Age-adjusted Stroke Mortality Research Articles

Indices of cerebral vascular function & health in young healthy adults: impact of sex and race

Background: Cerebral vascular diseases and neurocognitive conditions including stroke, cognitive impairment, & Alzheimer’s disease and related dementias are the fastest growing causes of morbidity and mortality. Studies have demonstrated sex differences in indices of physiological function associated with cardiovascular and metabolic disease risk/prevalence. Further, the incidence of these conditions is elevated in Black (BL) individuals; however, BL females have a reduced age adjusted stroke mortality compared to BL males. Reduced cerebral vascular function/health contributes to the risk for these conditions. Limited studies have examined the influence of sex and race on indices of cerebral vascular function/health. This study examined the potential interaction between race and sex in cerebral pulsatility index (PI: index of cerebral vascular stiffness) and cerebral vasomotor reactivity (CVMR) to a hypercapnic challenge (index of cerebral vasodilatory responsiveness). Hypothesis: We hypothesized: 1) females would have reduced PI and elevated CVMR relative to males. 2) BL individuals would exhibit augmented PI and reduced CVMR. 3) BL females would have reduced PI relative to BL males. 4) Lastly, we posit that CVMR will be negatively correlated with PI. Methods: Data is presented from 136 young healthy individuals. 40 BL males (age: 22±3 yr, BMI: 25±4 kg/m²), 37 BL females (age: 21±3 yr, BMI: 24±4 kg/m²), 39 White (WH) males (age: 24±3 yr, BMI: 25±3 kg/m²), and 20 WH females (age: 25±6 yr, BMI: 23±3 kg/m²). Heart rate, beat-to-beat blood pressure, end-tidal carbon dioxide concentration (PETCO2), and middle cerebral artery blood velocity (MCAv) were continuously recorded (minimum of 6 min). Cerebral vascular function/health was indexed as (a) PI ((MCAVv systolic − MCAv diastolic)/MCAv mean). (b) CVMR assessed as % increase in cerebral vascular conductance (CVCi) slope during a hypercapnic challenge (%CVCi/ΔPETCO2). Results: PI was elevated in males (male: 0.86±0.18, female: 0.77±0.11, P=0.03). There was no difference between races (WH: 0.83±0.19, BL: 0.79±0.13, P=0.27) nor was there a sex x race interaction ( P=0.54). CVMR assessed as %CVCi slope was not different between sexes (male: 2.4±1.7 %/mmHg, female: 2.7±1.2 %/mmHg, P=0.16) or BL & WH (WH: 2.7±1.3 %/mmHg, BL: 2.4±1.1 %/mmHg, P=0.16). CVMR was lower in the BL males relative to the BL females (BL male: 2.0±0.9 %/mmHg, BL female: 2.8±1.2 %/mmHg, P=0.002). There was no difference between WH males and females ( P=0.88). Lastly, there was not a significant correlation between PI and CVMR to hypercapnia ( P=0.16). Conclusion: These preliminary data suggest that relatively young and otherwise health White and Black females have augmented indices of cerebral vascular function/health relative to males. Furthermore, BL males have reduced cerebral vasodilatory responsiveness to a hypercapnic stimuli. The University of Texas at Arlington College of Nursing and Health Innovation and Institutional Start up Funds to Dr. Brothers. This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

County-Level Socio-Environmental Factors Associated With Stroke Mortality in the United States: A Cross-Sectional Study.

We used machine learning methods to explore sociodemographic and environmental determinants of health (SEDH) associated with county-level stroke mortality in the USA. We conducted a cross-sectional analysis of individuals aged ≥15 years who died from all stroke subtypes between 2016 and 2020. We analyzed 54 county-level SEDH possibly associated with age-adjusted stroke mortality rates/100,000 people. Classification and Regression Tree (CART) was used to identify specific county-level clusters associated with stroke mortality. Variable importance was assessed using Random Forest analysis. A total of 501,391 decedents from 2397 counties were included. CART identified 10 clusters, with 77.5% relative increase in stroke mortality rates across the spectrum (28.5 vs 50.7 per 100,000 persons). CART identified 8 SEDH to guide the classification of the county clusters. Including, annual Median Household Income ($), live births with Low Birthweight (%), current adult Smokers (%), adults reporting Severe Housing Problems (%), adequate Access to Exercise (%), adults reporting Physical Inactivity (%), adults with diagnosed Diabetes (%), and adults reporting Excessive Drinking (%). In conclusion, SEDH exposures have a complex relationship with stroke. Machine learning approaches can help deconstruct this relationship and demonstrate associations that allow improved understanding of the socio-environmental drivers of stroke and development of targeted interventions.

