It was with great interest that we read the article by Martínez Fernández et al.1 illustrating a relevant problem with emergency neurological care for stroke.
It is well-known today that providing specialised neurological care, especially in stroke units, significantly decreases mortality in stroke patients. Incorporating these units into local health systems is highly recommended, especially in Andalusia. Nevertheless, several comments should be made about this study. First, it contains major methodological problems that limit the validity of its results. The study compares 2 completely (and significantly) different populations, one with a mean age of 65, and the other with a mean age of 77. As the article points out, age and associated comorbidities are fundamental prognostic factors. Regarding the different types of strokes, it is striking that there were no deaths among the 13 cases of intracerebral haemorrhage in the first group, whereas 3 out of 4 died in the second group. This shows that risk levels were clearly different and that patient assignment to one group or the other was not random. Measuring stroke severity using a retrospective analysis of patient medical histories and the modified Rankin scale does not appear to be a suitable method. Lastly, performing a multivariate analysis that includes numerous subgroups and a sample size of approximately 50 patients per group also seems questionable.
Secondly, Spain's ‘stroke belt’ refers to specific geographic areas, and mainly Andalusia and Murcia.1,2 In these regions, as in the south-eastern United States, we find high rates of stroke mortality in areas which also show higher mortality rates due to coronary artery disease and heart failure. It is obvious that hospital care, as we have stated, plays a part in mortality, but we probably should also be searching for other causes outside of our healthcare centres. For example, we might examine conditions in schools, households, and municipalities, years before a patient's stroke occurs. Numerous studies have been carried out in the United States, where there is true concern for examining the causes of regional differences. The latest study of 30 239 subjects, named Reasons for Geographic and Racial Differences in Stroke (REGARDS), shows that only a small percentage of the increase in stroke is due to traditional risk factors, and that socioeconomic and health conditions during an individual's adolescent years will play a key part in increased stroke incidence and mortality.3,4
In any case, applying measures that will decrease stroke mortality must be a goal for everyone, including the health authorities.
Please cite this article as: Castilla Guerra L, Álvarez Suero J. La atención urgente al ictus en el «Cinturón del ictus» español. Neurología. 2014;29:185–186.
