Examination of Witnesses (Questions 272
- 279)
TUESDAY 14 DECEMBER 2004
PROFESSOR PETER
FENTEM, PROFESSOR
PETER WEISSBERG
AND PROFESSOR
KENNEDY LEES
Q272 Chairman:
Good afternoon, and welcome. My name is Sutherland and I am chairing
the Sub-Committee of this Select Committee. My colleagues all
have nameplates in front of them, so I shall not go round the
table; we would rather use our time talking to you and hearing
what you have to say. Just two points: first, thank you very much
for the written evidence that has come in. I know that some of
you have been directly, and all of you indirectly, involved in
that. The written evidence is immensely important to us. That
leads me to say that if, after this session, there are points
that you would like to amplify that you feel we have not done
full justice to, please feel free to communicate directly by e-mail
or letter any further material that you think we should have.
Lastly, I now must point out that we will be recorded and it may
go out on air at some point—perhaps some lonely hour of
the early morning—so anything you say will be heard by a
larger group than now sitting round the table. Can I kick off
with a fairly general question, then, and then we will go round
the table asking our questions. As you respond, if you could just
remind us who you are, partly for the oral record, and what organisation
you represent that would be helpful. Clearly, cardiovascular is
our central theme today. As your written evidence, and indeed
as our other understanding, makes us well aware, it has a huge
impact on the lives of many people but, particularly, older people.
I wonder if you would like to talk just a little bit about the
extent of this impact and how it affects more than the initial
trauma situation but, perhaps, the social aspects of life: quality
of life, economic aspects of life and what the impact of this
form of illness is. If you would then say just very briefly (and
we will come back to this in detail) what are the main areas of
research that you think are or should be pursued as a result of
this.
Professor Fentem:
My Lord Chairman, I am Peter Fentem, I am a trustee of the Stroke
Association and I was the Stroke Association's first Professor
of Stroke Medicine appointed in 1992, and I left my post in 1997.
It is perhaps relevant that before that I was Professor of Physiology
in Nottingham and my special interest was in the physiology of
older people, particular cardiovascular function. On the particular
question, clearly there are the figures available regarding mortality
and so on, and there is no doubt that many people die of stroke—about,
perhaps, 125,000 people in this country have a stroke and of those
something like 70,000 people die each year. I think, perhaps,
as a preliminary to this session, I could just quote what Professor
Ian Philp said recently (perhaps he said it to you): "Having
a stroke is one of the more alarming and devastating things that
can happen to a person, and will happen to a quarter of us over
the age of 45", always provided, as it were, we have a reasonable
expectation of reaching the age of 85. Twenty years ago nothing
could be done with stroke, there was a rather nihilistic attitude
to management, but now things are very different. I think that
is quite a good way of introducing things. I have mentioned mortality,
but mortality underestimates the burden of stroke both for the
individual who has the stroke and for the nation, and that I think
is the important thing. The important characteristic of stroke
is that it leads to disability. We talk about 125,000 having strokes
but, of course, quite a number survive a stroke albeit with quite
serious disability. So out there there are about a quarter-of-a-million
people who have disability as a consequence of their stroke. That,
of course, as I say, is a disaster for the quality of life of
many of them but, also, of course, is exceedingly expensive for
the country that looks after them.
Q273 Chairman:
Is there any estimate of how much?
Professor Fentem:
Two point three billion pounds, or 6 per cent of the national
spend, approximately, when it was last estimated.
Q274 Lord Mitchell:
Six per cent of the national spend—on?
Professor Fentem:
On health and social care. The impact on quality of life, of course,
is because of the range of disabilities; the outward, visible
signs are that people suffer from problems with their mobility
and with their ability to reach and so on, but there are others—sight,
hearing, incontinence and, of course, difficulties in communication.
There are some quite subtle cognitive impairments which interfere
with social interaction. Skipping on, perhaps, to the question
that you wanted me to deal with, I think it would suffice, at
the moment, if I say that I think the possible areas for research
are to do with acute care, with both primary and secondary prevention,
with rehabilitation, with the delivery of long-term care (and
I think this is where stroke has many things in common with the
care that is required by many different groups of frail old people)
and then there is the management of stroke in primary care, that
we really have not touched on.
