Correspondence
p<0·001) increase of major bleeding
complications in the aspirin group,
compared with placebo.6 Therefore,
the guidelines of the American Heart
Association 7 do not recommend
routine use of aspirin for primary
prevention of cardiovascular disease,
especially in adults older than
70 years and adults of any age who
are at increased risk of bleeding.
There is a low level of evidence to
recommend the use of low-dose
aspirin (ie, 75–100 mg per day
taken orally) in adults 40–70 years
of age who are at high risk and are
free from cardiovascular disease,
but are not at an increased risk of
bleeding. 6 Aspirin for secondary
stroke prevention should be limited
to people after an ischaemic stroke
or transient ischaemic attack,
and special considerations are
required for patients who are
taking oral anticoagulants or other
antiplatelet agents or who have
had a haemorrhagic stroke. Other
concerns with the polypill include its
side-effects and drug interactions,
potential overtreatment, cost
(particularly in low-income countries),
and the potential requirement of
laboratory tests before the initiation
of treatment.
However, in low-income countries,
where most people live on US$5∙50
a day or less (ie, nearly half the world
population),8 the polypill could be
the only tangible pharmacological
solution to reduce the burden of
cardiovascular disease. There is an
urgency to include the polypill in
the WHO Model Lists of Essential
Medicines to reduce the global burden
of stroke and cardiovascular disease.
The time has come for the
implementation of population-wide
primary stroke and cardiovascular
prevention strategies in combination
with individual prevention strategies,
including the use of digital tools (eg,
the Stroke Riskometer app and the
PreventS-MD webapp) for people at
any level of increased risk of stroke
and cardiovascular disease,9 and the
www.thelancet.com/neurology Vol 22 April 2023 295
WHO HEART programme for people
at high risk of cardiovascular disease.
VLF declares that the free Stroke Riskometer app
and PreventS-MD webapp are copyrighted and
owned by Auckland University of Technology.
VLF and MB are Co-Chairs of the Global Policy
Committee of the World Stroke Organization
(WSO). MB was a previous President of the WSO
and is currently Chair of the Senate of the WSO.
SM is the President of the WSO.
*Valery L Feigin, Michael Brainin,
Sheila C O Martins
valery.feigin@aut.ac.nz
National Institute for Stroke and Applied
Neurosciences, Auckland University of Technology,
Auckland 0627, New Zealand (VLF); Department of
Neuroscience and Preventive Medicine, Danube
University Krems, Krems an der Donau, Austria
(MB); Hospital de Clínicas de Porto Alegre,
Universidade Federal do Rio Grande do Sul, Hospital
Moinhos de Vento, Porto Alegre, Brazil (SCOM);
Brazilian Stroke Network, Porto Alegre, Brazil
(SCOM)
1 Joseph P, Roshandel G, Gao P, et al. Fixed-dose
combination therapies with and without
aspirin for primary prevention of
cardiovascular disease: an individual
participant data meta-analysis. Lancet 2021;
398: 1133–46.
2 Welsh J, Korda RJ, Joshy G, Banks E. Primary
absolute cardiovascular disease risk and
prevention in relation to psychological distress
in the Australian population: a nationally
representative cross-sectional study.
Front Public Health 2019; 7: 7.
3 Dalton ARH, Soljak M, Samarasundera E,
Millett C, Majeed A. Prevalence of
cardiovascular disease risk amongst the
population eligible for the NHS Health Check
Programme. Eur J Prev Cardiol 2013;
20: 142–50.
4 Yusuf S, Pinto FJ. The polypill: from concept
and evidence to implementation. Lancet 2022;
400: 1661–63.
5 Institute for Health Metrics and Evaluation.
GBD compare data visualization. 2019.
https://vizhub.healthdata.org/gbd-compare/
(accessed Nov 9, 2021).
6 McNeil JJ, Wolfe R, Woods RL, et al. Effect of
aspirin on cardiovascular events and bleeding
in the healthy elderly. N Engl J Med 2018;
379: 1509–18.