Impact of State Stroke Systems of Care Laws on Stroke Outcomes.

Since 2003, 38 US states and Washington, DC have adopted legislation and/or regulations to strengthen stroke systems of care (SSOCs). This study estimated the impact of SSOC laws on stroke outcomes. We used a coded legal dataset of 50 states and DC SSOC laws (years 2003-2018), national stroke accreditation information (years 1997-2018), data from the Healthcare Cost and Utilization Project (years 2012-2018), and National Vital Statistics System (years 1979-2019). We applied a natural experimental design paired with longitudinal modeling to estimate the impact of having one or more SSOC policies in effect on outcomes. On average, states with one or more SSOC policies in effect achieved better access to primary stroke centers (PSCs) than expected without SSOC policies (ranging from 2.7 to 8.0 percentage points (PP) higher), lower inpatient hospital costs (USD 610-1724 less per hospital stay), lower age-adjusted stroke mortality (1.0-1.6 fewer annual deaths per 100,000), a higher proportion of stroke patients with brain imaging results within 45 min of emergency department arrival (3.6-5.0 PP higher), and, in some states, lower in-hospital stroke mortality (5 fewer deaths per 1000). Findings were mixed for some outcomes and there was limited evidence of model fit for others. No effect was observed in racial and/or rural disparities in stroke mortality.

Abstract 13944: Young, Non-Hispanic Black Males and Females Exhibit Divergent Peripheral and Cerebral Vascular Reactivity

Introduction: In the U.S., cardiovascular and cerebrovascular diseases (CVD) remain more prominent in non-Hispanic black individuals than in other populations. Across most racial/ethnic groups, total CVD prevalence is ~10% lower in females; however, total CVD prevalence in black females (BF) is similar to that of black males (BM). Conversely, BM have ~23% higher age-adjusted stroke mortality compared to BF, a pattern not seen in other groups. While the mechanisms behind these race-by-sex differences are multifactorial, vascular dysfunction likely contributes. Our group and others have demonstrated reduced brachial artery and cerebrovascular vasodilation in black versus white individuals, though much of this work did not specifically address sex differences. To this end, we have recently investigated and reported divergent mechanisms of reduced cutaneous microvascular function in BM and BF; however, more work is needed to better understand whether such findings extend to other vascular regions. Hypothesis: We tested the hypothesis that BF and BM would have divergent degrees of reduced peripheral and cerebral vasodilator responsiveness. Methods: Eleven BF and 15 BM (22 ± 4 vs. 23 ± 3 yrs) underwent testing for brachial artery flow-mediated dilation (FMD; conduit artery function) and post-occlusive reactive hyperemia (PORH; microvascular function), along with cerebrovascular reactivity (CVR) to rebreathing-induced hypercapnia. Results: FMD was greater in BF versus BM (9.10 ± 3.49 vs. 5.84 ± 2.78%; P = 0.02), even when normalized to baseline diameter or shear rate ( P < 0.05 for both). BF had similar PORH when assessed as peak blood velocity (77.1 ± 19.9 vs. 79.4 ± 19.6 cm • s -1 ; P > 0.05) but lower peak blood flow (343.6 ± 169.8 vs. 495.4 ± 196.9 mL/min; P < 0.05) and blood flow AUC (133.6 ± 61.1 vs. 220.3 ± 130.7 mL; P = 0.04) relative to BM. CVR was greater in BF versus BM (0.024 ± 0.010 vs. 0.012 ± 0.006 cm • s -1 • mmHg -1 • mmHg -1 ; P < 0.01). Conclusion: These data suggest that young, BM have lower vascular reactivity than BF during some, but not all, tests of vascular function. More work in this area is needed to better understand the potential biological and social mechanisms influencing sex differences in vascular function and CVD risk in black individuals.

Mortality trends of stroke and dementia: Changing landscapes and new challenges.