Q275 Chairman:
Where do you draw the line between primary and secondary prevention?
Professor Fentem:
Primary being preventing a stroke ever happening, and secondary
prevention being to prevent people having a recurrence.
Professor Weissberg:
I am Peter Weissberg, I am currently the Medical Director of the
British Heart Foundation, having just taken over that post two
weeks ago, so I am not really familiar with the workings of the
British Heart Foundation yet. Up until that time I was the British
Heart Foundation's Professor of Cardiovascular Medicine at the
University of Cambridge and a practising clinical cardiologist.
My main research interest has been vascular disease, and that
is what I feel I should speak about. Put in a nutshell, certainly
the heart and, to a large extent, the brain are remarkably resilient
organs and they are well capable of doing their job for eight
decades or more, providing they have a decent vascular system
and a decent blood supply. Virtually all of the mortality and
morbidity that we see, either prematurely or of this age group,
is as a direct or indirect consequence of a problem with vascular
supply to that organ, and that is usually due to atherosclerosis
which causes coronary arteries and causes heart attack. As you
will all be aware, the incidence of heart attack, as we know it,
is falling in the under-65s, but of course that means it is rising
in the over-65s and it leaves behind the myocardial equivalent
of a stroke, which is damaged tissue, and that is heart failure.
Heart failure is a rapidly growing problem in the elderly, particularly
as we get better at salvaging patients from what would have been
a fatal heart attack, because we cannot prevent them having myocardial
damage, very often, and, as a consequence of that, they accumulate
more myocardial damage as time goes on and end up in the clinical
syndrome of heart failure. It is estimated that there are about
900,000 people in the UK with heart failure, at the moment, and
a not commonly recognised statistic is that the mortality from
that for about 40 per cent is one year, and it is a very miserable
year. The prognosis for heart patients is considerably worse.
If we follow exactly the same track that Peter has been following,
the estimated cost at the moment for people over the age of 65
to be treated for heart failure in the NHS is £625 million
a year. So it is enormous morbidity and enormous cost. If it affects
the cerebral arteries then stroke is a consequence and that has
just been covered, although it affects the peripheral arteries
as well—the arteries to the legs and to the kidneys—and
that leads to renal failure, it leads to gangrene and it leads
to the inability to walk, and maybe to blindness. So the major
focus, I think, in terms of research has necessarily to be on
the prevention of that vascular disease in middle age, because
it is certainly my belief that if we could prevent the development
of atherosclerosis in middle age then the consequences of vascular
disease would be very much less in the elderly, and they would
die of other things, in effect, because the organs involved are
pretty robust. In terms of where I see research going, we have
made pretty good headway, actually, in terms of understanding
the biology of atherosclerosis and tackling it in middle age through
lipid-lowering drugs, ace inhibitors—all drugs which have
been shown in clinical trials to reduce the progression of vascular
disease and the outcome of vascular disease. I think what we have
to turn our attention to is accepting that we are not going to
be able to prevent these problems and learn how to repair the
organs that are affected. Whilst that once upon a time might have
appeared rather science-fictional, I think with the advent of
stem cell research it becomes not science reality yet but it certainly
becomes plausible (and probably more plausible in the heart than
in the brain) that one might be able to use cells, either embryonic
stem cells, although they have their problems, or perhaps more
realistically bone marrow derived or circulating stem cells (these
are cells taken from that person and re-infused back into their
heart). There is good scientific evidence, at least, that some
of these cells can adopt the characteristics of a heart cell and,
in effect, repair an organ which was traditionally thought of
as being unrepairable. That is, in fact, the biggest problem.
The reason why cardiac and cerebral disease is such a problem
is that neither organ has the capacity to regenerate or repair,
unlike the liver for instance, so that once damaged it remains
damaged and probably goes downhill thereafter. So the scientific
focus at the cellular and molecular biological level now is understanding
the cellular processes that might allow one to induce repair in
those organs. I have applications sitting on my desk at the moment
for clinical trials in stem cells for heart attack patients, and
I think that does offer some promise for salvage, if you like,
of the heart and, therefore, downstream effects for the elderly.
