already respond to patients with the symptoms of a heart attack.

When a patient is brought to the emergency with a cardiac arrest, a whole team descends on the patient in a highly orchestrated attempt to revive him. Today, in most hospitals, when a patient with an acute stroke arrives there is.no orchestrated effort, but in fact, there is feeling of apathy. A further frustration is that there are some centres that have developed stroke protocols and stroke response teams, but reaching this type of care is by chance.

And this brings me to the importance of stroke units as a key strategy for improving outcomes. Even before the introduction of tPA, there was overwhelming evidence that managing stroke patients in centres with a special interest in stroke improves their outcomes.

Several studies have demonstrated that your chance of surviving and returning home is significantly improved if you receive care in a stroke unit. Moreover, these are not high-tech intensive care units. They are regular nursing units with a dedicated interdisciplinary stroke team and an organised care plan.

Stroke units have been shown not only to improve outcome but also to shorten the patient's length of stay and significantly reduce the cost of stroke. In short, to deliver optimal treatment we need specialised stroke units.

However, a 1999 survey of Ontario hospitals dealing with acute stroke revealed that only 4 per cent had dedicated stroke units.

In Ontario, the direct costs of stroke are approximately $529 million a year. Add another $328 million in indirect costs and the total burden to the Ontario economy is at least $860 million a year.

Left out of this estimate is the sheer human cost to the stroke patient and the stroke patient's family.

If we think there's a problem today, we haven't seen anything yet. Over the next 20 years, as the baby-boom generation ages, the number of strokes in Ontario could increase by 30 per cent.

The need for organising stroke care ranges across the entire spectrum from prevention to rehabilitation. We need to reorganise the way we deliver care so patients are more efficiently diagnosed, stabilised, treated and rehabilitated. Stroke patients need to be treated by interdisciplinary teams of specialised caregivers. Anything less should be considered unacceptable.

Once an acute stroke patient is successfully treated, our job is not over. Patients who have recovered from a stroke, no matter how minor, should not leave hospital without a clear plan for preventing another stroke.

You see, even though managing the acute stroke with clot busting agents is exciting, something that has already been portrayed on the television show ER is that the greatest impact we will have on stroke is by prevention. Prevention includes managing stroke risk factors and initiating stroke prevention strategies that will prevent a second potentially more devastating stroke.

It has been estimated that at least half of strokes can be prevented-simply by applying what we already know. We know that high blood pressure is a leading risk factor. Yet 42 per cent of Canadians with high blood pressure don't know that they have it. And of those who know they have it only 16 per cent have their blood pressure under control. And yet a person, whose high blood pressure is not successfully treated, faces up to a 40-per-cent risk of stroke within 10 years.

Let's add in the other risk factors-smoking, diabetes, high cholesterol, the presence of heart disease and family history of stroke-and one thing becomes blindingly apparent. It is that we must do a better job in stroke prevention.

We all know what should happen. Unfortunately the reality is different. Far too often I see patients after the fact, left devastated by their stroke where prevention or effective early intervention may have spared them this catastrophe. We desperately need a system in place to ensure our patients receive the care and stroke education that they deserve and that we should be able to deliver.

The health-care profession cannot reduce the impact of stroke without the public's help. There must be a level of awareness. For prevention this implies the recognition of stroke risk factors. For treatment this requires recognition of the symptoms associated with stroke.

So, in your own self-interest, you should all be aware of the risk factors and the symptoms of stroke.

On the table in front of you, you will see a card from the Heart and Stroke Foundation of Ontario listing signs and symptoms of stroke. Please take some time to read it and talk about it with your family, friends and colleagues.

It would be wonderful if you were all stroke aware. We need to think of a stroke as a "brain attack," much as we have learned to understand "heart attack." Very few of us would go to bed with chest pain and hope it would go away by morning. But over and again I see patients that were not aware of the symptoms of stroke going to bed with sudden speech difficulties or limb weakness, expecting their symptoms to be resolved by morning.

Even when patients recognise and react to stroke symptoms, in many cases the system fails to respond in an optimal manner. Left on their own, hospitals and emergency services cannot co-ordinate the necessary services. An organised regional approach is needed to insure that the right patient gets to the right hospital within the right time. This is the type of access that is well within our reach.

I'm pleased to say the Heart and Stroke Foundation has taken a significant leadership role towards this goal. The Foundation formed a steering committee to investigate ways to improve stroke care in this province.

This has led to the Heart and Stroke Foundation's "Coordinated Stroke Strategy" which has now been implemented in four pilot sites-Kingston, Hamilton, London and West Toronto. These sites are pulling together hospitals, emergency services, community agencies and health-care providers to develop an organised, regional approach to stroke across the entire continuum of care.

Lessons learned from the four Coordinated Stroke Strategy Sites will give us powerful insights for the province as a whole. This successful initiative convinced the Ontario government to work with us in setting up a Joint Strategy Working Group. Its mandate is to examine the entire continuum from stroke prevention to emergency care to rehabilitation.

Eventually we hope to bring organised stroke care to every community in Ontario, however remote. In our vision of the future, more remote areas could be linked to stroke centres through high-speed telecommunication links, fittingly named, "telestroke."

This is our road map for the future of stroke care and we are well on our way. The direction is clear and the goals are attainable. What we need now is the continuing involvement of our government partners to recognise stroke care in Ontario as a priority-facilitating the reorganisation of stroke care.

I hope that in 10 years' time I can stand here and say, without hesitation, that Ontario has the best-organised stroke care in the country, if not the world. With this infrastructure in place, we will be well-positioned to bring the new therapies, such as tPA, to all Ontarians.

When we look at what we can accomplish in this area, when we consider the rising numbers of stroke patients requiring treatment and rehabilitation, when we see how much we can achieve by a simple reorganisation of existing resources then there is only one conclusion we can come to: organised stroke care is simply common sense.

Mr. Ian Scott and Mr. Phil Lind, both stroke survivors, made brief remarks.

The appreciation of the meeting was expressed by George L. Cooke, President and CEO, the Dominion of Canada General Insurance Company and Immediate Past President, The Empire Club of Canada.