Stroke

If you only read four things:

  1. 80% of strokes can be prevented.
  2. Treatment of risks like hypertension and atrial fibrillation could prevent 10% of first strokes.
  3. Suffolk is one of the best performing counties in England for survival rates of under 75s.
  4. Almost two thirds of stroke survivors are left with a disability.

Key Points

Stroke is a brain injury caused by sudden interruption of blood flow. It can cause cerebral infarction (death of some brain tissue) and death. There are two main types of stroke:

  • Ischaemic (85% of cases1) - caused by a blockage (blood clot) in an artery carrying blood to the brain. The likelihood of this type of stroke increases with age.
  • Haemorrhagic – caused by a burst in a blood vessel leading to bleeding into the brain.

An episode where stroke symptoms and signs resolve themselves within 24 hours is known as a Transient Ischaemic Attack (TIA) or ‘mini-stroke’2.  

Data is provided for the Clinical Commissioning Groups (CCGs) that cover Suffolk,  as well as for North East Essex CCG, as it is part of the Integrated Care System (ICS) that covers most of Suffolk:

  • Great Yarmouth and Waveney CCG (GYWCCG) – part of Norfolk and Waveney STP
  • Ipswich and East Suffolk CCG (IESCCG) – part of Suffolk and North East Essex ICS (SNEE ICS)
  • West Suffolk CCG (WSCCG) – part of Suffolk and North East Essex ICS (SNEE ICS)
  • North East Essex CCG (NEECCG) – part of Suffolk and North East Essex ICS (SNEE ICS)

The numbers

Prevalence

In 2018/19, 25,053 patients were recorded on GP registers as having stroke or TIA, 2.0% of the population of the three Suffolk CCGs and North East Essex CCG (Figure 1). The prevalence of stroke is significantly higher in each CCG than England (1.8%)3. This may be because each CCG has a higher proportion of older people than England as a whole.

Figure 1: Stroke prevalence (all ages) in the three Suffolk CCGs and North East Essex CCG, percentage of people registered with a GP, 2018/193

Chart showing stroke prevalence (%): 3 Suffolk CCGs & North East Essex CCG - all are in line with or higher than England

Source: Public Health England. Cardiovascular disease profiles. (2019)

The greatest increase in numbers of people with a longstanding health condition caused by stroke is predicted for people aged 75 and over (Figure 2).

Figure 2: Estimated number of people with a longstanding health condition caused by stroke, Suffolk, by age band4

Chart showing more people aged over 75 have a longstanding condition caused by stroke, decreasing by age band until very few people 18-44 have been affected
Source: POPPI

Local factors affecting prevalence

Age

Stroke predominantly affects people over 50 years5, making age the single largest risk factor6. Stroke rates double every decade after 55 years of age7. The total incidence of stroke is projected to rise substantially over the next 20 years, as the population ages7.

Men are likely to experience their first stroke earlier than women: 68 is the mean age of onset for men compared to 73 for women8. Older patients tend to have higher in-hospital mortality rates as well as poorer functional outcomes, even after controlling for risk factors such as severity, or treatment7.

The number of people aged 65 and over in Suffolk will increase by 43% between 2019 and 2039 (Figure 3). The number of people aged 85 and over in Suffolk will almost treble from 21,500 to 59,000 (Figure 4)9.

Figure 3: Population change in Suffolk 2019-399

In 20 years 1 in 3 people in Suffolk will be aged 65 or over

Source: Public Health Suffolk, “Suffolk 20+: What could Suffolk look like in 20 years?,” Ipswich, 2019.

Figure 4: Suffolk population change by age group, 2019-399

43% of the growth in Suffolk's population from 2019 to 2039 is in people aged 65 and over

Source: Public Health Suffolk, “Suffolk 20+: What could Suffolk look like in 20 years?,” Ipswich, 2019.

Stroke is one of the top ten causes of childhood death in high-income countries10. Incidence is 2 to 13 per 100,000 people per year, and is most likely to occur in the first year10. There are over a hundred risk factors, including: arteriopathy (abnormalities in cerebral circulation), and cardiac disease10.

Incidence

  • The stroke all age admissions rate (to hospital) for England is 166.0 per 100,000 population (directly standardised rate)3.
  • Admissions rates in Ipswich and East Suffolk CCG are significantly lower (better) than England (Figure 5).  Admissions in other local CCGs are not significantly different to England.
  • Most people survive a first stroke; over three quarters need occupational or physiotherapy11.

