Current status of cerebrovascular disease in China
Stroke, also known as stroke or cerebrovascular disease, is caused by sudden rupture and bleeding of blood vessels inside the brain or ischemia and hypoxia in the brain due to blockage of blood vessels. The clinical manifestations are characterized by sudden onset of consciousness or distortion of the mouth and eyes, hemianopia, slurred speech, and cognitive impairment. Stroke includes ischemic stroke (transient ischemic attack, atherosclerotic thrombotic infarction, lacunar cerebral infarction, cerebral embolism) and hemorrhagic stroke (cerebral hemorrhage, subarachnoid hemorrhage). According to the data published by the Chinese Cardiovascular and Cerebrovascular Disease Epidemiology Collaborative Research Group, ischemic stroke accounts for 62.4% of stroke patients, cerebral hemorrhage accounts for 27.5%, and subarachnoid hemorrhage accounts for 1.8% of stroke patients in China. Zhang Guoping, Department of Neurology, Beijing Jitan Hospital, Capital Medical University
With the aging of the population and changes in the lifestyle of the masses in China, the incidence of stroke has been on a significant rise in recent years. According to epidemiological survey data, there are about 7 million stroke patients in China, 2 million new strokes each year, and about 1.5 million patients die from stroke each year, with an average of one new case every 15 seconds and one death every 21 seconds. With the dramatic changes in lifestyle, cardiovascular diseases are rising rapidly, among which cerebrovascular diseases have surpassed tumors and coronary heart diseases, ranking first in the national death and disability diseases, and the incidence rate is still rising at a rate of nearly 9% per year. International comparative studies suggest that the morbidity and mortality rates of cerebrovascular diseases in China are higher than the international average, second only to the former Soviet Union or Eastern Europe and a few other countries. With its high incidence, high recurrence rate, high disability rate, high mortality rate and increasingly high cost of prevention and treatment, cerebrovascular disease has caused huge economic losses to the country and society, and has become an important public health problem that seriously affects the people’s livelihood of China, and the need for prevention and treatment is extremely urgent and must be given high priority.
A series of studies in developed countries in Europe and the United States have shown that the integration of multidisciplinary, multi-level and multi-linked health care resources can facilitate stroke patients to receive a complete, continuous and organized health care system, i.e., from health promotion, early warning symptom recognition, rapid and rational transport or remote stroke consultation, to organized stroke units, rational rehabilitation and secondary prevention and management of complications after returning to the community. This has greatly improved the efficiency of stroke care, reduced the cost of care, and improved patient outcomes and quality of life. “During the Tenth and Eleventh Five-Year Plans, the first international standardized stroke unit in China was established by Beijing Tiantan Hospital, together with Xuanwu Hospital and Xitantan Hospital. Stroke Units” have been issued, and five projects have been completed in three years: (1) the establishment of standard stroke units; (2) the development of evidence-based guidelines for the diagnosis and treatment of cerebrovascular disease; (3) the study of the best training programs for stroke unit doctors, nurses, and rehabilitators; (4) the effectiveness of stroke units; and (5) the health economics study of stroke units. Since then, the research and clinical practice of stroke units in China has been initiated, which has attracted wide attention both at home and abroad. The Ministry of Health has included the stroke unit program among its 100 projects for ten years, and has received thousands of visits from hospitals at all levels nationwide, with a nationwide impact.
At present, the stroke medical service system has been funded by the “Beijing Medical and Health Science and Technology Joint Project” to establish the BATTLES model of acute stroke remote treatment system in Beijing. Established the China Acute Ischemic Stroke Thrombolysis Registry Network. The China National Stroke Registry (CNSR), funded by the Ministry of Science and Technology and the Ministry of Health under the Eleventh Five-Year Plan, has been established for the purpose of “medical quality improvement”. The National Stroke Registry (CNSR), funded by the Ministry of Science and Technology and the Ministry of Health under the 11th Five-Year Plan, is a nationwide prospective multicenter registry of new acute cerebrovascular events (mainly cerebral infarction, cerebral hemorrhage, subarachnoid hemorrhage, and transient ischemic attack) within 14 days, with long-term follow-up. Stroke patients are usually treated in the hospital for only two to three weeks. After stabilization during the risk period, patients must follow their doctor’s discharge orders and take their medication regularly and quantitatively, and must not increase or decrease their medication or stop it at will. The patient must follow the doctor’s instructions and take the medication regularly.
