Fransisca Indraswari, MD

Feigin VL, Owolabi M, Hankey GJ, Pandian J, Martins SC. Digital Health in Primordial and Primary Stroke Prevention: A Systematic Review. Stroke. 2022.

The COVID-19 pandemic has shifted healthcare towards digital devices to compensate for less physical interaction, without compromising on the quality of patient care. Stroke care has typically been focused on secondary prevention and acute management, i.e., thrombolysis and endovascular, while there are not many studies on primary prevention. Primordial stroke prevention refers to the activities to avoid development of risk factors for stroke, whereas primary stroke prevention refers to activities to treat or reduce exposure to risk factors for stroke. Feigin et al. have provided a systematic literature review on how primary and primordial stroke prevention can be achieved through technology. The unprecedented growth of smartphone or other digital technologies is being used in almost every area of healthcare, offering a unique opportunity to improve primordial and primary stroke prevention at the individual level. The aim of the study is to provide current knowledge, challenges and opportunities of digital health in primordial and primary stroke prevention.

Feigin et al. searched Scopus, MEDLINE, and PubMed for reports published in English up to September 31, 2021, for the last 10 years using the title, abstract or keywords search terms “stroke,” ”transient isch(a)emic attack,” “cerebrovascular disease,” etc. In addition, they searched Apple Store, Google Play and Android Stores for primary stroke prevention applications on September 31, 2021, using keywords: stroke, brain attack, cerebrovascular accident. They excluded from the analysis digital tools and digital-based interventions in people with established stroke, transient ischemic attack or cardiovascular diseases (CVD).

The search for scientifically grounded mobile and webapp digital technologies specifically aimed at primary stroke prevention (including CVD where stroke was included as one of the outcomes) yielded 2,369 tools, of which only 20 met the inclusion criteria (for quality characteristics of digital tools for primary stroke and cardiovascular diseases). Although all apps were properly validated, the majority of the apps (18/20) provided mainly stroke/CVD prediction estimates, and only two apps (HeartScore and Stroke Riskometer) and one webapp (PreventS-MD) met most of the requirements for an ‘ideal’ mHealth primary stroke prevention tool. There is suggestive evidence of benefits of digital health interventions for blood pressure control, smoking cessation, behavioral patterns, physical activity and weight loss. However, conclusive evidence concerning the benefit of such interventions on stroke occurrence is lacking.

Although the idea of digital health application into primary stroke prevention seems promising, there are limitations that need to be addressed, such as lack of motivation and long-term engagement of the users (sustainability), lack of scientifically accurate and valid digital tools aimed at primary stroke prevention, inconsistencies among digital technology platform, challenges faced by not so tech-savvy elderly population, and finally ethical and legal challenges with privacy protection. Therefore, in this review, the authors have suggested criteria to assess the validity of the digital apps for primary stroke evidence, which include: scientific evidence, target population, scalability, interface usability, interactivity or engagement.

In summary, this is indeed an interesting systematic review, given that they are the first one to suggest criteria for “basic”, “advanced”, and “ideal” digital tools for primary stroke and cardiovascular disease prevention. There are a few limitations, as they mentioned: It lacks the inclusion of non-English digital app, and they also did not provide quantitative analysis of the identified digital tools. Though the idea of implementing digital health app on primary stroke prevention seems promising in terms of patients’ engagement into maintaining a healthy lifestyle, more studies need to be done in order to validate these tools and incorporate them in patients’ preventive care.