Figure 5: Stroke all age admission trends, the three Suffolk CCGs and North East Essex CCG, 2018/19, directly standardised rate per 100,000 population3

Stroke admission trends are in line with England for Great Yarmouth & Waveney, West Suffolk, North East Essex CCGs. They are significantly lower than England in Ipswich & East CCG

Source: Public Health England. Cardiovascular disease profiles. (2019)

Notes: compared to England average: green is significantly better; amber is “not significantly different”.

Hospital admissions for stroke increase with age (Table 1) and are forecast to increase in older age groups over the next 20 years (Table 2).

Table 1: Hospital admissions for stroke (ICD-10: I61, I63 and I64) by age group and the three Suffolk CCGs and North East Essex CCG, 2018/19, rate per 100,000 people in age group

Age group IES NEE WS SNEE ICS GYW
Under 45 7.4 5.7 12.5 8.0 9.6
45 - 54 60.1 89.5 71.7 72.6 85.4
55 - 64 110.4 159.1 160.8 137.4 156.3
65 - 74 237.2 347.5 289.8 283.5 380.7
75 - 84 714.0 838.1 819.4 781.9 864.7
85 and over 1,455.9 1,641.8 1,260.5 1,471.6 1,430.4

Source: Hospital Episode Statistics; Office for National Statistics (2019)

Table 2: Hospital admissions for stroke (ICD-10: I61, I63 and I64) by age group and the three Suffolk CCGs and North East Essex CCG, percentage change 2018/19 to 2040

Age group IES NEE WS SNEE ICS GYW
Under 45 0.0% 0.0% 0.0% 0.0% 0.0%
45 - 54 -14.3% 0.0% -20.0% -5.0% 0.0%
55 - 64 0.0% 7.7% 12.5% 9.1% 0.0%
65 - 74 20.8% 24.1% 12.5% 22.1% 8.7%
75 - 84 71.4% 68.3% 66.7% 69.1% 51.6%
85 and over 118.4% 100.0% 127.8% 113.5% 95.5%
All ages 62.7% 56.8% 57.1% 59.1% 40.9%

Source: Hospital Episode Statistics; Office for National Statistics (2019)

The impact

  • Almost two thirds of stroke survivors are left with a disability12.
  • Absolute numbers for stroke are increasing due to population growth, ageing, and lifestyle changes7,13. Incidence is forecast to increase by 44% across the UK14.
  • In Suffolk by 2035, 7,288 adults will have a longstanding health condition caused by stroke (34% increase). 1,858 will be over 74 (72.3% increase)15.
  • East Suffolk will have the highest number of adults living with health conditions from strokes (2,617). Forest Heath and Mid Suffolk will see the highest rates of increase, over 40%.4,15
  • Stroke may increase depression16, which is found in up to 60% of stroke survivors17.

Mortality

  • Stroke is the fourth most common cause of death in Suffolk18.
  • Mortality from stroke has fallen over the last twelve years (Figures 6 and 7, 2004-06 to 2016-18).
  • Deaths from stroke are estimated to increase 56%19 due to the increasing older population20.

Figure 6: Stroke mortality rates (age standardised) for people aged 74 and under, the three Suffolk CCGs and North East Essex CCG, 2004-6 to 2015-173

Line chart showing general fall in stroke mortality rates for people aged 74 and under

Source: Public Health England. Cardiovascular disease profiles. (2019)

Figure 7: Stroke mortality rates (age standardised) for people aged 75 and over, the three Suffolk CCGs and North East Essex CCG, 2004-6 to 2015-173

Line chart showing a fall in stroke mortality rates for people aged 75 and over for Suffolk CCGs, North East Essex CCG and England

Source: Public Health England. Cardiovascular disease profiles. (2019)

What are the key inequalities in Suffolk?

Ethnicity

90.8% of Suffolk’s population is White British. White people are more likely to have an irregular heartbeat (atrial fibrillation), and to smoke and drink alcohol12, which all increase the risk of stroke.

People from Asian, African and African-Caribbean communities are more likely to have a stroke than other ethnic groups2,21, and to have a stroke at a younger age12. Contributing risk factors:

  • Black people are more likely to have high blood pressure and diabetes12,22.
  • South Asian populations are more prone to diabetes, high blood pressure, and high cholesterol23.

