In conversation with Adel Alhazzani, vice-president of MENA Stroke Organization; professor of neurology, consultant and vascular neurologist, Neuroscience Center, Section of Neurology, King Faisal Specialist Hospital and Research Center, Riyadh.
The way that the medical community in the Arab world has dealt with stroke can largely be summed up by one phrase: “falj la tuealij”, which loosely translates to “helpless case”, so says Adel Alhazzani, vice-president of the MENA Stroke Organization, professor of neurology, consultant and vascular neurologist at King Faisal Specialist Hospital and Research Center in Riyadh, the Saudi Arabian capital. Dr Alhazzani has dedicated the past two decades of his career to stroke-related advocacy and trying to alleviate the growing burden of stroke in the Middle East and North Africa (MENA) region.
According to the American Heart Association (AHA), over 80% of strokes are preventable.1 One major contributor to the global stroke burden is atrial fibrillation (AF), a common heart-rhythm abnormality. The risk of experiencing a stroke is up to five times higher in people with AF, and strokes related to AF are associated with greater disability and a higher rate of mortality. The asymptomatic nature of AF also means that, for many, stroke is the first sign of AF.2
A soaring and somewhat preventable epidemic
Stroke is the second highest cause of mortality in Saudi Arabia, and both incidence and mortality related to stroke are expected to double from 2014 levels by 2030. The soaring burden of stroke is primarily driven by a combination of an ageing population and the high prevalence of vascular and other risk factors, including hypertension, diabetes, obesity and tobacco use.3
Ageing is the leading risk factor for stroke, and approximately 75% of all strokes occur in individuals aged over 65 years.4 “We are relatively lucky that we still have a young population,” says Dr Alhazzani. Over 60% of the Saudi population is under the age of 30, meaning that there is an opportunity and urgent need to implement policy and initiatives today to mitigate the burden of stroke.5 “Low levels of awareness, access to care and access to effective treatment are among the biggest challenges contributing to the rising stroke epidemic,” says Dr Alhazzani.
Stroke is the leading cause of death and disability globally, accounting for approximately 34% of total healthcare expenditure. Although there are limited data available for the MENA region, the mean lifetime healthcare cost per stroke patient is estimated at over US$140,000 in the US.6 Yet, this is likely to be an underestimation, as Dr Alhazzani explains: “These figures leave out the wider socioeconomic burden associated with stroke survivors, in terms of unemployment and caregiver needs.”
Development of stroke care in Saudi Arabia
The development of stroke care in Saudi Arabia has been slower than that of other developed countries. Currently, 90% of patients receive care at non-specialised stroke hospitals, resulting in sub-optimal patient management.7 The Health Sector Transformation Programme and the development of care systems under the new Model of Care programme, as part of the national Vision 2030 development plan, have improved stroke awareness and care over the past decade.8 This includes developing a telemedicine-based stroke programme and SEHA Virtual Hospital, which improves access to stroke treatment, especially in remote areas.9
"We have established national standards for stroke care, leading to improved access to treatment,” says Dr Alhazzani. “Patients are also more aware of stroke symptoms and risks, though there is still much work to be done.”
An economic model assessing the development of a stroke care programme in Saudi Arabia shows that improved access to more effective treatments and strengthening resources and capacity in hospitals specialising in stroke management could lead to improved patient outcomes and cost savings of over US$600m over 15 years.7
Enhancing stroke prevention and management
“As my role is in acute care, we are often just dealing with the tip of the iceberg,” says Dr Alhazzani. He adds that the real low-hanging fruit in terms of preventing the anticipated surge in the burden of stroke lie in improving awareness and prevention of stroke and addressing the progression of conditions that increase the risk of stroke—including AF, diabetes and hypertension.
Awareness: “Public awareness is key,” says Dr Alhazzani, stating that AF and stroke are discussed much more in other developed countries owing to their populations' advanced age. However, the onset of both stroke and AF happens earlier in the Saudi population, meaning that awareness and health promotion initiatives need to target younger populations.3,10
Prevention: Primary prevention interventions for stroke include addressing modifiable risk factors such as unhealthy diet, physical inactivity and tobacco use, and ensuring that patients with AF, hypertension and diabetes manage their condition.11 “Poor treatment adherence is a particular challenge that increases the risk of stroke,” says Dr Alhazzani, explaining that prevailing stigma around lifestyle-related conditions like diabetes and hypertension means that many patients do not have adequate control over their condition. Many AF patients also do not recognise that they are at high risk for stroke and, therefore, do not adhere to stroke prevention and therapy.12 “We need a stroke prevention strategy that includes screening for vascular risk factors, prompt treatment and integration within the current patient pathways of the model of care,” says Dr Alhazzani.