7 Arnett DK, Blumenthal RS, Albert MA, et al.
2019 ACC/AHA guideline on the primary
prevention of cardiovascular disease: executive
summary: a report of the American College of
Cardiology/American Heart Association Task
Force on clinical practice guidelines. Circulation
2019; 140: e563–95.
8 The World Bank. Nearly half the world lives on
less than $5.50 a day. Oct. 17, 2018. https://
www.worldbank.org/en/news/press-
release/2018/10/17/nearly-half-the-world-
lives-on-less-than-550-a-day (accessed
Feb 25, 2023).
9 Brainin M, Feigin VL, Norrving B, Martins SCO,
Hankey GJ, Hachinski V. Global prevention of
stroke and dementia: the WSO Declaration.
Lancet Neurol 2020; 19: 487–88.
The International
Stroke Recovery and
Rehabilitation Alliance
The global burden of disability
after stroke is increasing 1 despite
therapeutic advances. One in four
adults will have a stroke and about
63% of these events will occur in
people younger than 70 years of
age. Increasing access to effective
rehabilitation is a global health
priority,2 particularly in low-income
and middle-income countries.
Optimising recovery requires both
new, biologically informed treatment
approaches and enhanced (high-
dose and high-quality) delivery of
training-based treatments. Patient-
centred research priority setting
exercises can highlight knowledge
gaps.3 Advances have been difficult
to achieve because stroke recovery
and rehabilitation practice is complex,
with multiple interacting domains
(eg, motor, language, and cognitive),
disability levels (impairment, activity,
and participation), and individuals
involved (eg, patient, family members,
and multidisciplinary team). Our
shared vision is a world where global
collaboration brings breakthroughs for
people living with stroke. Succeeding
will require highly coordinated
research efforts by international,
interdisciplinary teams.
The Stroke Recovery and For more on The Stroke
Rehabilitation Roundtable, created Recovery and Rehabilitation
Roundtable see https://journals.
in 2016, built consensus and aligned sagepub.com/page/wso/srrr
efforts for improvements in research
and practice. Our approach identified
priority areas and led to the creation of
international, interdisciplinary, expert
task forces that—together with junior
faculty—worked to identify consensus
objectives. Our first recommendations
were reported in a position paper4
and we have continued to provide
expert guidance on research methods,
research targets, and clinical practice.
The need to transition from being a
recommendation group to being an
action group for stroke recovery and
 Correspondence
rehabilitation became clear and, in
For more on ISRRA see 2020, we endorsed the International
https://strokerecoveryalliance. Stroke Recovery and Rehabilitation
com/
Alliance (ISRRA).
The greatest impact on the
burden of disability after stroke will
come through building research
partnerships that include people
with lived experience of stroke. Our
aim is to establish topic-specific,
strategic working groups, overseen
by our Scientific Committee. Diverse
in scope, the aims of current groups
include building the economic case
for rehabilitation and creating criteria
for Centres of Clinical Excellence. Task
forces on exercise and frailty are recent
additions. Building impactful research
projects both in high-income countries
and in low-income and middle-
income countries is a top priority. Our
approach creates a dynamic Alliance
that will focus on achieving our vision.
Our membership includes a full
array of clinicians and researchers with
an interest in recovery after stroke,
from acute stroke physicians to basic
scientists, from 36 countries. ISRRA
is open to all, and our work has just
begun.
We thank the many individuals who have
contributed to the work of past Stroke Recovery and
Rehabilitation Roundtables and to the building of
the strategy and work plans for the Alliance to date.
Our work is sponsored by the National Health and
Medical Research Council (NHMRC; Australia) Centre
of Research Excellence in Stroke Rehabilitation and
Brain Recovery (APP 1077898), the Canadian
Partnership for Stroke Recovery, NHMRC (Australia)
Centre of Research Excellence in Stroke Trials
(APP 2015705), Moleac, and Ipsen.