Deprivation

Stroke risk increases for people experiencing greater deprivation7. People from the most deprived areas of the UK are twice as likely to have a stroke, and three times more likely to die from stroke24. People with lower socioeconomic status are also more likely to have: strokes younger21, increased comorbidities25, worse outcomes21, and less access to support services26.

A Norfolk study showed a difference between the highest (professional) and lowest (unskilled) social classes. Differences were less noticeable between middle groups, possibly because, in rural areas, class may affect lifestyle (diet, physical activity) less than in cities27. Current social class is linked to parental social class, so lower social class or deprivation as a child may increase stroke risk. For example, low birth weight (linked to poor maternal nutrition) has been associated with increased stroke occurrence as an adult27.

Educational attainment is said to be the most important determinant of health inequality in later life26.  Fewer years in education have been linked to increased stroke risk in women21.

In Suffolk, more deprived areas are mostly found in urban areas (Figure 8), although there may be hidden deprivation in rural areas.

Figure 8: IMD quintile by LSOA in Suffolk, 2019

Map showing Suffolk's areas of relative deprivation are more likely to be in towns, and in the rural north west and north east of the County.

Source: Indices of Multiple Deprivation, 201928

Sex

Women have more strokes and worse outcomes compared to men6,7. They are more likely to have long-term disability, reduced quality of life, dementia, depression and post-stroke mortality. Researchers have suggested this may be because:

  • women live longer than men,
  • women delay longer than men in getting medical advice, so treatment is later7,
  • older women are more likely to live alone (70% of one person households aged 65 and over are female in Suffolk, 69% in England29), so have difficulty getting emergency care13, or
  • women may be more likely to present with non-specific and diffuse stroke symptoms7.

Women’s blood pressure and cholesterol levels increase after menopause13. Strokes in women are associated with a higher prevalence of arterial hypertension, AF and pre-stroke disability; men have a higher prevalence of heart disease, peripheral vascular disease, smoking and alcohol use7,13. There are no noted gender differences in stroke recurrence12.

Risks

Ten modifiable risk factors account for 90% of the risk of stroke (Figure 9)9. Key are high blood pressure (hypertension), high cholesterol, smoking, obesity/diet, atrial fibrillation and diabetes5.

Figure 9: Risk factors for stroke30

Chart illustrating the text, also showing healthy diet and regular physical activity are protective factors

Source: Nottinghamshire Health & Wellbeing Board: Stroke JSNA

Hypertension

Hypertension (high blood pressure) is the biggest avoidable risk factor for stroke20,22. At least half of all heart attacks and strokes are linked to hypertension, which increases the risk of stroke by up to three times31. Treating hypertension prevents strokes22.

15.8% (197,264) people across the three Suffolk CCGS and North East Essex CCG have hypertension (Figure 10). Each CCG has prevalence that is significantly higher than England (14.0%) and the East of England region (14.3%)3.

Figure 10: prevalence of hypertension (all ages), % people registered with a GP in the three Suffolk CCGs and North East Essex CCG, 2018/193

Chart illustrating the point in the text that the % patients with recorded hypertension is higher in the CCGs than England

Source: Public Health England. Cardiovascular disease profiles. (2019)

Nearly 30% of adults in the UK have high blood pressure. It is estimated that there are around 132,250 people with undiagnosed high blood pressure in the three Suffolk CCGs and North East Essex CCG area (Figure 11).

Figure 11: Numbers of people with undiagnosed high blood pressure the three Suffolk CCGs and North East Essex CCG (2016/17 data)31

Ipswich & East Suffolk, and North East Essex are the two local CCGs with highest numbers of people with diagnosed hypertension, and the highest numbers of undiagnosed cases

Source: British Heart Foundation, High blood pressure: how can we do better? (2018 update)

There are also opportunities to improve the management of blood pressure, as not all patients who have had a stroke have hypertension treated to target. Ipswich and East Suffolk CCG has a significantly higher (better) percentage of stroke or TIA patients with controlled blood pressure compared to England, and Great Yarmouth and Waveney CCG has a significantly lower (worse) percentage of patients with controlled blood pressure (Figure 12). Percentages for North East Essex and West Suffolk are statistically similar to England.

