Author: Edward S. Cooper, Philip B. Gorelick, Richard Frank Gillum
Date Released: 1998
Page Count: 230
Isbn10 Code: 3805567138
Isbn13 Code: 9783805567138
From The New England Journal of Medicine Behind the straightforward and simplistic title of this slim book lies comprehensive and up-to-date information regarding an important and unresolved problem: the high incidence of stroke in black persons. The subtitle, A Guide to Management and Prevention, summarizes the goals of the editors in organizing this important multiauthored book. In the introduction and overview, Kuller distills, in typically succinct and insightful fashion, a tremendous amount of epidemiologic, pathophysiologic, and interventional observations germane to the topic. Indeed, the beauty of all of the chapters is their brevity, which permits rapid reading and easy digestion. The book has three sections -- "Pathophysiology, Clinical Presentation, and Diagnosis," "Epidemiology and Primary Prevention," and "Acute Treatment, Secondary Prevention, and Rehabilitation" -- followed by an epilogue on directions for future research. Among the chapter authors are the three editors, all of whom are experts in various aspects of this problem, and leading researchers in specific areas of the field. Some may question the need for a book on this topic and ask why stroke in blacks differs from stroke in other groups. Although no qualitative differences have been identified, the frequency and severity of stroke are greater and the age of onset earlier in blacks, and the predisposing risk factors are well known and amenable to intervention. Moreover, there is evidence for differences between blacks and whites in the occurrence of intracranial and extracranial atherosclerosis. In addition to covering these issues, this book compares stroke among American blacks with that among non-American blacks, a comparison that suggests that a variety of factors may account for differences in the frequency of stroke among blacks in various parts of the world. The single most frequently identified risk factor for stroke in American as well as non-American blacks, however, is hypertension. The incidence of stroke from cardiogenic causes (specifically, embolism) appears to be lower among blacks than among whites, whereas the rates of stroke from intracerebral hemorrhage, subarachnoid hemorrhage, and lacunar infarction appear to be greater among blacks. Several authors emphasize different aspects of the paramount role of high blood pressure in stroke and discuss the increased frequency and inadequate treatment of hypertension in blacks as major causes of the increased risk of stroke. Estimates indicate that hypertension is responsible for as many as 70 percent of strokes, with age, smoking, and diabetes important as contributing factors. Recent studies have demonstrated the importance of reductions in systolic pressure alone for decreasing the risk of stroke in elderly persons. The contributory role of diabetes mellitus is discussed by Johnson, who indicates that the effect of strict glycemic control on the risk of stroke in persons with diabetes is uncertain. Recent data from the United Kingdom Prospective Diabetes Study, which were not available at the time that this book was prepared, provide evidence of the benefit of "tight" glucose control in reducing the risk of stroke in persons with diabetes and suggest that there is a 90 percent greater reduction in the incidence of stroke with "tight" control of blood pressure. These findings strongly identify blood pressure as a major risk factor for stroke and, in combination with previous observations, mandate aggressive reduction of blood pressure in persons at risk. There are also socioeconomic factors that contribute to stroke in blacks and that act as barriers to effective treatment and prevention. Indeed, primary prevention is a recurring theme throughout this book, driving home the necessity of identifying preexisting risk factors and of intervening appropriately. Issues addressed include limited access to health care, low use of high-cost procedures, delays in obtaining medical care, and limited access to rehabilitative services. Two chapters merit attention for their excellence and erudition. One is a chapter on the treatment of ischemic stroke by Friday, Cooper, and Mignott, which I consider to be a "must read" for anyone who sees patients with stroke. This chapter includes new recommendations on the use of tissue plasminogen activator, a discussion of investigational drug trials, and a lucid commentary. Schneck, Chaturvedi, Thompson, and Gorelick present an erudite discussion of antiplatelet and anticoagulant studies, although little information pertaining specifically to blacks is available. This information will be useful for decisions regarding drugs and doses both for treatment of acute stroke and for secondary prevention. This is an excellent, easily perused book that will be useful to anyone interested in stroke in general and in blacks specifically. The importance of primary prevention is a message that emerges resoundingly. Reviewed by Myron H. Weinberger, M.D. Copyright © 2000 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
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