There is a Public Health England TV advertisement from almost a decade ago which had the tagline “The faster you act, the more of the person you save.” The ad, which was a part of an award-winning stroke campaign, showed the public the signs and symptoms to look out for to identify someone suffering from a stroke.
The message was clear: the sooner people received medical attention, the better their chances of a good recovery.
Stroke is a medical condition that occurs when there is a blocked artery or burst blood vessel leading to reduced blood flow and oxygen supply to the brain. There are two types of strokes, ischaemic and haemorrhagic stroke.
Common symptoms include weakness or the inability to move on one side of the body (hemiparesis), vomiting, drowsiness, headaches, and loss of consciousness. These can often go unrecognized as stroke symptoms. As a result, a person suffering from stroke may be delayed in accessing treatment or not be treated at all.
Ten percent of the 55 million deaths that occur every year worldwide are caused by stroke. It is also the 6th leading cause of serious long-term adult disability.
It has been estimated that the incidence of stroke in Malaysia is more than 40,000 annually. It is responsible for at least 11,680 lives to be lost or 10.7 per cent of total deaths each year. The general incidence of stroke increased three-fold from 2010 to 2014. It was among the top 5 causes of hospitalization from 2012 to 2019. Estimates by the Institute for Health Metrics and Evaluation indicate that stroke represents the third leading cause of mortality in Malaysia.
The risk factors for stroke are similar to those for coronary heart disease: hypertension, high cholesterol, and diabetes. Lifestyle factors include unhealthy diets, sedentary or low physical activity, obesity, and smoking.
A growing emergency
Combined with analysis from the “Monitoring Stroke Burden in Malaysia” project and data from the Ministry of Health’s National Stroke Registry (2009-2016), the picture of stroke in Malaysia is alarming.
On average, 92 stroke admissions occurred daily across healthcare facilities nationwide. Men were predominantly affected (56 per cent). The profile of newer cases appear to be increasingly younger where 40 per cent of stroke patients were below the age of 60. Almost 32 people died due to stroke each day.
The Global Burden of Disease Report 2016 projected that by 2040, stroke would become the second leading cause of mortality, with one in four Malaysians expected to suffer from this condition. It is already a major cause of disability for adults here.
Therefore, stroke is a disease of immense public health importance with serious economic and social consequences. Based on 40,000 stroke admissions per year, the cost of stroke management is estimated to be around RM 213 million annually.
To be afflicted with this condition is often a devastating and life changing event as many stroke patients end up with permanent disability. However, with timely and efficacious treatment, it is possible to significantly reduce its severity, bringing hope of a better recovery.
Providing effective treatment within the first 60 minutes of a stroke is a key objective. Known as the “golden hour”, the intention is to minimise disability as well as severe and permanent deficits. Therapies such as thrombolysis are used to break-up blood clots up to 4.5 hours from the first onset of symptoms.
Failure or delay in getting treatment could result in large portions of the brain becoming affected, brain cells being deprived of oxygen, and die. This could lead to the person dying a few days later, which happens in 80 per cent of cases.
While significant improvements have been made to stroke care in Malaysia over the past decade, saving lives and reducing the impact of stroke for many, it is still dependent on awareness of both the public and healthcare professionals to recognise the signs and symptoms of stroke. Rapid recognition of the condition allows for the possibility of it being treated rapidly.
Studies found that only 21 per cent of stroke patients were able to be treated at a medical facility within 3 hours of the onset of symptoms. The median time was at 7 hours or more. Delays were caused by lack of awareness and recognition of stroke symptoms.
It remains crucial that doctors treat stroke patients as early as possible.
The Malaysia Stroke Council and the National Stroke Association Malaysia (NASAM) recommends using the B.E.F.A.S.T formula to check for the most common symptoms of stroke.
Time is of the essence in achieving good outcomes for stroke. The public has a major role in ensuring that stroke is recognised as a medical emergency and that it is necessary to seek help quickly.
Patients who were delayed in receiving treatment and deteriorated required more medical support and nursing assistance, attended outpatient therapy more frequently, and were more likely to seek alternative therapies.
Therefore, ensuring that a person is able to obtain an early accurate diagnosis and have access to timely and efficacious treatment after prompt referral to an appropriate medical facility, is critical.
In 2012, thrombolytic therapy was first approved for use in Malaysian public hospitals. Today, while there are 71 hospitals nationwide (37 and 34 in the public and private sectors respectively) having thrombolysis service, only 10 public hospitals currently provide full access to this treatment through Acute Stroke Units (ASU) which operate 24-hours, 7 days’ a week. Data from the National Stroke Registry also showed that only 0.65 per cent of stroke patients were treated with thrombolysis.
Unfortunately, the current state of stroke management in Malaysia is still considered suboptimal and there is room for improvement. Major hospitals in each state should have at least one “stroke ready” ASU to ensure that such time-critical services are within reach of those who need it. Malaysia has the potential to provide this, and the capacity to improve and enhance existing services.
Improved stroke care and better outcomes
Recent advances in thrombolysis and thrombectomy have shown a strong impact on such treatments restoring function and saving the lives of acute stroke patients.
The stroke incidence in low-income and middle-income countries (LMICs) such as Malaysia has more than doubled over the past four decades. However, it has declined by 42 per cent in high-income countries within the same period. These gains have been mainly due to improved access to appropriate health care and treatment.
Providing the best care in treating stroke requires investing in strengthening links in a chain of survival and better outcomes.
A recent White Paper produced by the Galen Centre for Health and Social Policy on stroke care in Malaysia highlighted the improvements and investments needed in existing stroke management.
This includes increasing public education to improve identification of stroke; increasing the number of neurologists and related multi-disciplines managing stroke cases; improving access and coverage oof thrombolytic therapy; establishing stroke care teams in each hospital and increasing the availability and improving existing rehabilitation services.
Stroke remains one of this country’s greatest health challenges. However, Malaysia has within its means and the opportunity to transform people’s outcomes and experiences of stroke.
Addressing the gap in the provision of acute stroke services, particularly ensuring that efficacious treatment is available and provided during the critical 4.5 hours, will save lives, improve outcomes, and reduce the overall cost of stroke, to society, the economy and most importantly, the individual.