Figure 12: % Patients with stroke or TIA and most recent blood pressure reading is 150/90 mmHg or less, the three Suffolk CCGs and North East Essex CCG, 2018/193

Figure illustrating the text - Great Yarmouth and Waveney has a lower (worse) % than England

Source: Public Health England. Cardiovascular disease profiles. (2019)

Atrial fibrillation

An irregular heartbeat (atrial fibrillation) increases the risk of blood clots and ischaemic stroke18. People with atrial fibrillation (AF) have five times the risk of stroke19. AF increases stroke mortality15. 7,000 strokes could be avoided annually in England if AF was appropriately managed20, e.g. by prescribing anticoagulants to the elderly21.

AF-related strokes have increased since 1999 and are more likely to affect people from ethnic minorities21.

The prevalence of atrial fibrillation is significantly higher than England in the four local CCGs (Figure 13)6.

Estimated undiagnosed atrial fibrillation in CCG populations, all ages, 20196:

  • 3.4% Great Yarmouth and Waveney CCG
  • 3.2% West Suffolk CCG
  • 3.1% Ipswich and East Suffolk CCG
  • 3.1% North East Essex CCG

Figure 13: Prevalence of atrial fibrillation by the three Suffolk CCGs and North East Essex CCG, 2012/13 – 2018/193

Time line showing the % patients with recorded AF is higher in the local CCGs than England, and that the % has increased for the local CCGs and England since 2012/13e CCGs at a

Source: Public Health England. Cardiovascular disease profiles. (2019)

Diabetes

High levels of glucose in the blood can damage arteries causing atherosclerosis and increasing stroke risk. People with diabetes have a 25% excess risk of stroke17,32.

Recorded diabetes prevalence is significantly lower than England in Ipswich and East Suffolk, and significantly higher in Great Yarmouth and Waveney, the other CCGs are statistically similar to England (Figure 14).

Figure 14: Prevalence of diabetes by the three Suffolk CCGs and North East Essex CCG, people aged 17 and over, 2018/193

Chart illustrating text: diabetes prevalence is lower than England in IES CCG and higher in GYW

Source: Public Health England. Cardiovascular disease profiles. (2019)

Obesity

Obesity and being overweight increases ischaemic stroke risk, blood pressure, cholesterol and glucose levels33. Stroke is also associated with abdominal body fat. For every 0.01 increase in waist-to-hip ratio, there is a 5% increase in risk of cardiovascular disease22. Weight loss reduces the risk of stroke and also improves blood pressure22.

64.5% adults (aged 18 and over) in Suffolk are overweight or obese (2017/18), significantly higher than England (62.0%)34. Data from GP records shows that the percentage of patients recorded as being obese in the Suffolk and North East Essex CCGs is significantly higher than England, except for West Suffolk, which has a significantly lower percentage of patients recorded as being obese (Figure 15).

Figure 15: Prevalence of obesity by the three Suffolk CCGs and North East Essex CCG, registered patients aged 17 and over, 2018/193

Illustrates text showing all local CCGs except West Suffolk had higher % obesity than England

Source: Public Health England. Cardiovascular disease profiles. (2019)

Psychosocial factors

Depression is associated with a 34–63% excess risk of stroke35. Stress also increases stroke risk36. People with mental health conditions are more likely to have unhealthy lifestyles, including smoking and alcohol misuse. They also appear less likely to self-care37.

In 2018/9, the recorded prevalence of depression in people aged 18 and over was statistically significantly higher than England in Great Yarmouth and Waveney CCG, West Suffolk CCG, and North East Essex CCG. Ipswich and East Suffolk CCG was statistically similar to England (Figure 16)3.

Figure 16: Prevalence of depression by the three Suffolk CCGs and North East Essex CCG, North East Essex CCGs, registered patients aged 18 and over, 2018/193

Illustrates text to show significantly higher rates of depression in all local CCGs except Ipswich and East

Source: Public Health England. Cardiovascular disease profiles. (2019)

Smoking

Half (52%) the people under 45 who have a stroke are smokers23,38. Smoking increases the risk of stroke three to fourfold. The risk increases by 25% for every 10 daily cigarettes. Stroke survivors who continue to smoke are twice as likely to have another stroke33.  Secondhand smoke increases the risk of stroke 1.5-2 times39.

Smoking rates are significantly higher than England among patients registered in GYWCCG and NEECCG, and statistically significantly lower in IESCCG (Figure 17). GYWCCG also has a statistically significantly higher percentage of adults (aged 18-64) in routine and manual occupations that smoke (39.5% compared to 25.4% England)3.