Primary care: Primary care physicians have a pivotal role in stroke prevention, including educating patients about lifestyle interventions and treating noncommunicable diseases that elevate stroke risk. They often provide long-term care for stroke survivors. “Increasing awareness in the primary care setting and emphasising the guidelines and clinical practices is essential to promoting proactive management of high-risk populations,” says Dr Alhazzani.
Data: "While we have data on stroke at regional and institutional levels, often this data sits in silos,” says Dr Alhazzani. “There is an urgent need to develop the national stroke registry.” Accurate data on the burden and impact of stroke will make the case for investment in stroke prevention and management.
Read more about policy pathways to mitigate the rise of atrial fibrillation in Saudi Arabia here
References
[1] Spence JD, Azarpazhooh MR, Larsson SC, Bogiatzi C, Hankey GJ. Stroke Prevention in Older Adults: Recent Advances. Stroke. 2020 Dec;51(12):3770-3777. doi: 10.1161/STROKEAHA.120.031707. Epub 2020 Oct 30. PMID: 33121384.
[2] Yang SY, Huang M, Wang AL, Ge G, Ma M, Zhi H, et al. Atrial fibrillation burden and the risk of stroke: A systematic review and dose-response meta-analysis. World J Clin Cases. 2022;10(3):939-53.
[3] Basri R, Issrani R, Hua Gan S, Prabhu N, Khursheed Alam M. Burden of stroke in the Kingdom of Saudi Arabia: A soaring epidemic. Saudi Pharmaceutical Journal. 2021;29(3):264-8.
[4] Yousufuddin M, Young N. Aging and ischemic stroke. Aging (Albany NY). 2019 May 1;11(9):2542-2544. doi: 10.18632/aging.101931. PMID: 31043575; PMCID: PMC6535078.
[5] The World Bank. Population estimates and projections.
[6] Rochmah TN, Rahmawati IT, Dahlui M, Budiarto W, Bilqis N. Economic Burden of Stroke Disease: A Systematic Review. Int J Environ Res Public Health. 2021 Jul 15;18(14):7552. doi: 10.3390/ijerph18147552. PMID: 34299999; PMCID: PMC8307880.
[7] Al-Senani F, Al-Johani M, et al. A national economic and clinical model for ischemic stroke care development in Saudi Arabia: A call for change. Int J Stroke. 2019 Oct;14(8):835-842. doi: 10.1177/1747493019851284. Epub 2019 May 23. PMID: 31122171; PMCID: PMC6823921.
[8] Chowdhury S, Mok D, Leenen L. Transformation of health care and the new model of care in Saudi Arabia: Kingdom's Vision 2030. J Med Life. 2021 May-Jun;14(3):347-354. doi: 10.25122/jml-2021-0070. PMID: 34377200; PMCID: PMC8321618.
[9] Arab News. Saudi Health Ministry to provide remote treatment for stroke patients. 2022. https://www.arabnews.com/node/2208396/saudi-arabia
[10] Hersi A, Abdul-Moneim M, Almous'ad A, et al. Saudi Atrial Fibrillation Survey: national, observational, cross-sectional survey evaluating atrial fibrillation management and the cardiovascular risk profile of patients with atrial fibrillation. Angiology. 2015 Mar;66(3):244-8. doi: 10.1177/0003319714529180. Epub 2014 Mar 31. PMID: 24687415.
[11] Tai WA. Stroke: Primary Prevention. FP Essent. 2022 Jan;512:11-17. PMID: 35006660.
[12] Al-Shamiri M, Arafah D, Althabit N, Alahmari M, Amlih H, Qadrah B, et al. Perception, Knowledge and the Awareness among Saudi Atrial Fibrillation Patients about Their Disease and Its Stroke Risk. Indian Journal of Applied Research. 2017;VOLUME 7:593.
