A systematic comparison of key features of ischemic stroke prevention guidelines in low- and middle-income vs. high-income countries

J Neurol Sci. 2017 Apr 15:375:360-366. doi: 10.1016/j.jns.2017.02.040. Epub 2017 Feb 20.


Background and purpose: Implementation of contextually appropriate, evidence-based, expert-recommended stroke prevention guideline is particularly important in Low-Income Countries (LMICs), which bear disproportional larger burden of stroke while possessing fewer resources. However, key quality characteristics of guidelines issued in LMICs compared with those in High-Income Countries (HICs) have not been systematically studied. We aimed to compare important features of stroke prevention guidelines issued in these groups.

Methods: We systematically searched PubMed, AJOL, SciELO, and LILACS databases for stroke prevention guidelines published between January 2005 and December 2015 by country. Primary search items included: "Stroke" and "Guidelines". We critically appraised the articles for evidence level, issuance frequency, translatability to clinical practice, and ethical considerations. We followed the PRISMA guidelines for the elaboration process.

Results: Among 36 stroke prevention guidelines published, 22 (61%) met eligibility criteria: 8 from LMICs (36%) and 14 from HICs (64%). LMIC-issued guidelines were less likely to have articulation of recommendations (62% vs. 100%, p=0.03), involve high quality systematic reviews (21% vs. 79%, p=0.006), have a good dissemination channels (12% vs 71%, p=0.02) and have an external reviewer (12% vs 57%, p=0.07). The patient views and preferences were the most significant stakeholder considerations in HIC (57%, p=0.01) compared with LMICs. The most frequent evidence grading system was American Heart Association (AHA) used in 22% of the guidelines. The Class I/III and Level (A) recommendations were homogenous among LMICs.

Conclusions: The quality and quantity of stroke prevention guidelines in LMICs are less than those of HICs and need to be significantly improved upon.

Keywords: Developing countries; Guideline; Practice guideline; Primary prevention; Secondary prevention; Stroke.

Publication types

  • Review

MeSH terms

  • Brain Ischemia / complications
  • Brain Ischemia / epidemiology
  • Databases, Bibliographic / statistics & numerical data
  • Developed Countries / statistics & numerical data*
  • Developing Countries / statistics & numerical data*
  • Guidelines as Topic / standards*
  • Humans
  • Stroke / epidemiology
  • Stroke / etiology
  • Stroke / prevention & control*