The real culprit behind ischemic stroke – carotid atherosclerosis
Stroke is divided into ischemic stroke and hemorrhagic stroke, of which about 65% are ischemic stroke. The real culprit behind ischemic stroke is carotid atherosclerosis, and high LDL cholesterol is the main cause of atherosclerosis. Hyperlipidemia is a manifestation of abnormal fat metabolism or functioning, which is called dyslipidemia in modern medicine when blood cholesterol or triglycerides are too high or HDL cholesterol is too low and LDL cholesterol is too high. HDL cholesterol can prevent atherosclerosis, while LDL cholesterol can cause atherosclerosis. In other words, the more LDL cholesterol exceeds the normal value, the more likely it is that a stroke will occur. Therefore, LDL cholesterol is often referred to as “bad cholesterol”.
Numerous studies have shown that hyperlipidemia is a risk factor for stroke, coronary heart disease, myocardial infarction, and sudden death. In addition, hyperlipidemia is an important risk factor for hypertension, abnormal glucose tolerance, and diabetes. Hyperlipidemia can also lead to fatty liver, liver cirrhosis, cholelithiasis, pancreatitis, fundus bleeding, blindness, peripheral vascular disease, claudication, and hyperuricemia. The main causes of hyperlipidemia are associated with an excessive diet of high-fat, high-calorie, high-protein foods and too little exercise.
Atrial fibrillation is the most likely cause of cerebral embolism
Atrial fibrillation is a common and important arrhythmia with a prevalence of about 4% in the population and a higher prevalence in the elderly, with a prevalence of 10% in those older than 75 years of age. The number of foreign visits for atrial fibrillation accounts for 3-11% of all emergency room visits, and 1/3 of the people treated for arrhythmias in cardiovascular hospitals in China are in atrial fibrillation. Because atrial fibrillation is easy to form thrombus in the atria, the thrombus is easily dislodged after it is formed, and the dislodged “embolus” will reach any part of the body with the blood flow, and once it is stuck somewhere, it will cause embolism, and the common one is cerebral embolism. Because the embolus can be repeatedly shed, it is easy to recur. The incidence of embolism in patients with atrial fibrillation is 5 to 7 percent. Patients with risk factors are more likely to have cerebral embolism, such as heart valve disease, coronary heart disease, hypertension, heart failure, large atria, history of embolism and transient cerebral ischemia, and elderly people over 65 years old, etc. The rate of death and disability after cerebral embolism is very high, and the chance of cerebral embolism caused by atrial fibrillation at the age of 80 is 5 times higher than that of people without atrial fibrillation.
Poorly controlled diabetes and hypertension can also lead to stroke
If blood sugar is not well controlled, it can damage blood vessels and interfere with cholesterol metabolism, which can lead to atherosclerosis. Therefore, it is crucial to control diabetes well and also to avoid other complications. Hypertension is the most important risk factor for cerebral hemorrhage and cerebral infarction. A study in China showed that for every 10 mmHg increase in systolic blood pressure, the relative risk of stroke increased by 49%, and for every 5 mmHg increase in diastolic blood pressure, the relative risk of stroke increased by 46%, after controlling other risk factors. In a randomized controlled clinical trial of systolic hypertension in elderly Chinese, the mortality rate of stroke was 58% lower in the antihypertensive treatment group than in the placebo control group after 4 years of follow-up. Recommendations: (1) Raise awareness of stroke prevention among the population and take the initiative to care for their blood pressure; it is recommended that blood pressure should be measured once a year for people aged ≥35 years and frequently (at least once every 1-2 months) for patients with hypertension to adjust the dose of medication. (2) Hospitals at all levels should establish a system for measuring blood pressure in adults at the first visit as soon as possible.
Stroke should be rushed to hospital within 3 – 6 hours
To get timely and effective treatment for stroke, you must know its early symptoms. If one or more of the following symptoms appear and recur briefly, you should be highly alert to the possibility that this is a precursor of stroke and should be treated in hospital in time.
1. sudden blackness or blurred vision in one or both eyes for a short period of time, sudden double vision or with vertigo.
2. sudden numbness (wood) on one side of the hand, foot or face or with weakness of the limbs, sudden dumbness of the tongue and unclear speech.
3. sudden vertigo, or with nausea and vomiting, or even with panic and sweating, etc.
4. sudden fall without any premonition, or accompanied by short period of confusion.
Time is the key to save brain cells, remember: to lose time is to lose brain. Patients should preferably be treated effectively within 3 – 6 hours of onset. Once the onset of the disease, the patient’s family or friends should urgently call 120 emergency vehicles to transport the patient to a hospital with neurological conditions for medical treatment, do not drive the patient to the hospital on their own, so as to avoid accidents on the way to do nothing and delay the patient’s condition.