Stroke and dementia are important causes of death in the United States and may be interrelated as competing risks for mortality. No previous studies have simultaneously compared age- and sex-specific mortality trends between stroke and subtypes of dementia at a population level. Insights gained from this study can help identify high-risk populations and inform healthcare service requirements for managing stroke and dementia in the United States. To examine nationwide trends in mortality from stroke and subtypes of dementia in the United States by age group and sex. Population-based cross-sectional study. U.S. mortality data from 2007 to 2016. All U.S. residents whose primary cause of death was stroke, Alzheimer's disease, vascular dementia, or Lewy body dementia. Age-adjusted mortality, mortality trends among men and women were analyzed separately using joinpoint regression. From 2007 to 2016, age-adjusted stroke mortality fell by 21.6%. Age-adjusted mortality (per 1,000,000) for Alzheimer's disease, vascular dementia, and Lewy body dementia increased by 1.2-fold, 2-fold, and 3-fold, respectively. Annual age-adjusted stroke mortality decreased by an average rate of 2.67% per year, while annual age-adjusted mortality for Alzheimer's disease, vascular dementia, and Lewy body dementia increased by an average rate of 2.06%, 4.90%, and 12.13% per year, respectively. Mortality from stroke and dementia increased with age. Greater reductions in stroke mortality and greater increases in dementia mortality were seen in women than men; and in older than younger (<65 years) people. There has been a striking rising trend in dementia mortality coincident with a reduction in stroke mortality in the United States. There are persistent age and sex disparities in stroke and dementia mortality trends. Our findings support the pathophysiological relationship between stroke and dementia, and have important implications for future research, healthcare planning, and provision.

Examining Stroke Disparities in Florida: Relationships Among County Classification, Age-Adjusted Stroke Mortality Rates, and the Presence of Primary Stroke Centers.

Preventing Chronic Disease (PCD) is a peer-reviewed electronic journal established by the National Center for Chronic Disease Prevention and Health Promotion. PCD provides an open exchange of information and knowledge among researchers, practitioners, policy makers, and others who strive to improve the health of the public through chronic disease prevention.

Evaluation of Between-County Disparities in Premature Mortality Due to Stroke in the US

Identifying the factors associated with premature stroke mortality and measuring between-county disparities may provide insight into how to reduce variations and achieve more equitable health outcomes. To examine the between-county disparities in premature stroke mortality in the US, investigate county-level factors associated with mortality, and describe differences in mortality disparities by place of death and stroke subtype. This retrospective cross-sectional study linked the mortality and demographic data of US counties from the Centers for Disease Control and Prevention WONDER database to county-level characteristics from multiple databases. The outcome measure was county-level age-adjusted stroke mortality among adults aged 25 to 64 years in 2637 US counties from 1999 to 2018. This study was conducted from April 1, 2019, to October 31, 2020. Generalized linear Poisson regressions were fitted to investigate 4 sets of factors associated with county-level mortality: demographic composition, socioeconomic status, health care and environmental features, and population health. The Theil index score was calculated to assess the mortality disparities. Stroke mortality was measured as the number of deaths attributed to stroke in the data set. Out-of-stroke-unit death was defined as any death occurring in outpatient or emergency departments or at the pretransport location. Five stroke subtypes were included in the analysis. Although mortality did not change substantially from 1999 to 2018 (from 12.62 to 11.81 per 100 000 population), the proportion of deaths occurring out of the stroke unit increased from 23.56% (4328 of 18 369) to 34.57% (6978 of 20 188). A large percentage of stroke of an uncertain cause was reported, with most deaths (55.20%) occurring out of the stroke unit. In the county with the highest premature stroke mortality, the incidence was 20.78 times as high as that in the county with the lowest mortality (65.04 vs 3.13 deaths per 100 000 population). The highest between-county disparities were found for stroke of uncertain cause. For out-of-stroke-unit death, county-level mortality was largely associated with demographic composition (31.6%) and health care and environmental features (25.8%). For in-hospital death, 29.8% of county-level mortality was associated with population health and 28.7% was associated with demographic composition. These findings suggest that strategies addressing specific factors that underlie the mortality disparities among US counties, especially for out-of-stroke-unit death and stroke of uncertain cause, may be useful when tailored to the county-level context before implementing interventions for the neediest counties.

