Personal ViewWhat MONICA told us about stroke
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A very large non-commercial international stroke study is extremely cumbersome… and possible
During the years that MONICA was done, dramatic societal changes took place. Some of the MONICA centres in central and eastern Europe did not survive the changes that happened between 1989 and 1991. In 1987, the MONICA Parliament (yes, it was a grandiose project, with even a parliament) met in East Berlin, underneath portraits of Lenin and Ulbricht. 3 years later, no funds were available to support the investigators from the German Democratic Republic. The East German MONICA Project collapsed.
The quality of stroke care makes a profound difference for individuals and the population
One of the fascinating parts of MONICA is that the 10 years of the project spanned dramatic transition in central and eastern Europe. Those MONICA centres that survived the changes could monitor the effects on stroke occurrence before and after the transition. How do societal changes of revolutionary dimensions affect the risk of stroke and of dying from stroke?
The first observation in MONICA was that official stroke mortality was not always reliable or comparable between countries. When the
The results of ecological studies must be interpreted with great caution
The research design of MONICA avoided many of the problems that commonly trouble epidemiological studies. But despite its longitudinal design and prospective, uniform data collection for both risk factors and events, MONICA is an ecological study with small real possibilities for hypothesis testing.
The main hypothesis in both coronary and stroke modules of MONICA was that changes in classic cardiovascular risk factors in the population affect rates of cardiovascular disease.1, 9 MONICA provided
Socioeconomic factors seem to outweigh classic risk factors in predicting stroke trends
Data from Russia and Denmark show that classic risk factors might not be the best indicators of trends.1, 12 In Novosibrisk, Russia, over 10 years, body-mass index, cholesterol concentrations, and blood pressure all decreased, and yet rates of strokes did not change. In Denmark, the overall classic risk-factor burden was largely unchanged, but stroke rates fell by an average of 3–4% per year.1, 6
Although the MONICA investigators had a wide range of expertise, in hindsight, there was an absence
Community-based intervention programmes are difficult to assess
Longitudinal monitoring of risk factors, stroke, and myocardial infarction, as in the MONICA Project, would seem suited to the assessment of community-based prevention programmes. Indeed, some of the MONICA centres planned for such an assessment. One intervention and one control population were included in both Moscow and Novosibirsk, but the intervention programmes could not be pursued with reasonable intensity. The northern Sweden MONICA Project covered two counties, one with an ambitious
A large-scale multinational project creates a long-lasting research infrastructure
The most important outcome of MONICA is probably the development of infrastructure for cardiovascular research and international collaboration. PubMed lists more than 1000 MONICA publications from 21 countries; previously, several of the countries had a weak tradition in cardiovascular epidemiological research.
MONICA is the mother of many offspring projects, some of them very large. Risk-factor monitoring and follow-up of the MONICA cohorts have been continued within the multinational MONICA
The broader perspective—stroke fits the health-transition concept
The changes in risk-factor patterns and cardiovascular morbidity and mortality in MONICA can be interpreted within the general framework of health transition. Originally called epidemiological transition, health transition describes the course of disease patterns in populations.25, 26 In low-income countries, stroke is increasing, mainly owing to increasing numbers of people of stroke-prone age (figure 2). In most less developed countries, urbanisation involves lifestyle changes that increase
A plea for population-based interventions to reduce the burden of stroke
In most wealthy countries, there have been substantial investments in stroke care—improved competence, structured stroke services, and new methods in acute care and rehabilitation. The MONICA data show that this investment has been worthwhile for improvement in survival, including in large populations in many countries. The data also show how fragile such achievements can be. Worse stroke care rapidly affects stroke mortality rates—survival is worse, as seen in the former USSR countries in the
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A Prototype Worldwide Survey of Diagnostic and Treatment Modalities for Stroke
2015, Journal of Stroke and Cerebrovascular DiseasesFrequency and determinants of intracranial atherosclerotic stroke in Urban Pakistan
2014, Journal of Stroke and Cerebrovascular DiseasesCitation Excerpt :This is the first study that has directly assessed the prevalence and determinants of ICAD in the sixth most populous nation in the world, which like so many developing low and middle countries is facing the noncommunicable disease epidemic of stroke and MI now recognized as a global health threat.21 This study confirms the importance of ICAD as a mechanism of stroke in this region and mirrors the findings from similar international regions.2-12,22 ICAD accounts for roughly one fifth of all acute stroke events, 85% of all large-artery strokes, and is the most frequent mechanism of ischemic stroke.
Trends in stroke survival incidence rates in older australians in the new millennium and forecasts into the future
2014, Journal of Stroke and Cerebrovascular DiseasesCitation Excerpt :In Australia up to 2005-2006, the declines in deaths from stroke were about 2 times higher than reduction in hospitalizations (4.0% versus 2.2%).12 It appears, therefore, that declining mortality rates as a result of improvements in prevention, acute stroke management, and therapy3,55,56 may had a significant effect on the NSS. The plausible and encouraging decline in stroke deaths occurred in parallel with demographic changes.
The global burden of stroke
2011, Stroke: Pathophysiology, Diagnosis, and ManagementThe Global Burden of Stroke
2011, Stroke