Large-scale international clinical trials over the past decade have confirmed that the use of intravenous or arterial thrombolytic therapy within 3 hours can achieve significant results. There is growing evidence that the shorter the interval between stroke onset and effective treatment, the better the outcome of thrombolytic therapy and the lower the disability and mortality rates. However, even in large cities such as Beijing and Shanghai in China, less than 1% of patients are treated with thrombolysis within 3 hours, indicating that our awareness of the disease is still weak.
In recent years, the development of neurointerventional technology has made the diagnosis and treatment of cerebrovascular disease less invasive, patients recover faster, and the treatment effect has been significantly improved. Neurointerventional technology is a type of technology in which a catheter is introduced into the blood supply vessels of the brain through the femoral artery puncture for examination and treatment. The adoption of this technology has enabled the treatment of many cerebrovascular diseases to avoid complicated and dangerous surgeries, opened up a new treatment pathway for some cerebrovascular diseases that are extremely difficult to be treated by conventional surgery, and greatly expanded the indications for surgery for various cerebrovascular diseases. With digital subtraction cerebral angiography, various types of cerebrovascular diseases can be diagnosed and treated accordingly, including ultra-early arterial selective thrombolysis for cerebral thrombosis, spring coil filling for cerebral aneurysm and angioplasty and stent placement for intracranial and extracranial vascular stenosis. With the development of large DSA equipment and interventional materials in the last decade, the treatment has been improved.
Early rehabilitation in a stroke unit in a timely manner
The Stroke Unit is a new model of medical care for managing inpatients with stroke, which combines each of the traditional approaches to stroke treatment, such as medication, functional rehabilitation, speech therapy, psychological counseling, and health education, into a harmonious and tightly integrated system of treatment. The stroke unit was first introduced in Northern Ireland in Europe with unexpected success, and its form has since been innovated, from geriatric stroke rehabilitation groups to acute stroke units, mobile stroke units, and now stroke units that combine supervised treatment and early rehabilitation in the acute phase of stroke. The stroke unit is the most effective of the four proven treatments for stroke (i.e., stroke unit, thrombolysis, antiplatelet therapy, and anticoagulation). It means that the most effective treatment for stroke is not one drug and one technique, but a new model of ward management.
The stroke unit is a combination of acute care and early rehabilitation and consists of the following elements: hardware with intensive care unit, functional physical rehabilitation room, speech training room and psychological counseling room. The software includes the first emergency treatment for stroke, standardized drug treatment, individualized rehabilitation training, and health education for patients and family members on stroke prevention and treatment.
Compared with traditional wards, the stroke unit emphasizes “urgency” and “early”. When a stroke patient arrives at the emergency room, he or she is immediately transferred to the stroke unit for examination, resuscitation and treatment. At the same time, functional rehabilitation begins. From the moment the patient enters the stroke unit and lies down on the bed, the rehabilitation physician prescribes functional exercises for each patient’s condition. During the acute period, the patient’s affected limbs are constantly positioned into relevant positions by the nurses to prevent the formation of passive postures. As soon as the acute period is over, functional rehabilitation begins. Therefore, in the stroke unit, many patients are already out of bed on the second or third day by targeted early functional, speech or psychological rehabilitation exercises.
In July 2001, the first standard “Stroke Unit” in China was built in Beijing Tiantan Hospital under the guidance of Prof. Wang Dengjun. In September 2002, Beijing Xitantan Hospital established a stroke unit in the neurology cadre ward and started clinical application and research. The stroke unit model has been used to treat more than 5,000 cases of stroke patients, with significant results. The benefits of the stroke unit are: improved treatment outcome, reduced complications, reduced mortality and disability, improved long-term prognosis, reduced health care costs, and increased patient satisfaction.
The stroke unit is a new model of stroke treatment and management, and the stroke unit protocol is the most effective, cost-effective, safe, and rational treatment measure. Stroke units are now being used nationwide to standardize the treatment and management of stroke patients in China, greatly improving treatment outcomes and reducing the burden on the state, society and individuals.