Differences in Hypercapnia‐Induced Cerebral Vasodilation Between Young, Black Men and Women

In the U.S., stroke prevalence and age-adjusted mortality are greater in the black population than all other racial/ethnic groups. Further, black women (BW) exhibit an ~15% lower age-adjusted stroke mortality than black men (BM), suggesting either cerebrovascular protection in BW or cerebrovascular impairment in BM. While the mechanisms underlying the increased burden of stroke in black individuals remain incompletely understood, vascular dysfunction likely contributes to these negative health outcomes. Our group and others have previously demonstrated impaired vasodilation in the brachial artery, cutaneous microvasculature, and cerebral vasculature in black versus white men and women. However, investigations into gender differences in young, black individuals' cerebral vasodilatory responsiveness remain lacking. Therefore, this study tested the hypothesis that BW and BM exhibit divergent cerebral vasodilatory responses to a rebreathing-induced hypercapnic stimulus. To test this hypothesis, 11 BW and 15 BM (mean ± SD; age: 22 ± 4 vs. 23 ± 3) participated in this study. Each participant was instrumented for the continuous measurement of end-tidal carbon dioxide concentration (PETCO2; capnograph), beat-to-beat mean arterial pressure (MAP; finger photoplethysmography), and middle cerebral artery velocity (MCAv; transcranial Doppler ultrasound) at baseline and during rebreathing induced-hypercapnia. Absolute cerebral vascular conductance index (CVCi = MCAv/MAP) and percent change CVCi (ΔCVCi = [CVCiΔPETCO2 – CVCiBL]/CVCiBL • 100) were calculated at baseline and a ΔPETCO2 of 3, 6, 9, and 12 mmHg (only 8 BW were analyzed at 12 mmHg due to some individuals not reaching this stage). No differences in MAP were observed between BW and BM at baseline or any ΔPETCO2 (BL: 91 ± 9 vs. 89 ± 7 mmHg; Δ3: 88 ± 11 vs. 88 ± 9 mmHg; Δ6: 93 ± 8 vs. 89 ± 8 mmHg; Δ9: 94 ± 8 vs. 90 ± 9 mmHg; Δ12: 95 ± 10 vs. 91 ± 9 mmHg; interaction P = 0.11). At baseline, BW had a greater absolute CVCi than BM (0.80 ± 0.10 vs. 0.68 ± 0.13 cm/s/mmHg; P = 0.04). This pattern was also observed at each ΔPETCO2 stage (Δ3: 0.91 ± 0.11 vs. 0.67 ± 0.13 cm/s/mmHg; Δ6: 0.98 ± 0.10 vs. 0.71 ± 0.12 cm/s/mmHg; Δ9: 1.04 ± 0.09 vs. 0.78 ± 0.13 cm/s/mmHg; Δ12: 1.11 ± 0.11 vs. 0.80 ± 0.16 cm/s/mmHg; all P < 0.001). Despite the baseline differences between groups, BW still exhibited a greater ΔCVCi at each stage of ΔPETCO2 than BM (Δ3: 12.9 ± 5.3 vs. 0.1 ± 9.4%; Δ6: 23.0 ± 6.8 vs. 5.5 ± 10.2%; Δ9: 29.9 ± 12.9 vs. 16.0 ± 11.2%; Δ12: 40.7 ± 16.8 vs. 19.0 ± 12.3%; all P < 0.05). These data suggest that young, BW exhibit greater cerebrovascular responsiveness to a hypercapnic stimulus relative to young, BM, which may partially explain the lower age-adjusted stroke mortality in BW. However, the mechanisms responsible for these observed differences remain undetermined and should be the subject of future research.

Frontiers of Upstream Stroke Prevention and Reduced Stroke Inequity Through Predicting, Preventing, and Managing Hypertension and Atrial Fibrillation: A Call to Action From the Value in Healthcare Initiative's Predict & Prevent Learning Collaborative.