Q276 Baroness Walmsley:
Professor Weissberg, you said that when the heart tissue is damaged,
it tends to go downhill after. Is there potential for stem cell
therapy to actually prevent that further degeneration?
Professor Weissberg:
There are two reasons why it goes downhill thereafter. One is
that there may be further vascular events. We are all familiar
with the major heart attack that strikes somebody down in the
street and is a very major event—and likewise with stroke—but
what we are less familiar with is the fact that all the time most
of us are having micro-infarcts ("infarct" is the term
used for death of tissue); that is, little bits of the tissue
in the heart and brain being picked off as a consequence of this
vascular disease throughout life, and that accumulates. That is
one reason why the heart may continue deteriorating. The other
reason is that if you effectively wipe out a third or a quarter
of the heart the other three-quarters can cope for a limited period
of time before it starts to fail, and that is why it tends to
be cumulative.
Professor Lees: Kennedy
Lees, I am Professor of Cerebrovascular Medicine at the University
of Glasgow. My main work is as a clinician and clinical triallist
in stroke, and I am interested very much in both the prevention
and treatment of acute stroke. I do not disagree with anything
my colleagues have said. I think the enormity of the expenditure
on stroke, particularly, is absolutely massive. I do not think
we can prevent all strokes. I think one of three things is going
to get most of us: it is either going to be cancer, heart disease
or stroke. We can delay this, I think, and that is a useful thing
to do, but eventually one of those is going to get us. One of
the things that really worries me and my colleagues is that stroke
does carry a very similar prognosis if not a worse prognosis than
most forms of cancer, in terms of mortality—the survival
time—and also in terms of the disability. It is just as
devastating to be left unable to communicate or unable to be independent
as it is to realise that you are slipping downhill from cancer.
However, we spend about 1 per cent on stroke research of what
we spend on cancer research in this country. It is not just in
this country, this does apply internationally, but we are particularly
bad on that. It is a tiny proportion, and yet there are clearly
things that we can do. The one area on which I absolutely agree
with Professor Weissberg is that we must work on prevention and
work on repair. The other area we can work on is dealing with
the condition as it happens, because if you fail to prevent there
is no point in sitting there for the first few hours after a stroke
is happening and watching it develop to its full extent and then
starting the rehabilitation process, because there are things
you can do in that interim. So if it is an ischaemic stroke, a
stroke that is caused by a lack of blood supply, where the brain
tissue is dying from this lack of blood supply, we should be trying
to restore the blood supply, and there is very good evidence—proof—that
treatment with thrombolytic drugs can restore the blood supply
and can make a difference—not in everybody but if there
is a Number Needing to Treat of eight—that is, for every
eight patients treated, one extra complete recovery will occur—that
is really a very powerful treatment, far more powerful in stroke
than it is in myocardial infarcts.
Q277 Chairman:
Can I ask within what time period does it have an effect?
Professor Lees: That
is the point. There is a three-hour time window in which the drugs
are licensed, at the moment, but there is pretty good evidence
that they could work much later. One of the areas of research
that we desperately need to look at is extending that time window.
There is very good reason to think that we can extend it; in many
other countries they have access to imaging—that is MRI
scans or CT perfusion scans—which will allow us to detect
salvageable tissue still there at later times and allow us to
direct treatment to the patients in whom that treatment would
be beneficial. We, unfortunately, in this country have virtually
no centre that can provide that sort of imaging quickly; there
are only half-a-dozen centres in the country that are really using
the drugs regularly and really getting access to this imaging,
which is not particularly high-tech; these are scanners that are
available in most hospitals but we do not have access for our
stroke patients. I think that is an area that we could definitely
be working on.
Q278 Baroness Hilton of Eggardon:
You have already begun to address what you would like to do about
the problems. I wonder whether you would like to develop that
further and tell us what your priorities are and what you see
as being the chief scientific challenges within each of your disciplines
or organisations. Are you addressing different aspects of these
problems or are you all addressing the same priorities?
