The Afro-Caribbean (AC) population of Martinique, a French Caribbean island, was found to have a high prevalence of vascular risk factors in a stroke epidemiology study conducted in 1998-1999 (ERMANCIA I). This led to initiation of community-based prevention strategies and a follow-up study using the same methodology (ERMANCIA II) was completed 13 years later (2011-2012). This program involved a large number of local healthcare professionals, both specialists and general practitioners, focusing on patient education regarding health behaviors (diet, physical activity) and engaging patients in tracking their risk factors (blood pressure, blood glucose). A dedicated stroke unit was also formed in 2003 at the local University Hospital of Fort de France.
In this article, Olindo et al evaluated this implementation program. In both ERMANCIA I and II, a comprehensive approach to determination of every stroke by a thorough evaluation of all hospital records and community resources was completed. Patient demographics, vascular risk factors, stroke subtypes, and outcomes were tracked.
The population of Martinique was stable between the study periods (380,000-390,000 people), and the majority is AC. First-ever stroke was identified in 544 AC patients during the ERMANCIA II study period, compared to 580 in 1998-1999. The age-standardised rates significantly decreased by 31% overall between the two evaluations (26% in males, 34% in females). Though the stroke rate of older people declined, a significant increase in those in a 35-44 year age group was noted, with an incidence rate ratio [IRR] 2.25 (95% confidence interval of 1.07-3.70). Frequencies of pre-morbid dyslipidemia, smoking, and atrial fibrillation were significantly higher in the 2011-2012 period; hypertension, diabetes, alcoholism, and coronary disease frequencies remained unchanged. When looking at subtypes, only ischemic stroke was found to be (statistically) significantly reduced over time, and only in women. Overall, the 30-day case-fatality ratio did not change, but the proportion of patients with a good outcome at 1 month (modified Rankin score ≤2) was significantly higher in ERMANCIA II (47% vs. 37.6% in 1998-1999, p=0.03). Along with decreasing stroke incidence, a stable high prevalence of hypertension and diabetes as well as increased proportion with dyslipidemia and tobacco use was found over the two time periods.
There were clearly limitations and challenges – the authors pointed out a lower proportion of patients evaluated by phone or from next of kin reports in ERMANCIA II compared to I. A noted decrease in the proportion of lacunar infarction could partly be explained by change in principal neuroimaging modality, from CT to more extensive MRI use in 2011-2012. This report describes stroke incidence in two periods of time; we cannot get an extensive understanding of the temporal trends. Nevertheless, there is a lot that can be learned from this work, which should be improved and emulated more extensively. It demonstrated that, even within this particular ethnic cohort, an increased stroke incidence was found in males compared to females aged 55-74 years. Just as is occurring elsewhere, the disturbing trend of increased smoking and obesity is contributing to higher stroke rates in younger population groups in Martinique.
This manuscript is another demonstration of the fact that efforts targeting prevention and appropriate management of stroke patients (patient education, dedicated stroke unit care) can reduce its incidence and improve outcomes. Further reduction of stroke incidence in Martinique will need to include addressing tobacco use and medication noncompliance in more effective ways. Much more can still be done. As shown in this report, large-scale epidemiology studies that track a condition, with its risk factors (and facilitators/barriers to addressing them), over time can be very powerful. If we were able and willing to do this for stroke in a coordinated manner at various levels (in a given city/state/country, regionally and even internationally), we could accelerate progress in addressing the enormous burden of cerebrovascular disease. Much can be learned from not only tracking health metrics (including risk factors, care quality, costs, and outcomes) over time, but also by comparing regions/populations where progress is being made and where it is not.