Stroke is one of the leading causes of morbidity and mortality in the United States. While age-adjusted stroke mortality was falling, it has leveled off in recent years due in part to advances in medical technology, health care options, and population health interventions. In addition to adverse trends in stroke-related morbidity and mortality across the broader population, there are sociodemographic inequities in stroke risk. These challenges can be addressed by focusing on predicting and preventing modifiable upstream risk factors associated with stroke, but there is a need to develop a practical framework that health care organizations can use to accomplish this task across diverse settings. Accordingly, this article describes the efforts and vision of the multi-stakeholder Predict & Prevent Learning Collaborative of the Value in Healthcare Initiative, a collaboration of the American Heart Association and the Robert J. Margolis, MD, Center for Health Policy at Duke University. This article presents a framework of a potential upstream stroke prevention program with evidence-based implementation strategies for predicting, preventing, and managing stroke risk factors. It is meant to complement existing primary stroke prevention guidelines by identifying frontier strategies that can address gaps in knowledge or implementation. After considering a variety of upstream medical or behavioral risk factors, the group identified 2 risk factors with substantial direct links to stroke for focusing the framework: hypertension and atrial fibrillation. This article also highlights barriers to implementing program components into clinical practice and presents implementation strategies to overcome those barriers. A particular focus was identifying those strategies that could be implemented across many settings, especially lower-resource practices and community-based enterprises representing broad social, economic, and geographic diversity. The practical framework is designed to provide clinicians and health systems with effective upstream stroke prevention strategies that encourage scalability while allowing customization for their local context.

Abstract WMP57: Geographic Disparities in Stroke and Life Expectancy Significantly Attributable to Ambient PM2.5 Pollution Across the Counties of the United States

Background: We aimed to test the hypotheses that ambient particulate matter (PM2.5) is significantly associated with the risk of stroke mortality and life expectancy (LE) reduction, and the degrees of these associations differ across the counties and regions of the United States (U.S). Methods: Annual average county-level data (n=1561 counties) from U.S. Centers for Disease Control and Prevention, and Environmental Protection Agency on PM2.5 measures in 2005-2010, age-adjusted stroke mortality in adults aged ≥35 in 2013-2015, and LE in 2010, as well as % of poverty rate, number of primary care physicians per 1000 residents (as a marker of healthcare support) and county-level % of rural population as covariates were analyzed using linear and multilevel hierarchical regression analyses. Results: Significant county-level variations in annual average PM2.5 levels (range: 7.2-14.7 ug/ 3 ), stroke mortality (30.1-219.0 per 100,000 population in males, and 35.0-249.0 in females), and LE (65.0-81.7 years in males and 72.7-85.0 in females) were observed across the nation. Population-weighted PM2.5 levels were significantly and positively associated with stroke mortality in males (r=0.49, p&lt;.0001), and in females (r=0.42, p&lt;.0001), and negatively associated with LE in males (r=-0.39, p&lt;.0001) and females (r=-0.37, p&lt;.0001). Adjusted multilevel analysis indicates that PM2.5 was significantly associated with stroke mortality rates (β=1.27, p&lt;.0001) in both sexes, and with LE in males (β=-0.18, p=&lt;.001), and in females (β=-0.09, p&lt;.001). The adverse impacts of PM2.5 were even worse in counties with higher % of poverty rates and poorer healthcare support compared to their counterparts. Analyses by regions indicate that the highest risk of PM2.5 for stroke (assessed by regression coefficients) was shown for males and females living in the South, followed by Midwest, Northeast, and West. Similar results of the risk of PM2.5 for LE reduction were observed across the regions. Conclusion: The study, using U.S. national representative datasets provides new and important evidence that geographic disparities in stroke mortality and LE are significantly attributable to ambient PM2.5 pollution across the nation.

Racial and Ethnic Disparities in Hospital Mortality among Ischemic Stroke Patients in Hawaii

We evaluated disparities in in-hospital mortality rates among whites, Native Hawaiians and other Pacific Islanders (NHOPI), Filipinos, and other Asian groups in Hawaii who were hospitalized for acute ischemic stroke. Using a statewide hospital claims database, we performed a retrospective study including sequential acute ischemic stroke patients between 2010 and 2015. We compared in-hospital mortality rates among whites, NHOPI, Filipinos, other Asian groups excluding Filipinos, and other races (Blacks, Hispanics, Native Americans, mixed race). A total of 13,030 patient discharges were included in this study. The mean (±SD) age in years at the time of stroke was 63.5 ± 14.3 for NHOPI, 69.6 ± 14.4 for Filipinos, 67.8 ± 14.2 for other race, 71.4 ± 13.8 for whites, and 76.1 ± 13.5 for other Asians (P < .001). NHOPI patients had higher rates of diabetes (48.8%), obesity (18.4%), and tobacco use (31.3%) compared with patients in other racial-ethnic categories. Filipino patients had the highest rate of hemorrhagic transformation (9.7%). Age-adjusted stroke mortality rates were highest among Filipinos (15.9%; 95% confidence interval [CI] = 14.3%-17.6%), followed by other Asian groups (15.1%; 95% CI = 14.0%-16.2%), NHOPI (14.8%; 95% CI = 12.8%-16.8%), other race (14.4%; 95% CI = 11.3%-17.4%), and lowest among whites (12.8%; 11.5%-14.2%). After adjusting for other confounding variables, Filipinos had higher mortality (odds ratio = 1.22, 95% CI = 1.03-1.45), whereas other Asian groups, NHOPI, and other race patients had mortality rates that were similar to whites. In Hawaii, Filipino ethnicity is an independent risk factor for higher in-hospital stroke mortality compared with whites.