Professor Fentem:
We are different organisations, of course, with a quite different
remit. I think it is worth just saying a little bit more about
acute care because acute care is high on the Stroke Associations'
agenda. Although there are probably only a limited number of patients
who after a stroke can benefit from thrombolycis—ie, clot-busters—nevertheless,
I think the particular problem that we need to address and which,
I am sure, Kennedy Lees would explain further, is that the mortality
in this country in the first 30 days after a stroke is about 30
per cent, on average. There are problems because elsewhere in
the world we are not always comparing like with like but the 30-day
mortality in Canada is between 11 and 15 per cent. Those are a
lot of deaths, and on the present evidence it would appear that
it depends on the admission of patients to stroke units and the
detailed care within those units. We do not know which components,
at this stage, are producing this effect but one thing that we
suspect is important is the imaging. The point I would like to
make is that this, of course, would lead to changes in the way
the ambulance service transports patients, because you would need
to get rapid admission to hospital, and it is not only a matter
of the scanners but where you put them; in Canada the scanners
are in A&E, and the interpretation of the scan is undertaken
by people either on site or on the end of a telephone link to
a computer. So that is one area that we feel needs to be explored
in detail. I suppose this will come up somewhere in the meeting,
but this is where the opportunities will present when the National
Stroke Clinical Research Network is formed, and this is an important
opportunity, not only for stroke, of course, but for some of the
conditions. In the case of prevention, certainly for patients
in the younger age groups we think that prevention is feasible
and the research area that we think is important is the question
of what is the package and how do you deliver it? In South London,
St Thomas's, Guy's and Kings have one of our programme grants
and are looking at that particular question in the incidence of
secondary prevention. It is no use identifying the fact that high
blood pressure after stroke matters if you do not decide to do
something about it, and clearly there are many, many patients
who are not getting attention to their continuing problems after
they have had their first stroke. Rehabilitation I mentioned as
one of the other areas, and of course possibly your attention
will have already been drawn to Professors Tallis and Frackowiaks'
report on putting the neurosciences to work, and that covers many
of the issues which are important in relation to rehabilitation.
We must understand the rehabilitation, we must understand what
works and what does not work, and we must stop providing token
rehabilitation. If you, by any chance, have had a chance to look
at the National Audit Office report The Way to go Home,
you will have seen that many hospitals were only providing 10
minutes of physiotherapy a day to many of their patients. It just
so happens that stroke is used as a marker for that study but
the approach to rehabilitation goes right across the needs,of
older people whose independence is threatened. Then, of course,
there is the question of continuing care, community care. Again,
we feel we have to challenge adequately the current wisdom which
is that you can have six weeks' physiotherapy after your stroke
on the assumption that that is the end of the improvement that
can be achieved. Yet those units which are being brave enough
now to re-introduce physiotherapy to people who are obviously
deteriorating have shown that it works. I hope that gives a flavour
of some of the issues that the Stroke Association thinks are important.
Q279 Lord May of Oxford:
I had a specific question, going back to your comparison with
Canada (and you did qualify it by saying you were not comparing
like with like) but I am curious: it does seem to me there is
a difference between keeping people alive and the quality of the
life that you keep them alive for. I would ask, as it were, of
the 30 people that die in Britain versus the 15 that die in Canada
in the first 30 days, what is the quality of that surviving life
of the 15 who survive in Canada? Is this a measure of the more
heroic attempt to keep more people alive in some form of life
in North America, or is it really something that is more operational?
Professor Lees: May
I respond to that? It definitely is not just keeping people alive
who would otherwise be left disabled. If you look at the figures
for the recovery as well, you will see that countries like Germany
and Canada have a far higher proportion of patients making a good
recovery. One of the extremely disturbing facts is that in this
early period of acute care if you do not provide good care then
somebody who could well make a good recovery can be left disabled
unnecessarily or die unnecessarily. So I think it is extremely
important to recognise that this is a measure of overall care,
but we can move everybody up one or two stages and get many more
people back home and functioning normally.
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