knowledge, service developments and research. It is estimated that there are 4.5 million deaths a year from stroke in the world and over 9 million stroke survivors. Almost one in four men and nearly one in five women aged 45 years can expect to have a stroke if they live to their 85th year. The overall incidence rate of stroke is around 2-2.5 per thousand population. The risk of recurrence over 5 years is 15-40%. It is estimated that by 2023 there will be an absolute increase in the number of patients experiencing a first ever stroke of about 30% compared with 1983. There is a total prevalence rate of around 5 per thousand population. One year after a stroke, 65% of survivors are functionally independent, stroke comprising the major cause of adult disability. Correspondence to. Dr Charles D A Wolfe. Department of Public Health Sciences, Guy^ Hospital, 42 Weston Street London SE1 3QD, UK The socio-economic impact of stroke is considerable world-wide, both in industrialised and non-industrialised countries. Stroke is assuming an increasing impact in terms of media attention, patient and carer knowledge, service developments and research. However, it still remains a 'Cinderella' specialty and is not apportioned relevant resources to allow effective services to be delivered equitably. This is despite considerable advancements in the evidence base to reduce the impact of stroke both in terms of prevention and treatment. Governments around the world have set conservative targets to reduce mortality from stroke, particularly in younger people, and the stroke physicians of Europe have set targets to reduce the impact of stroke over the next 10 years1 - 2 . The impact of stroke can be considered from several perspectives which are often overlapping: patients, their families and carers, primary care, acute hospitals and purchasers of healthcare along with policy makers. This chapter will provide an up-date on the impact of stroke focussing on areas that still require considerable attention. A useful description of how to assess the needs of a population for stroke by Wade3 has been drawn on for this chapter, as have the English intercollegiate guidelines for stroke4 . British Medical Bulletin 2000, 56 (No 2) 275-286 C The British Council 2000 Downloaded from https://academic.oup.com/bmb/article/56/2/275/303250 by guest on 17 April 2022 Stroke The disease Mortality The definition of stroke used in assessing its impact will be that used by the World Health Organization: 'a syndrome of rapidly developing clinical signs of focal (or global) disturbance of cerebral function, with symptoms lasting 24 hours or longer or leading to death, with no apparent cause other than of vascular origin'. This includes subarachnoid haemorrhage but excludes transient ischaemic attack (TIA), subdural haematoma, and haemorrhage or infarction caused by infection or tumour. It also excludes silent cerebral infarcts. It would appear that studies are likely to underestimate the total burden of cerebrovascular disease, the data discussed being mainly based on symptomatic stroke. There are a number of classifications of stroke, none of which are ideal. Routine National Health Service data utilise the International Classification of Disease (ICD)5 . A useful clinically-based classification has been developed by Bamford and colleagues in which prognosis is related to subtype of stroke, although this classification does not adequately describe the risk factors associated with the subtypes, which is important for secondary prevention6 . Mortality data are readily available, reasonably accurate with regard to stroke and used both to assess the overall need for stroke care and, increasingly, by policy makers as outcome measures of health services. When interpreting mortality data, it would be useful to have information on case-severity and incidence of stroke, both of which influence the mortality rate. The World Health Organization data (1996) indicate that deaths from circulatory diseases are among the world's commonest diseases killing more people than any other disease, and accounting for at least 15 million deaths, or 30% of the annual total, every year7 . Stroke accounts for 4.5 million of these. In the past, such diseases were thought of as affecting exclusively industrialised nations. However, as non-industrialised countries modernise, cardiovascular diseases are assuming importance, accounting for at least 25% of deaths, i.e. 10 million a year. Two-thirds of the stroke deaths occur in non-industnalised countries. There are an estimated 9 million stroke patients world-wide. In 1997, there were 57,747 deaths in England and Wales from stroke, with 2525 from subarachnoid haemorrhage5 . Stroke is the third most 276 British Medical Bulletin 2000,56 (No 2) Downloaded from by guest on 17 April 2022 The impact of stroke common cause of death in the UK after myocardial infarction and cancer and is consequently a focus for the UK Government1 . The target is to reduce deaths from stroke in the under 75-year-olds by two-fifths by 2010 and the White Paper outlines strategies to reduce impact, which include prevention and therapeutic interventions, often without supporting evidence. There are noticeable differences in the standardised mortality ratios (SMR) for stroke (i.e. mortality rates adjusted for age and sex differences in populations) between regions of Europe and in the UK specifically, ranging