Figure 17: Prevalence of smoking by the three Suffolk CCGs and North East Essex CCG, registered patients aged 15 and over, 2018/193

Illustrates text: SMoking prevalence is significantly higher in North East Essex, and Great Yarmouth & Waveney

Source: Public Health England. Cardiovascular disease profiles. (2019)

Alcohol

Moderate alcohol consumption may protect against ischaemic stroke: two drinks per day for men, and one per day for women40. Heavy drinking (more than two drinks a day) and binge drinking increase risk33, particularly in midlife (50-75), when risk increases by 34% compared to light drinking (<0.5 drink/day). This creates a stroke risk comparable with diabetes or hypertension41.

Across England, frequency of drinking increases with age (Figure 18)42. Higher socio-economic groups consume more alcohol43.

There were 118,078 admission episodes for alcohol-related conditions in Suffolk in 2017/18 (548 per 100,000 population). This is significantly lower than England (632 per 100,000)34.

Figure 18: Drinking frequency in the week before interview, England, all persons (aged 16 and over) by age band, 201742

chart showing drinking frequency increases with age

Source: Office for National Statistics, “Adult drinking habits in England (2017 data),” 2018.

Costs

The average cost to society of a person experiencing a stroke44 (using 2015 prices) is:

  • £45,409 in the first 12 months after stroke (cost of incident stroke),
  • £24,778 in subsequent years (cost of prevalent stroke).

The average cost of NHS and personal social care in the first year after a severe stroke was almost double that for a minor stroke (£24,003 compared to £12,869). Average costs varied little between men and women, and between ischaemic and haemorrhagic stroke, but were higher for ages 85 and older. Lower informal care costs among older adults balanced the total average costs across ages.

PANSI forecasts4 suggest costs to Suffolk in 2015 of £135 million, rising to £350 million in 2035.

Figure 19: Estimated population benefits if average blood pressure in people with high blood pressure is reduced by 10 mmHg*, the three Suffolk CCGs and North East Essex CCG (2015/16 data)31

Chart showing reduction in stroke events by local CCG if blood pressure was reduced in people with hypertension

Source: High Blood Pressure, How can we do better?

What are we doing?

Stroke care has improved over the last 20 years45. This is partly through audit programmes such as the Sentinel Stroke National Audit Programme11 (SSNAP) which assesses best practice.

Work locally

General / cross-cutting

Public Health Suffolk funds training for pharmacies to become a Healthy Living Pharmacy that can engage “seldom heard” populations, and deliver services such as: smoking cessation, alcohol intervention and weight loss. 127 pharmacies in Suffolk are Healthy Living Pharmacies.

Smoking

OneLife Suffolk runs smoking cessation services as part of the NHS Smokefree campaign.

Diabetes

OneLife Suffolk ran a health promotion campaign in 2018 on the prevention of Type 2 Diabetes, working with pharmacies, GP practices and hospitals to:

  • encourage people to assess their risk of Type 2 Diabetes though the Diabetes UK risk tool
  • encourage 40-74-year olds to have their NHS Health Check
  • increase awareness of how people can reduce their risk by signposting to other services
  • signpost people with Type 2 diabetes to weight management and exercise services

Obesity

  • Eat Out Eat Well recognises caterers offering healthy meals that can help to reduce the risk of hypertension, diabetes and stroke.
  • OneLife Suffolk run weight management groups for adults, families and teens, as well as maintenance sessions for people who have completed a course.

Alcohol

  • Turning Point, together with Suffolk Family Carers and Iceni, run drug and alcohol treatment.
  • Suffolk Public Health grants funds to projects developed by voluntary or community groups and partnerships to help people continue their recovery from drug and alcohol problems.

Physical inactivity

  • Since 2012, when the Most Active County started:
    • 16,000 more adults are achieving at least 150 minutes of physical activity per week
    • 27,000 more adults are playing sport at least 3 times a week
    • 29,000 more adults are walking for 10 minutes or more at least 5 times a week
  • Get Help to Get Active for people with cardiovascular disease, type 2 diabetes and cancer
  • Health Walks in Suffolk http://onelifesuffolk.co.uk/our-services/health-walks/ 
  • Active Suffolk initiatives include: This Girl Can, Workplace Health, Fit Villages, Women on Wheels

Psychosocial factors

National & regional schemes

  • The NHS provide a free helpline and apps to help people quit smoking www.nhs.uk/smokefree
  • The NHS Health Check programme (www.healthcheck.nhs.uk) aims to identify and prevent conditions including heart disease, stroke, and diabetes, offering five-yearly checks to 40-74-year olds with no pre-existing conditions. In the period 2014/15 – 2018/19, 58.0% of the eligible population of Suffolk (aged 40-74) received an NHS health check (129,736 people). This is statistically significantly higher than England (43.3%) and the East of England (48.5%)46.

