Dear Editors,

We read with interest the manuscript published by Fernandes et al.¹ As stated by Asplund², stroke mortality is an equation between incidence (a marker of primary prevention) and 30-day case-fatality proportion (a marker of hospital quality of care). In MONICA study, stroke events from 39 populations, each of about 500,000 people, were recorded over 10 years. Some populations showed a decrease in mortality, two-thirds due to case-fatality reduction and one-third due to incidence reduction. The manuscript from Lotufo's group deserves attention by showing the early case-fatality in three different hospitals in three Brazilian cities. In fact, 7-day case-fatality was recently implemented as an indicator to measure early stroke death (by neurological causes) because

important clinical decisions are made in the first week after hospital admission³.

Up to 10 days after an ischemic stroke, Fernandes et al. reported a case-fatality rate of 7% (57/804; 95%CI 5.3–8.0). In 11 stroke centers in Canada, from 2003 to 2005, Saposnik et al. found 6.9% of case-fatality rate for 7 days³. Despite these data came from hospitalar series and could have a selection bias (did not capture deaths occurred before hospital admission), they translate the “real world” and should be used as a benchmark to compare stroke centers with others. In Brazil, this can be very useful once last March, 2012 the Ministry of Health launched the Brazilian Stroke Act, which encompasses lysis for stroke centers and more stroke units countrywide⁴.

Norberto Cabral

Anderson R. R. Gonçalves

References

1. Fernandes TG, Goulart AC, Campos TF, et al. Early stroke case-fatality rates in three hospital registries in the Northeast and Southeast of Brazil. Arq Neuropsiquiatr 2012;70:869-873.

2. Asplund K. What MONICA told us about stroke. Lancet Neurol 2005;4:64-68.

3. Saposnik G, Hill MD, O'Donnell M, Fang J, Hachinski V, Kapral MK; Registry

of the Canadian Stroke Network for the Stroke Outcome Research Canada (SORCan) Working Group. Variables associated with 7-day, 30-day, and 1-year fatality after ischemic stroke. Stroke 2008;39:2318-2324.

4. Ministério da Saúde (BR). Protocolos clínicos e diretrizes terapêuticas. [cited at 2012 Jul 14] Available at: http://portal.saude.gov.br/portal/arquivos/pdf/pcdt_trombolise_avc_isq_agudo.pdf

Correspondence: Norberto Luiz Cabral; Rua Plácido Olimpio de Oliveira 1244; 89202-451 Joinville SC - Brasil; E-mail: nlcabral@terra.com.br

Conflict of interest: There is no conflict of interest to declare.

Received 10 December 2012; Received in final form 14 December 2012; Accepted 21 December 2012.