Trend of declining stroke mortality in China: reasons and analysis

IntroductionThere is a downward trend of stroke-related mortality in the USA. By reviewing all published articles on stroke mortality in China, we analysed its trend and possible factors that have...

Consistent declining trends in stroke mortality in Brazil: mission accomplished?

Stroke mortality rates are declining in Brazil, but diferences among regions need to be better investigated. The age-adjusted stroke mortality trends among adults (30-69 years-old) from Brazilian regions were studied between 1996 and 2011. Method Data were analyzed after: 1) reallocation of deaths with non-registered sex or age; 2) redistribution of garbage codes and 3) underreporting correction. A linear regression model with autoregressive errors and a state space model were fitted to the data, aiming the estimation of annual trends at every point in time. Results Although there were high values, a steady decrease of rates was observed. The decreasing trends among all regions were statistically significant, with higher values of decline among the Northeast and Northern regions, where rates were the highest. Conclusion Standardized methodology use is mandatory for correct interpretation of mortality estimates. Although declining, rates are still extremely high and efforts must be made towards prevention of stroke incidence, reduction of case-fatality rates and prevention of sequelae.

Does Place of Residence or Time of Year Affect the Risk of Stroke Hospitalization and Death? A Descriptive Spatial and Temporal Epidemiologic Study.

BackgroundIdentifying geographic areas with significantly high risks of stroke is important for informing public health prevention and control efforts. The objective of this study was to investigate geographic and temporal patterns of stroke hospitalization and mortality risks so as to identify areas and seasons with significantly high burden of the disease in Florida. The information obtained will be useful for resource allocation for disease prevention and control.MethodsStroke hospitalization and mortality data from 1992 to 2012 were obtained from the Florida Agency for Health Care Administration. Age-adjusted stroke hospitalization and mortality risks for time periods 1992–94, 1995–97, 1998–2000, 2001–03, 2004–06, 2007–09 and 2010–12 were computed at the county spatial scale. Global Moran’s I statistics were computed for each of the time periods to test for evidence of global spatial clustering. Local Moran indicators of spatial association (LISA) were also computed to identify local areas with significantly high risks.ResultsThere were approximately 1.5 million stroke hospitalizations and over 196,000 stroke deaths during the study period. Based on global Moran’s I tests, there was evidence of significant (p<0.05) global spatial clustering of stroke mortality risks but no evidence (p>0.05) of significant global clustering of stroke hospitalization risks. However, LISA showed evidence of local spatial clusters of both hospitalization and mortality risks with significantly high risks being observed in the north while the south had significantly low risks of stroke deaths. There were decreasing temporal trends and seasonal patterns of both hospitalization and mortality risks with peaks in the winter.ConclusionsAlthough stroke hospitalization and mortality risks have declined in the past two decades, disparities continue to exist across Florida and it is evident from the results of this study that north Florida may, in fact, be part of the stroke belt despite not being in any of the traditional stroke belt states. These findings are useful for guiding public health efforts to reduce/eliminate inequities in stroke outcomes and inform policy decisions. There is need to continually identify populations with significantly high risks of stroke to better guide the targeting of limited resources to the highest risk populations.