Establishing and standardizing community-based rehabilitation treatment and strengthening stroke prevention
Currently, the diagnosis and treatment of cerebrovascular disease in China is still faced with uneven distribution of medical resources, low awareness of stroke among the public, and the standardization of cerebrovascular disease treatment. Especially in remote suburban areas, it is difficult for patients with cerebrovascular disease or high-risk groups to receive timely and effective treatment or intervention. In this situation, the Guidelines Collaborative Group of the Cerebrovascular Disease Group of the Chinese Academy of Neurology promulgated the 2010 Chinese Guidelines for the Diagnosis and Treatment of Acute Ischemic Stroke and the 2010 Chinese Guidelines for the Secondary Prevention of Ischemic Stroke/Transient Ischemic Attack, which provide constructive guidance on the diagnosis and treatment of stroke patients and the prevention of recurrence in China, with the aim of helping clinicians to standardize the diagnosis and treatment process and reduce the risk of stroke. The guidelines are intended to help clinicians standardize the treatment process and reduce the risk of stroke to people’s health. The Guidelines emphasize the importance of secondary prevention of stroke to effectively prevent recurrence and reoccurrence of stroke. The Guidelines emphasize the importance of secondary prevention of stroke, in which the physician treats the current stroke while intervening effectively for the next recurrence. The majority of cerebrovascular disease is largely dependent on prevention, and preventive measures are the most important factors in reducing the incidence, recurrence, disability, and mortality of cerebrovascular disease. If these measures are taken well, a large number of patients can have less morbidity. Even if they do, they will not be as severe and dangerous.
In developed countries, patient compliance is very high, and patients comply well with the advice and medication given by doctors. In our country, because the health insurance policy is not universal, many patients have to pay out of pocket. Therefore, it is very common for patients to stop taking their medication after a period of time for various reasons. Dependence is relatively low. We emphasize the popularization of public health knowledge, good preventive measures, early prevention, reduce the incidence of disease, and the disability rate will be reduced. As a doctor, in addition to saving patients themselves, the greater task is to educate the general public about health science, so that they can do a good job of prevention and treatment as prescribed. It is not advisable to stop taking medication without permission, or to seek and take medication indiscriminately, especially to believe in some TV commercials and incorrect propaganda.
The Guidance of the State Council on the development of urban community health services indicates that: First, we should adhere to the government-led, encourage the participation of social forces, and develop the community health service system in various forms. Second, the nature and functions of community health services should be clarified and improved to provide safe, effective, convenient and economical services for the public. Third, we must be determined and make great efforts to reasonably adjust and allocate community health resources. Fourth, we should strengthen the internal incentive and external supervision mechanisms of community health service institutions, strict access to community health service institutions, personnel and technical programs, reform the personnel and income distribution systems, etc., and make whether community residents benefit and are satisfied the main criteria for evaluating their work. Fifth, we should coordinate the development of community health services, establish a system of graded medical care and two-way referral, and improve health insurance, drug production and distribution, medical assistance, education, personnel and other related supporting policies. Sixth, we should explore innovative community health investment mechanisms, establish a stable funding mechanism, and explore the government’s “money to buy services” and other funding and compensation methods, and gradually increase investment with the growth of financial resources. At present, the central government has decided to develop community health services to solve the problem of difficult and expensive access to the public to a fairly important position, while encouraging the participation of social forces to develop community health service system in various forms.
Community health services are widely used in many countries in the world, especially in some developed countries, where patients are first seen by community doctors and only referred to higher level hospitals or specialist hospitals if they cannot be treated. Under this system, hospitals are mostly quiet and not crowded. Medical institutions treat patients according to their different conditions, so that limited medical resources can be used to maximum effect. Such a medical pattern has great value in establishing a highly efficient and low-cost medical system, which is beneficial to both the people and the country. As an important part of medical reform, the Ministry of Health has promoted the two-way referral system and the “first-call” system in community hospitals nationwide, encouraging “minor illnesses in the community and major illnesses in the hospital; surgery in the hospital and post-operative care in the community”. In the case of stroke, “emergency care in the hospital, rehabilitation in the community” is needed to facilitate long-term, standardized rehabilitation training for patients.
Community medical service is not a competitive relationship with large hospitals, but a reasonable division of labor, close collaboration and complementary advantages. Community health care mainly to meet the needs of residents to see a doctor convenient, economical, community health capacity to improve, can significantly ease the pressure on large hospitals, so that large hospitals can better play the role of training primary care staff, solve difficult cases, and overcome the difficulties of medical research. In foreign countries, there are almost no outpatient departments in large hospitals, and people who go to large hospitals are referred from community health services, so that community doctors can find more suitable hospitals and doctors according to the actual situation of each resident. In the United Kingdom, the birthplace of community health services, community hospitals have nearly 50 percent of all physicians, with an average of one community general practitioner for every 2,000 people.
The development of community health can also absorb a large number of medical and health personnel to go deeper into the grassroots, directly providing more and better services to the general public. Such a pattern not only makes the distribution and utilization of medical resources more equitable and reasonable, but also gives a solid operational basis for the construction of medical ethics, reform of the pharmaceutical purchase and sale system, and reform of the medical security system. It is an important part of urban community construction, a basic way to achieve primary health care for all, and an important element to promote social equity, maintain social stability and build a harmonious society. Of course, any new thing faces a lot of problems in its initial stage of development. The National Development and Reform Commission published the results of a public opinion survey on social and public services in Beijing, in which 41.4% of the 2,000 residents interviewed said that they would not choose to go to a community hospital if someone in their family had a minor illness, and their dissatisfaction with medical services was mainly focused on several aspects such as low medical standards, non-disclosure of drug prices, rudimentary medical equipment, poor medical service attitude and medical environment.
