The leading opinion of Morgenstern and Smith, addressing the issue of priorities of stroke research in a global context, raises a number of important questions:
- Should prevention be the number one priority?
- What emphasis should be placed on improving stroke outcomes?
- What is the best environment in which stroke research can be realized?
These questions need to be put in the context of stroke being the second most common cause of death globally (primary cause of death in many parts of the world) and yet a research capability well below that of the better known disease categories of heart disease and cancer.
Intuitively, one would always like to have more resources directed toward disease prevention. However, this goal, in the face of the minimal resources available seems unrealistic.
In reality, we have an ideal research capacity in the form of stroke units to improve outcomes given the strong evidence base for their efficacy. Fortunately, there is a global push to make stroke units universally available.
By integrating the practical stroke unit management with pragmatic and relatively low cost clinical research programs, a halo effect of expertise in acute management, secondary prevention, and even primary prevention tends to occur. Hence, promotion of research using stroke units as the fundamental tools would seem to be a pragmatic approach. This does not preclude a focus on primary stroke prevention pursue. As eloquently argued by Morgenstern and Smith, stroke prevention needs to be a global initiative, particularly with developing countries where epidemiological transition is fast occurring.
The importance of identifying new risk factors for stroke was emphasized by the recent INTERSTROKE study, which gave us new evidence to test hypothesis about risk factor control and stroke incidence reduction. Ongoing and planned studies of salt reduction, use of antiplatelet agents in the elderly, etc., are just some examples of this research direction.
Priorities in stroke research have been established by a number of organizations such as the National Institutes of Health (NIH) and were part of the original Helsingborg Declaration. Given that priorities may vary in differing global regions, the setting of such priorities by organizations such as European Stroke Organization, the American Heart Association, and the more recently formed Asia Pacific Stroke Organization would be a powerful political statement. Similarly, a global view put forward by the World Stoke Organization, in collaboration with the World Health Organization, would set a global benchmark to which individual countries could aspire.