Stroke Becomes the 3rd Important Cause of Death in Korea; Is It a Time to Toast?

Aside from cancer, stroke has long been the number one cause of death in Korea, followed by heart disease. Last year, our gov­ ernment reported that this order was reversed, due primarily to a decrease in stroke mortality (Figure 1). The change is strik­ ing; ten years ago (in 2002), stroke mortality was about two times higher than that of heart disease (77 per 100,000 vs. 36.9 per 100,000, respectively) while in 2012, the mortality rate due to heart disease and stroke was 52.5 and 51.1 per 100,000 peo­ ple, respectively. One of the important reasons for the rapid decline in stroke mortality is the improved quality of stroke care during the last 10 years; public awareness of stroke symptoms improved, the proportion of patients visiting hospitals within 3 hours increas­ ed, and door to needle time shortened, due in part to the wide­ spread use of a computerized in­hospital alert system. Accord­ ingly, the rt­PA treatment rate increased from 4.6% in 2005 to 7.9% in 2010. The proportion of hospitals equipped with a qualified stroke unit has also increased from 1.1% in 2005 to 19.4% in 2010. Another reason for this trend may be the fact that stroke has become a less dangerous disease in Korea. Hemorrhagic strokes, which are associated with high mortality, have been steadily de­ clining, from 35.3% in 2000 to 23.9% in 2009, probably in asso­ ciation with improved control of hypertension. Moreover, many aneurysms are now detected at routine health check­ups and treated before rupturing. For these reasons, the stroke fatal­ ity rate in Korea is now one of the lowest among OECD coun­ tries. Whatever the reason, the declining stroke mortality mer­ its congratulation. However, it may not be good news. Due to improved stroke care, and changing stroke subtypes, stroke fatalities have decreased. However, this paradoxically in­ creases the number of stroke survivors. Stroke survivors need long­term preventive medicine, including antiplatelets, antico­ agulants, or statins. Risk factors must be strictly managed and in some patients, operative therapies (such as carotid endarterec­ tomy or stenting) are needed. These treatments are costly. Al­ though hemorrhagic strokes are more costly in the acute stage, long­term care is significantly more expensive for secondary prevention of ischemic stroke. Furthermore, stroke survivors, especially those who develop recurrent strokes, are often dis­ abled, depressed, and cognitively impaired. They significantly increase caregiver burden, and labor power will be lost from not only patients but also their caregivers. In short, stroke has changed from a devastating fatal disease to a manageable illness requiring long­term, costly care. With accumulating stroke survivors, individual and social burdens will skyrocket. More importantly, despite the relatively improved Figure 1. Secular trend of mortality associated with major diseases in Korea. 200