Professor Urs Fischer, secretary general of ESO, underlines some of the challenges involved in boosting stroke treatment and prevention in Europe today.
The European Stroke Organisation (ESO) is a pan-European society of stroke researchers and physicians, national and regional stroke societies, and lay organisations founded in December 2007. ESO is a nongovernmental organisation comprised of individual and organisational members. The aim of ESO is to enhance the treatment and care and to reduce the burden of stroke by changing the way that stroke is viewed and treated. This can only be achieved by professional and public education and by enabling institutional changes. By offering and sharing best practice approaches, ESO’s goal is to harmonise and enhance stroke management in Europe. ESO works as the voice of stroke in Europe to bring about political change. ESO focuses on European level projects while also working toward global solutions.
Pan European Networks asked Professor Urs Fischer, ESO’s secretary general, for his thoughts on some of the challenges involved in boosting stroke treatment and prevention in Europe today, as well as why it is important for stroke to no longer be classified as a cardiovascular disease (CVD), but a brain disease.
Why is it important for stroke to be classified as a brain disease?
Classifications of diseases have a major impact on who cares about a specific disease. Stroke affects the brain and is therefore a brain disease. Many patients who have experienced a stroke often go on to have neurological sequelae, such as a cognitive disability (i.e. dementia) or seizures, etc. This demonstrates that stroke primarily affects the brain, and while the blood vessel – in this instance supplying blood to the brain – is also affected, this is also the case with numerous other diseases which aren’t classified as a cardiovascular disease because it is the organ in question which receives the majority of the impact (an affection of the arteries of the kidney is also classified as renal and not cardiovascular disease). And yet, stroke has actually been classified as a CVD, which is not appropriate.
What was the impact of the 2016 decision by the neurology and circulatory topic advisory groups to return the cerebrovascular block to the Vascular Chapter in the WHO’s International Classification of Diseases?
People have realised that stroke is one of the leading causes of death, not only in Europe but globally, and people have become aware that stroke is one of the, if not the, most important causes of early disability.
Despite these facts, however, stroke care and stroke research is clearly underfunded, and while healthcare organisations care about cardiac diseases or cancer, stroke often becomes sidelined. It is, therefore, crucial that stroke becomes a much higher priority on the political agenda of both politicians and healthcare institutions, because patient care and research is fundamental to the future fight against this terrible disease.
It is interesting to note that in acute stroke therapy, currently thrombolysis and other treatments are highly effective. Yet there are simply not enough stroke centres providing the new treatment modalities, which is a major problem. These therapies are not only highly beneficial for the patient and his relative, they are also highly cost-effective.
Health inequalities have a significant impact on stroke treatment in Europe today. How would you characterise this, and how do you feel it can – begin to – be addressed? How important is a more holistic approach amongst relevant stakeholders to enhance the availability of therapies?
Treatment should always start with prevention, and if you look at Europe, there are huge inequalities with regard to both treatment and prevention. The prevalence of hypertension in different European countries, for instance, is huge, particularly when one compares eastern with western European countries. Moreover, while incidences of hypertension are higher in the east of Europe, this is compounded by the fact that the number of patients treated for hypertension is much lower.
It is therefore understandable that in these countries, incidences and prevalence of stroke are much higher but at the same time treatment possibilities are also much lower. We therefore have to find a way to address these inequalities. In order to succeed there is a need to change the whole system, not just a single part of the chain – it is not enough to only build stroke units or stroke centres; you also have to establish stroke prevention programmes.
Additionally, it is also important to make governments aware of just how cost-effective it is to prevent stroke, as well as how to treat stroke more effectively and efficiently.
In addition to a quite startling lack of preventive strategies, there also appears to be barriers to the approval of new therapies and medical devices. What more could be done in Europe to boost clinical trials etc. and get things from bench to bedside?
We need to focus on how we can improve clinical trials in Europe. One of the main issues I have experienced myself in the trials I am involved in is the fact that when you should work across borders you are required to comply with a different set of regulations and ethical policies and have to deal with different regulatory boards. There is a real need for harmonisation at the European level. As such, the European Stroke Organisation is now heading up the Trial Alliance, where we attempt to address those problems.
Another significant issue is funding – it is extremely difficult to gain the required funding for a stroke trial, not least because we have to compete with so many other fields. And while there are funding instruments at the European level – such as Horizon 2020 – for us, the opportunities are few – and, of course, a clinical trial costs millions of euro.
Finally, although the industry will sometimes conduct – and pay for – clinical trials, there is still a need for independent research to be carried out on the drugs that have been developed, and, currently, much of that is missing.
Where would you like to see priorities focus moving forwards – catheter-based therapy, for instance?
The funding that is available should be spent on the areas where we will have the biggest impact. At the moment, there are numerous unanswered but important questions. One example of the most important concerns is the timeframe in which anticoagulants can be used by clinicians once a patient has had a stroke. For many of these unanswered questions, we still do not know how long we have to wait. In this case – the pivotal trials included patients later than two weeks after symptom onset and, therefore, recommendations advise a waiting period of at least two weeks, which is, essentially, too long. There is an urgent need for independent research into the efficacy and safety of these drugs so that they can be used at the right time and deliver the best benefit possible.
Professor Dr Urs Fischer, MD MSc
Extraordinarius for Acute Neurology and Stroke
Co-Chairman, Stroke Centre Bern
Co-Director, Clinical Trial Unit Bern
Secretary General, European Stroke Organisation
This article will appear in Pan European Networks: Science & Technology issue 24, which will be published in September, 2017.