Health and Social Care Committee

Inquiry into Stroke Risk Reduction

SRR 2 – Association of British Neurologists

Dear Mr Drakeford

The National Assembly for Wales’ Health and Social Care Committee inquiry into stroke risk reduction.

The Association of British Neurologists represents almost every neurologist working in the UK and therefore we feel that the Association does have something to contribute to your consultation.

As you will know, neurologists are mainly involved in secondary stroke prevention, that is reducing the high risk of stroke after a patient has had a stroke or a transient ischaemic attack (TIA). We are not sure whether your inquiry will extend to such activity; your remit seems to be for primary stroke prevention, that is reducing the much lower risk of stroke (and other vascular events such as myocardial infarction) in the population at large before any stroke has occurred. Of course the interventions in both cases are similar (blood pressure control etc) but the way they are delivered is not. Secondary prevention relies on well  trodden pathways in secondary care which neurologists are very involved with (neurovascular clinics, stroke units etc) while primary prevention relies on interventions at the community level (eg reducing salt in food, encouraging exercise etc) and in primary care (screening for high blood pressure, atrial fibrillation etc).

But in both cases similar principles apply, in particular whether an intervention really does reduce stroke risk, and if so by how much, what are the adverse consequences, and is the extent of the reduction worthwhile – in the broadest sense - to the individual and to the community at large. So often interventions are exaggerated on the basis of relative reduction in risk (eg from a risk of stroke of 10% in 10 years to 5%, a relative risk reduction of 50%) rather than absolute reduction in risk (in this case only 5%, in other words 20 people have to be treated for 10 years for one to benefit, or any individual has a 1 in 20 chance of being personally benefited).

We would urge you not to pursue the methods of commercial screening companies active in the UK, such as Lifeline screening http://www.lifelinescreening.co.uk whose literature has the potential to scare people into screening to prevent stroke, and then to offer interventions for which there is no evidence of benefit (eg screening for carotid stenosis) or interventions which are already available within the NHS, at least in England (such as screening for abdominal aortic aneurysms). Furthermore, with respect to atrial fibrillation for which you are seeking particular comments, we understand that doing an ECG as Lifeline does is not as cost effective as opportunistic feeling the pulse and only doing an ECG if the pulse is irregular. As neurologists, however, we would defer to the cardiologists on matters of atrial fibrillation.

We are encouraged that you are undertaking this enquiry. If at a later date you would like us to comment on your report, particularly if it does refer to secondary prevention for which we have some responsibility, we would be delighted to do so.

Yours sincerely

Professor Martin Rossor, President

Dr Gareth Llewelyn, Chair, Services & Standards Committee

Professor Charles Warlow, Non Executive Policy Advisor