296 www.thelancet.com/neurology Vol 22 April 2023
*Julie Bernhardt, Dale Corbett,
Sean Dukelow, Sean Savitz,
John M Solomon, Rachel Stockley,
Katharina S Sunnerhagen,
Geert Verheyden, Marion Walker,
Margit Alt Murphy,
Anna Katharina Bonkhoff,
Dominique Cadilhac,
S Thomas Carmichael, Emily Dalton,
Numa Dancause, Jodi Edwards,
Coralie English, Erin Godecke,
Kate Hayward,
Sureshkumar Kamalakannan,
Joosup Kim, Gert Kwakkel,
Catherine E Lang, Natasha Lannin,
Mindy Levin, Elizabeth Lynch,
Gillian Mead, Juan Pablo Saa, Nick Ward
j.bernhardt@unimelb.edu.au
Stroke Theme, Florey Institute of Neuroscience and
Mental Health—Austin Campus, Heidelberg,
VIC 3084, Australia (JB, KH, JPS); Department of
Cellular and Molecular Medicine (DCo) and School of
Epidemiology and Public Health (JE), University of
Ottawa, Ottawa, ON, Canada; Department of Clinical
Neurosciences, University of Calgary, Calgary, AB,
Canada (SD); Institute for Stroke and
Cerebrovascular Disease at UTHealth—Houston,
Houston, TX, USA (SS); Centre for Comprehensive
Stroke Rehabilitation and Research, Manipal College
of Health Professions, Manipal Academy of Higher
Education, Manipal, India (JMS); School of Nursing,
University of Central Lancashire, Preston, UK (RS);
Department of Clinical Neuroscience, Rehabilitation
Medicine, Institute of Neuroscience and Physiology,
University of Gothenburg, Gothenburg, Sweden
(KSS, MAM); Department of Neurological
Rehabilitation (KSS) and Department of
Occupational Therapy and Physiotherapy (MAM),
Sahlgrenska University Hospital, Gothenburg,
Sweden; Department of Rehabilitation Sciences,
KU Leuven, Leuven, Belgium (GV); School of
Medicine, University of Nottingham, Nottingham,
UK (MW); Department of Neurology, Massachusetts
General Hospital, Boston, MA, USA (AKB);
Department of Medicine, School of Clinical Sciences
at Monash Health (DCa, JK) and Department of
Neuroscience, Central Clinical School (NL), Monash
University, Melbourne, VIC, Australia; Department
of Neurology, David Geffen School of Medicine at
University of California Los Angeles, Los Angeles,
CA, USA (STC); Department of Neurosciences,
Université de Montréal, Montreal, QC, Canada (ND);
School of Health Sciences, The University of
Newcastle, Newcastle, NSW, Australia (CE); School
of Medical and Health Sciences, Edith Cowan
University, Joondalup, WA, Australia (EG);
Department of Physiotherapy, The University of
Melbourne, Melbourne, VIC, Australia (KH, ED);
Department of Social Work, Education and
Community Wellbeing, Northumbria University,
Newcastle, UK (SK); Department of Rehabilitation
Medicine, Amsterdam University Medical Centres,
Amsterdam, Netherlands (GK); Department of
Physical Therapy, Washington University in St Louis,
St Louis, MO, USA (CEL); School of Physical and
Occupational Therapy, McGill University, Montreal,
QC, Canada (ML); Caring Futures Institute, Flinders
University, Adelaide, SA, Australia (EL); Usher
Institute, The University of Edinburgh, Edinburgh,
UK (GM); Department of Clinical and Motor
Neuroscience, UCL Queen Square Institute of
Neurology, University College London, London,
UK (NW)
1 Wafa HA, Wolfe CDA, Emmett E, Roth GA,
Johnson CO, Wang Y. Burden of stroke in
Europe: thirty-year projections of incidence,
prevalence, deaths, and disability-adjusted life
years. Stroke 2020; 51: 2418–27.
2 Gimigliano F, Negrini S. The World Health
Organization “Rehabilitation 2030: a call for
action”. Eur J Phys Rehabil Med 2017;
53: 155–68.
3 Leitch S, Logan M, Beishon L, Quinn TJ.
International research priority setting exercises
in stroke: a systematic review. Int J Stroke 2023;
18: 133–43.
4 Bernhardt J, Hayward KS, Kwakkel G, et al.
Agreed definitions and a shared vision for
new standards in stroke recovery research:
The Stroke Recovery and Rehabilitation
Roundtable taskforce. Int J Stroke 2017;
12: 444–50.