The burden of stroke in Africa: a glance at the present and a glimpse into the future: review article

SummaryObjectiveInformation on the current burden of stroke in Africa is limited. The aim of this review was to comprehensively examine the current and projected burden of stroke in Africa.MethodsWe systematically reviewed the available literature (PubMed and AJOL) from January 1960 and June 2014 on stroke in Africa. Percentage change in age-adjusted stroke incidence, mortality and disability-adjusted life years (DALYs) for African countries between 1990 and 2010 were calculated from the Global Burden of Diseases (GBD) model-derived figures.ResultsCommunity-based studies revealed an age-standardised annual stroke incidence rate of up to 316 per 100 000 population, and age-standardised prevalence rates of up to 981 per 100 000. Model-based estimates showed significant mean increases in age-standardised stroke incidence. The peculiar factors responsible for the substantial disparities in incidence velocity, ischaemic stroke proportion, mean age and case fatality compared to high-income countries remain unknown.ConclusionsWhile the available study data and evidence are limited, the burden of stroke in Africa appears to be increasing.

Stroke mortality rates vary in local communities in a metropolitan area: racial and spatial disparities and correlates.

For the past decade, stroke has held steady as one of the top 4 leading causes of death in the United States. Aggregated data provide information about how the country or individual states are faring with respect to stroke mortality, but disaggregation provides data that may facilitate targeted interventions and community engagement. We analyzed deaths from stroke to residents of Chicago to calculate age-adjusted stroke mortality rates (AASMRs). We calculated AASMRs for Chicago by race/ethnicity, sex, and community area. We also examined the correlation between AASMR and (1) racial/ethnic composition of a community area and (2) median household income. The AASMR for Chicago (44.9 per 100,000 population) was significantly higher than the national rate (42.2). Within both the United States and Chicago, the highest AASMRs were found among non-Hispanic blacks, followed by non-Hispanic whites, and then Hispanics. There was a strong, positive correlation between the proportion of black residents in a community area and the AASMR (0.58). There was a strong, negative relationship between household income and the AASMR for the entire city (-0.56) and for the predominantly black community areas (-0.47). These data provide insight into where the worst stroke mortality problems reside in Chicago. We anticipate that the data can be used to work toward the development of solutions to the high stroke mortality rates observed in several of Chicago's community areas and in similar communities throughout the United States.

Knowledge, perceptions and thoughts of stroke among Arab-Muslim Israelis

Age-adjusted stroke mortality rates in Israel are higher among Arabs compared with Jews; therefore, knowledge of stroke signs and prevention strategies is especially important in the Arab population. Data on stroke knowledge among Arabs in Israel are lacking. We aimed to examine knowledge, perceptions and thoughts of stroke among Arab-Muslim Israelis. A complementary mixed method design was used. Ninety-nine Arab Muslims living in Israel, older than 40 years, with no history of stroke, were personally interviewed. Knowledge of stroke was assessed using quantitative analysis by a semi-structured interview. Information on perceptions and thoughts evoked by stroke was analyzed using qualitative analysis by the constant comparative method. Rates of reported knowledge-related variables were presented. Mean (SD) age of participants was 50.1 (8.0) years, 52.5% were women. Most of the participants (84.8%) knew the causes of stroke but only 29.3% mentioned sudden weakness or paralysis in one side of the body as a warning sign and other warning signs were even less known. The main known risk factor was hypertension (43.3%). Although knowledge of stroke prevention was poor, 89% were interested in learning about stroke and its prevention. The qualitative findings showed that stroke evokes negative thoughts of mental and physical burden and is associated with death, disability, dependence and depression. Levels of stroke knowledge among Arab-Muslim Israelis are low to moderate. Healthcare professionals should assist high risk populations in controlling and treating risk factors in order to reduce mortality and disability following a stroke.

How Do We Know If We Are Making Progress in Reducing the Public Health Burden of Stroke?

See related article, p, 2207. Much of the description of the differential burden of specific diseases and temporal changes in these burdens is based on mortality data. Stroke mortality rates have declined dramatically in the 20th century and into the new millennium. This has been acclaimed as one of the top 10 public health achievements of these eras.1,2 In 1999, the age-adjusted stroke death rate was 61.6 per 100 000, but it decreased by 37% in only 11 years to 38.9 per 100 000 in 2009 (most recent year available).3 Stroke has been stable as the third leading cause of death throughout most of the 20th century but in 2008, it declined to the fourth leading cause of death in the United States.4–6 Preliminary mortality data for 2009 and 2010 show that although stroke remains the fourth leading cause of death, the age-adjusted death rates for stroke continue to decrease, specifically by 4.3% between 2008 and 2009 and by 1.5% between 2009 and 2010.7,8 This dramatic and sustained decline in stroke mortality is indeed remarkable and raises questions regarding the underlying causes of the decline, including the possibility that it could be an artifact of the classification system for causes of death. What define disease-specific causes of death are codes on death certificates related to “underlying cause of death” (UCOD). In this issue of Stroke , Burke and colleagues9 report on their examination of 2000 to 2008 death certificate data of both UCOD and “any mention cause of death” to investigate …

