No improvement in risk of stroke-related deaths

No improvement in risk of stroke-related deaths

Reported July 07, 2009

Heart attacks are down sharply in Canada and more people who have them are leaving hospital alive.

The stroke story isn’t so simple.

While stroke rates have fallen over the last five years, overall there has been no improvement in a person’s risk of dying within 30 days of being admitted for a “brain attack,” according to a new national report.

And despite growing calls on doctors to curb the use of cesarean sections to deliver babies, the nation’s C-section rate now stands at an all-time high, according to Canadian Institute of Health Information data. C-sections now account for nearly 28 per cent of deliveries in Canada.

The Canadian C-section rate increased 23 per cent over seven years — from 22.5 per cent in 2001-02 to 27.7 per cent in 2007-08.

In B.C. and PEI, more than 30 per cent of babies are now born via cesarean.

Overall, more than 78,000 C-sections were performed in Canada in 2007-2008, making it the single most frequently performed surgical intervention on Canadian women, according to CIHI.

Highlights of this year’s annual “health indicators” report include:

Heart attacks: The rate of Canadians being admitted to hospital with a heart attack is falling. Between 2003-04 and 2007-08, there was a 13-per-cent drop. (The rates don’t include Quebec because of differences in data collection.) Over the same time, the 30-day, in-hospital death rate from heart attack fell 11 per cent, and unplanned re-admissions to hospital after a heart attack decreased by one-third.

Overall, 49,220 Canadians were hospitalized for heart attacks in 2007-08. The rates were highest in Newfoundland and Labrador, and lowest in B.C.



Men had four times as many heart attacks as women between the ages of 20 and 44, but the gender gap shrinks with age: By age 65, men have only one and a half times more myocardial infarctions than women.

People in the poorest neighbourhoods were 66 per cent more likely to hospitalized with a heart attack than those in the richest neighbourhoods.

The report also reflects a dramatic shift in how doctors are restoring blood to dying heart muscle. Heart attacks result when blood vessels supplying blood to the heart are suddenly blocked. Angioplasty, a procedure that uses a balloon to open a clogged artery, and stents — tiny, cage-like tubes that keep arteries propped open — have become the favoured treatment for heart attacks over bypass surgery, where the chest is opened and blood vessels taken from other parts of the body are used to reroute blood around the blocked artery.

Over the past decade, the number of angioplasties performed in Canada has more than doubled, while cardiac bypass dropped 18 per cent. In 2007-2008, there were more than 36,000 discharges for angioplasty. Men were more likely than women to undergo angioplasty or bypass for heart attacks.

Stroke: Hospitalization rates fell 14 per cent between 2003-04 and 2007-08, according to the CIHI data. The in-hospital death rate for stroke improved only for patients aged 20 to 44, a 28-per-cent drop.

“But there are so few strokes in that age group that it doesn’t make a difference in the overall number,” says Helen Angus, vice-president of research at CIHI. The rate didn’t change for other ages and held steady at 18 per cent, or just about double the risk of dying in hospital from a heart attack.

“The important thing is that we are preventing people from having a stroke in the first place,” through lifestyle interventions such as quitting smoking and lowering blood pressure, says Dr. Frank Silver, a spokesman for the Canadian Stroke Network and professor of neurology at the University of Toronto.

“We are getting better at treating a stroke in progress and we’re especially better in reducing the severity of the stroke, the burden from the stroke in terms of the neurological deficit.”

And while the overall mortality rate hasn’t changed, “there is a lot of variation between hospitals” and designated regional stroke centres, Silver says. Stroke patients who are treated by a neurologist or neurosurgeon are 40 per cent less likely to die. But only a quarter of stroke patients in Canada were treated by a specialist last year.

“There’s a big push across the country to organize stroke care across the country,” Silver said.

He said it’s unfair to compare stroke with heart attacks. “They’re very different diseases. Stroke is clearly more devastating.”

Doctors are using potent clot-busting agents that run the risk of actually increasing mortality.

“What we’re showing is that we’re maintaining the same mortality, but improving the outcomes of those patients who survive,” Silver says. “There’s nothing worse than living with a stroke but being disabled and bed-ridden for the rest of your life.”

C-sections: In the 1960s, about five per cent of Canadian women delivered via C-section. Today, C-sections account for more than one-quarter of deliveries in Canada. Women who are older, obese, having their first child or expecting a multiple birth are more likely to have a cesarean section.

In Canada, the number of deliveries for older mothers is increasing. So, too, are multiple births, mainly because of increased use of fertility treatments. But other factors are driving the rates.

“There is an attitudinal difference between some care-providers. Some try as much as they can to assist women to have a natural, normal birth and there are some who don’t feel it’s as important,” says Dr. Jan Christilaw, president of B.C. Women’s Hospital and Health Centre.

That holds true for all of Canada, she says, and not just B.C., where the C-section rate was 31.3 per cent in 2007-08. The rate was 37.5 per cent in the greater Victoria area.

While life-threatening risks are rare, lethal complications such as blood clots are more common in women who have cesarean sections. The surgery also increases the risk of wound and bladder infections.

“Most C-sections that are done are done because they really are the best thing for mom and baby. I’m not trying to say that it’s always a negative thing,” Christilaw says.

“But if you can manage to have a normal delivery, and do it safely, you will have better outcomes and better complications than if you have to resort to cesarean sections.”

Hip fractures: About 10 to 20 per cent of people who break a hip die within six months, 50 per cent are unable to walk without assistance and 25 per cent require long-term home care. Elderly women suffer 80 per cent of broken hips.

The hip-fracture rate dropped 21 per cent over the 10-year period ending 2007-08. But waits for hip-repair surgery have increased, with fewer patients getting surgery on the day of admission to hospital, or the next day.

Knee replacement rates increased by 83 per cent over the same period, with the fastest growth (128 per cent) in 45- to 54-year-olds. That group also saw the highest increase (66 per cent) in hip replacements.

One of the biggest declines was in preventable hospitalizations, “things like diabetes or hypertension complications that actually could, and probably should be managed in the community,” Angus says. The rate dropped by 29 per cent from 2001-02 to 2007-08.

Source : Canwest News Service