In the western world, stroke is the third commonest cause of death (after heart disease and all cancers), is probably the commonest cause of severe disability,1,2 and accounts for a large proportion of healthcare resources. Its impact on individual patients, their families, and society as a whole is immense. About 200 people per 100 000 population will have a first ever stroke every year.3 Their mean age is about 72 years and men and women are affected in roughly equal numbers. Despite the uncertainty over whether stroke incidence is rising, falling, or remaining static,3,4 the absolute number of patients is likely to increase, as incidence increases with age and most populations are ageing.

Stroke has in the past held a low priority for many professional groups; in 1988 the King's Fund Forum concluded that hospital, primary care, and community services for stroke in the United Kingdom were "haphazard, fragmented and poorly tailored to the patients' needs".5 However, increasing awareness of the impact of stroke has led to it being identified as a priority for improving services and research.6,7 Numerous well conducted randomised trials and systematic reviews of medical and surgical treatments for acute stroke, as well as primary and secondary prevention strategies, mean that we are now considerably better equipped to know which treatments work and which should be abandoned and what sort of services we should be providing for our patients.

In this chapter, we will describe our approach to the management of acute stroke, focusing mainly on the first few days. Although the WHO definition of stroke (see below) includes subarachnoid haemorrhage, we will not consider this distinct syndrome further, as it is covered in detail elsewhere in this book. Our approach is based on our interpretation of the available evidence, with particular emphasis on randomised controlled trials and systematic reviews, since we believe that these provide the most reliable data on the risks and benefits of treatments. However, where such evidence is either absent or insufficient (and despite the many welcome advances, there is still much we do not know for sure), we will describe what we do in routine practice. We accept that other interpretations of the evidence are possible and are likely to be influenced by the context in which one works. For example, in the United Kingdom, unlike some other countries, our patients tend not to demand "treatment" (whether of proven benefit or not), "fee for service" is rare, and the resources available for health care are restricted so that only cost effective treatments will be advocated for widespread use. Lastly, although rehabilitation and secondary prevention are not the focus of this chapter, it is important to emphasise that for many patients, their management after the acute stage currently has the greater impact on their lives. With the advent of new acute strategies, this balance may change.

Your Heart and Nutrition

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