What else could we do?

  • Increase testing for contributing conditions:
    • commission pharmacists to offer blood pressure checks / pulse checking
    • encourage take up (and follow up) of NHS Health Checks
  • Increase diagnosis of conditions such as AF, hypertension and diabetes:
    • in 2015/16 there were an estimated 7,200 cases of undiagnosed AF in Suffolk47
    • there may be approximately 7,500 people with undiagnosed diabetes in Suffolk (2015/16)48
  • Improve management of contributing conditions, in line with latest NICE guidance:
    • commission pharmacists to support people in taking their medication49
    • improve management of hypertension in Great Yarmouth and Waveney CCG
    • Warfarin reduces stroke risk by approximately 44%13, aspirin by approximately 22%50
    • statins reduce the risk of a major vascular event (including stroke22) by roughly a quarter for each mmol/L reduction in LDL (during each year taken, after the first)51
  • Reduce: smoking, obesity, and alcohol consumption in the over 50s. A year after quitting smoking, stroke risk is reduced by half; after 5 years, it is as if the quitter had never smoked33.  
  • Continue promoting physical activity, healthy eating and emotional wellbeing. 40 minutes of exercise, three to four times a week, is recommended for prevention, and for stroke survivors33. Lack of exercise can increase risk by 25-30%33. Every 200g/day fruit eaten reduces risk by 32%33.
  • Increase compliance with SSNAP indicators for CCGs and acute hospitals.  Three quarters of eligible stroke survivors received a 6 month follow-up assessment in Ipswich and East Suffolk but none in Waveney52 (Apr-Jul 2017). In 2016/17 in West Suffolk, only 38% of eligible patients with AF were being treated before their stroke, against 63.9% in Great Yarmouth and Waveney52.

Useful links

References

1.         Royal College of Physicians. Stroke guidelines | RCP London. (2016). Available at: https://www.rcplondon.ac.uk/guidelines-policy/stroke-guidelines. (Accessed: 12th December 2017)

2.         Diley, I., Kanka, D. & Suffolk County Council. Epidemiology of stroke in Suffolk. (2013).

3.         Public Health England. Fingertips Cardiovascular Disease Profiles. Available at: https://fingertips.phe.org.uk/profile-group/cardiovascular-disease-diabetes-kidney-disease/profile/cardiovascular. (Accessed: 17th December 2019)

4.         Institute of Public Care. PANSI - Projecting Adult Needs and Service Information.

5.         NICE: National Institute for Health and Care Excellence. Lipid modification Cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease methods evidence and recommendations. (2014).

6.         Wilson, M. E. Stroke: understanding the differences between males and females. Pflügers Arch. - Eur. J. Physiol. 465, 595–600 (2013).

7.         Gibson, C. L. Cerebral ischemic stroke: is gender important? J. Cereb. Blood Flow Metab. 33, 1355–1361 (2013).

8.         Public Health England. New figures show larger proportion of strokes in the middle aged. (2018). Available at: https://www.gov.uk/government/news/new-figures-show-larger-proportion-of-strokes-in-the-middle-aged. (Accessed: 1st February 2018)

9.         Public Health Suffolk. Suffolk 20+: What could Suffolk look like in 20 years? (2019).

10.       Mallick, A. A. & O’Callaghan, F. J. K. Risk factors and treatment outcomes of childhood stroke. Expert Rev. Neurother. 10, 1331–1346 (2010).

11.       Sentinal Stroke National Audit Programme. Available at: https://www.strokeaudit.org/Home.aspx.

12.       Stroke Association. State of the Nation: stroke statistics 2018. (2018). Available at: https://www.stroke.org.uk/resources/state-nation-stroke-statistics. (Accessed: 1st February 2018)

13.       Barker-Collo, S. et al. Sex Differences in Stroke Incidence, Prevalence, Mortality and Disability-Adjusted Life Years: Results from the Global Burden of Disease Study 2013. Neuroepidemiology 45, 203–214 (2015).