Taming the Burgeoning Stroke Epidemic in Africa: Stroke Quadrangle to the Rescue (P01.002)

Objective: This is a systematic review of the existing literature to examine the burden and profile of stroke in the WHO African region and proffer coordinated and responsive means of tackling the epidemic. Background Africa is currently experiencing epidemiological transition with growing burden of stroke and other non-communicable diseases, initially adding to the infectious and poverty-related disease burden and later becoming the dominant causes of death and disability. There is inadequate pooled data describing the total burden of stroke in Africa. Design/Methods: A systematic review of the literature was conducted according to the Centre for Reviews and Dissemination Guidelines using Pubmed, African Journals On-Line and Google Scholar databases. Over 1300 articles were obtained. All abstracts were screened, and every article that might have contained relevant information was read in full. Their heterogeneity made meta-analysis impossible. So a critical assessment of the data with a narrative review was conducted. Results: Stroke has an annual incidence rate of up to 316 per 100 000, a prevalence rate of up to 315 per 100 000 and a 3-year fatality of up to 84% in Africa. In 2002, model-based estimated age-adjusted stroke mortality rates ranged between 168 and 179 per 100 000 population for countries in the African region. There is severe scarcity of facilities and human resources for prevention, investigations, acute care and rehabilitation of stroke patients in Africa. Conclusions: Africa bears a heavy burden of stroke. I propose a stroke quadrangle comprising a concerted network of four pillars: demographic surveillance and stroke research network; integrated community-based primary and secondary prevention programs; easily accessible and well-equipped acute stroke care services; and neurorehabilitation centres and services. This network could be reinforced using information and communication technologies, telemedicine facilities and linked health information systems. Disclosure: Dr. Owolabi has nothing to disclose.

Abstract 2535: Urban Versus Rural Differences In Stroke Risk: The CDC Wonder Estimates Of Mortality, And REasons For Geographic And Racial Differences In Stroke (REGARDS) Estimates Of Incidence And Survival After Stroke

Introduction: Rural-urban disparities in stroke are poorly understood and incompletely characterized. US stroke incidence, mortality, and survival after stroke have not, to our knowledge, been previously reported by urban-rural status. Methods: Data for US residents over age 45 from the CDC WONDER system were used to describe the age-adjusted stroke mortality rates between 1999 and 2007 for each county in the US, stratified by rurality. Stroke was defined by ICD-10 codes 60-69. Rurality was defined at the county level using the National Center for Health Statistics 6-level classification scheme. Data from the REGARDS Study, a longitudinal cohort study of 30,239 black and white participants aged 45+ from 48 states, were used to estimate the age and sex adjusted hazard ratio for incident stroke, and to assess survival after stroke, using the same urban/rural classification scheme. Results: Between 1999 and 2007, stroke mortality (per 100,000) for those aged 45+ was higher in rural counties for both whites and blacks, with a 20% difference in whites (156.6 for rural versus 131.0 for central metropolitan) and a 32% difference in blacks (237.4 versus 179.6). Among 27,740 REGARDS participants who were stroke-free at baseline with follow-up data, 614 adjudicated stroke events occurred over a mean 4.9 years of follow-up. For whites, incident stroke risk did not change with higher urbanization (HR reported in table ). There was a consistently lower risk of incident stroke with higher urbanization for blacks although this difference did not reach statistical significance (see table ). Follow-up was available on 609 of the stroke events. Risk of death after stroke appeared consistently (although generally non-significantly) lower with greater urbanization (see table ) for both blacks and whites. Discussion: Greater urbanization appears to be associated with lower stroke mortality for both whites and blacks, although differences may be larger for blacks. This difference in mortality may be due to both decreased incidence and survival following stroke for blacks; however, higher mortality for rural whites appears to be only due to decreased survival. Reasons for differences in incidence and survival following stroke may be related to control of vascular risk factors and access to care although further study is required.