Therefore, we hope to establish 3-5 new, standardized community hospitals in major cities such as Beijing, Shanghai and Chongqing, which can be remodeled, expanded, redesigned and planned, and a few representative community hospitals will be selected for pilot projects at the beginning. The community hospitals will have unified training of medical and nursing staff, unified decoration of environment, unified configuration of equipment, unified standard of service, and unified price setting, and will face the public in the form of city-wide or even national chain community hospitals, and these new community hospitals will be included in the designated hospitals for medical insurance with government support. To provide safe, effective, convenient, fast, warm and humane services for the masses, so that the first choice of community hospitals become the active choice of the masses, so that patients can get standardized rehabilitation treatment out of their homes.
Stroke requires long-term effective prevention
Prevention of cerebrovascular disease is a long-term process and should not be a surprise. The four cornerstones of health should be mastered, i.e. reasonable diet, moderate exercise, smoking and alcohol cessation, psychological balance, plus regular special medical checkups.
I. Reasonable diet
People should develop the habit of reasonable diet, can often eat the following foods.
1. vegetables Leafy vegetables such as: cauliflower, cabbage, celery, Brussels sprouts, etc. Leafy vegetables can provide a lot of fiber, vitamins, trace elements, etc., which can prevent cardiovascular sclerosis. There are also spinach, lettuce, squash, zucchini, carrots, peppers, sweet potatoes, etc. These bright vegetables are not only rich in trace elements, vitamins and fiber, but also do not contain antioxidant biotin, which can lower blood lipids and prevent hardening of blood vessels. Commonly used soybean oil, canola oil or olive oil cooking, these vegetable oils are rich in unsaturated fatty acids, which can maintain normal cerebrovascular function.
Fresh fruits such as: apples, grapes, apricots, peaches, strawberries, tomatoes, etc. Fruits are rich in trace elements, vitamins, fiber and antioxidant biotin, which can help prevent cerebrovascular diseases.
3. Whole grains such as bread made of gluten-containing flour, brown rice, oatmeal, popcorn, etc. These foods contain a lot of fiber, which can lower LDL cholesterol and prevent cerebral vascular hardening.
4. low-fat or fat-free dairy products Low-fat or fat-free milk, low-fat cow’s milk cheese, and yogurt can reduce the risk of cerebrovascular disease. People who are not used to drinking milk can also consume soy milk, tofu, dried tofu, and fresh or dried beans. Beans contain a lot of vegetable proteins, lipids and fiber that are good for brain health.
5. Deep-sea fish such as tuna, salmon, sardines, swordfish, etc. Deep-sea fish is rich in unsaturated fatty acids and other nutrients, which is beneficial to the brain vascular health.
6. moderate amount of red wine red wine has the effect of reducing low-density cholesterol, moderate consumption can reduce the risk of cerebrovascular disease.
Second, one hour of exercise every day
Now comfortable life, people eat well, move less, so it is important to strengthen the exercise of daily life, at least one hour of exercise every day, the body’s excess fat consumption. Exercise can be brisk walking, cycling, swimming, etc., as long as it suits you.
Third, quit smoking and limit alcohol
Frequent smoking is a recognized risk factor for ischemic stroke, and its pathophysiological effects on the body are multifaceted, mainly affecting the systemic vascular and blood system, accelerating atherosclerosis, promoting platelet aggregation, lowering HDL levels, etc. Long-term passive smoking can also increase the risk of stroke. Drinking alcohol must be moderate, do not abuse alcohol, the daily alcohol content of men should not exceed 50g, women should not exceed 20g.
Maintain a healthy mind and good mood
Avoid the causes of stroke, such as bad mood, anger, excitement, overexertion, overexertion, excessive exercise, sudden sitting up, constipation, watching TV for too long, etc.
Five, regularly do special medical examination
Nowadays, people are more aware of medical checkups, but some problems are not easily detected during general checkups. Therefore, it is recommended to do special medical checkups, such as carotid ultrasound, in addition to blood lipid and blood sugar tests, to prevent stroke.
In conclusion, the threat of stroke to human life and health is very serious, and the burden on families and society is huge. If everyone can clearly understand its risk factors and actively prevent it, the incidence of cerebrovascular disease will surely drop significantly.