14.       King’s College London. King’s College London - Report predicts growth in stroke rates for UK. Available at: https://www.kcl.ac.uk/newsevents/news/newsrecords/2017/05-May/Report-predicts-growth-in-stroke-rates-for-UK.aspx. (Accessed: 13th December 2017)

15.       Institute of Public Care. POPPI - Projecting Older People Population Information.

16.       Gale, C. R. et al. Factors associated with symptoms of anxiety and depression in five cohorts of community-based older people: the HALCyon (Healthy Ageing across the Life Course) Programme. Psychol. Med. 41, 2057 (2011).

17.       Department of Health. Cardiovascular Disease Outcomes Strategy: Improving outcomes for people with or at risk of cardiovascular disease. (2013).

18.       Office for National Statistics. Leading causes of death (2018). (2019).

19.       King’s College London & Stroke Alliance for Europe. The burden of stroke in Europe: Appendix overview of stroke burden and care. (2017).

20.       King’s College London & Stroke Alliance for Europe. The Burden of stroke in Europe: the challenge for policy makers. (2017).

21.       Marshall, I. J. et al. The effects of socioeconomic status on stroke risk and outcomes. Lancet Neurol. 14, 1206–1218 (2018).

22.       Meschia, J. F. et al. Guidelines for the Primary Prevention of Stroke. Stroke 45, 3754 LP-3832 (2014).

23.       Stroke Association. State of the Nation: Stroke Statistics 2017. (2017). https://www.healthysuffolk.org.uk/projects/eating/eat-out-eat-well

24.       Stroke Association. State of the Nation stroke statistics 2016. (2016).

25.       Charlton, J., Rudisill, C., Bhattarai, N. & Gulliford, M. Impact of deprivation on occurrence, outcomes and health care costs of people with multiple morbidity. J. Health Serv. Res. Policy 18, 215 (2013).

26.       Rahman, M. M., Khan, H. T. A. & Hafford-Letchfield, T. Correlates of Socioeconomic Status and the Health of Older People in the United Kingdom. Illness, Cris. Loss 24, 195–216 (2016).

27.       McFadden, E., Luben, R., Wareham, N., Bingham, S. & Khaw, K.-T. Social class, risk factors, and stroke incidence in men and women: a prospective study in the European prospective investigation into cancer in Norfolk cohort. Stroke 40, 1070–7 (2009).

28.       Public Health Suffolk County Council. Indices of deprivation 2019: summary. (2019).

29.       Office for National Statistics & Nomis. DC1109EW - Household composition by age by sex. Census (2011). Available at: http://www.nomisweb.co.uk/livelinks/14174.xlsx.

30.       Hamilton, G. & Nottinghamshire Health & Wellbeing Board. Stroke JSNA. (2017).

31.       British Heart Foundation. High blood pressure: how can we do better? (2018 update). (2018). Available at: https://www.bhf.org.uk/for-professionals/healthcare-professionals/data-and-statistics/bp-how-can-we-do-better. (Accessed: 17th December 2019)

32.       Wang, Y., Rudd, A. G. & Wolfe, C. D. A. Trends and survival between ethnic groups after stroke: the South London Stroke Register. Stroke 44, 380–7 (2013).

33.       Niewada, M. & Michel, P. Lifestyle modification for stroke prevention: facts and fiction. Curr. Opin. Neurol. 29, 9–13 (2016).

34.       Public Health England. Local authority health profile. (2019). Available at: https://fingertips.phe.org.uk/health-profiles#page/0/gid/1938132694/pat/6/par/E12000006/ati/102/are/E10000029. (Accessed: 27th November 2019)

35.       Daskalopoulou, M. et al. Depression as a Risk Factor for the Initial Presentation of Twelve Cardiac, Cerebrovascular, and Peripheral Arterial Diseases: Data Linkage Study of 1.9 Million Women and Men. PLoS One 11, e0153838 (2016).

36.       Bang, O. Y., Ovbiagele, B. & Kim, J. S. Nontraditional Risk Factors for Ischemic Stroke. Stroke 46, 3571 LP-3578 (2015).

37.       Frankenberg, R. & Suffolk County Council. Links between physical health in mental health. Mental Health Needs Assessment 7 (2017). Available at: https://www.healthysuffolk.org.uk/uploads/Physical_health_in_mental_health.pdf. (Accessed: 4th January 2018)

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