Incidence Of First-ever Stroke Research Articles

Disparities in Stroke Incidence Over Time by Sex and Age in Latin America and the Caribbean Region 1997 to 2021: A Systematic Review and Meta-Analysis.

Background High-income country studies show unfavorable trends in stroke incidence (SI) in younger populations. We aimed to estimate temporal change in SI disaggregated by age and sex in Latin America and the Caribbean region. Methods and Results A search strategy was used in MEDLINE, WOS, and LILACS databases from 1997 to 2021, including prospective population-based observational studies with first-ever stroke incidence in Latin America. Reports without data broken down by age and sex were excluded. Risk of bias was assessed with The Joanna Briggs Institute's guide. The main outcomes were incidence rate ratio and relative temporal trend ratio of SI, comparing time periods before 2010 with after 2010. Pooled relative temporal trend ratios considering only studies with 2 periods in the same population were calculated by random-effects meta-analysis. Meta-regression analysis was used to evaluate incidence rate determinants. From 9242 records identified, 6 studies were selected including 4483 first-ever stroke in 4 101 084 individuals. Crude incidence rate ratio in younger subjects (<55 years) comparing before 2010:after 2010 periods showed an increase in SI in the past decade (incidence rate ratio, 1.37 [95% CI, 1.23-1.50]), in contrast to a decrease in older people during the same period (incidence rate ratio, 0.83 [95% CI, 0.76-0.89]). Overall relative temporal trend ratio (<55:≥55 years) was 1.65 (95 CI%, 1.50-1.80), with higher increase in young women (pooled relative temporal trend ratio, 3.08 [95% CI, 1.18-4.97]; P for heterogeneity <0.001). Conclusions An unfavorable change in SI in young people, especially in women, was detected in population-based studies in the past decade in Latin America and the Caribbean. Further investigation of the explanatory variables is required to ameliorate stroke prevention and inform local decision-makers. Registration URL: https://www.crd.york.ac.uk/prospero/ Identifier: CRD42022332563.

Incidence and outcomes for stroke in Ulaanbaatar, Mongolia, during 2019–21: a prospective population-based study

In the absence of reliable data to quantify the burden of stroke, we aimed to determine the incidence and outcome of stroke through the conduct of a prospective population-based study in Ulaanbaatar, Mongolia, during 2019-21. All cases of stroke were identified through surveillance of multiple overlapping sources of hospitalised, ambulatory, and deceased individuals, using standardised diagnostic criteria in adult (aged ≥16 years) residents of the six urban districts of Ulaanbaatar, Mongolia (population person-years, N=1 896 965) between Jan 1, 2019, and Dec 31, 2020. Data on sociodemography, medical history, and management were collected. Crude and standardised incidence were calculated for first-ever stroke and its major pathological subtypes, and reported with 95% CIs. Outcomes were 28-day case fatality ratios and functional recovery on the modified Rankin scale at 90 days and 1 year. 3803 strokes in 3738 patients were identified, of which 2962 were first-ever incident cases (mean age 59 years [SD 13], 1161 [39·2%] females). Annual incidence of first-ever stroke (per 100 000) was 156·1 (95% CI 150·5-161·8) on a crude basis, 171·6 (157·5-185·6) when age-adjusted to the Mongolian population, and 140·3 (136·7-143·9) when age-adjusted to the world population. World-adjusted incidence of pathological subtypes were 66·6 (95% CI 64·8-68·3) for ischaemic stroke, 54·5 (53·0-56·1) for intracerebral haemorrhage, and 18·7 (18·3-19·1) for subarachnoid haemorrhage. Men were twice as likely to suffer ischaemic stroke and intracerebral haemorrhage as women, but the risks were similar for subarachnoid haemorrhage; these patterns were consistent across age-groups. The predominant risk factors were hypertension seen in 1363 (63·1%) of 2161, smoking in 596 (26·8%) of 2220, regular alcohol consumption in 533 (24·0%) of 2220, obesity in 342 (16·1%) of 2125, and diabetes in 282 (12·7%) of 2220. There was little use (0·9%) of thrombolysis for acute ischaemic stroke, partly due to delays in presentation after the onset of symptoms (median 16·0 h [IQR 3·0-48·0]). The 28-day case-fatality rate was 36·1% (95% CI 34·3-37·9) overall, and 14·8% (12·8-16·7) for ischaemic stroke, 52·9% (49·9-55·8) for intracerebral haemorrhage, and 54·3% (49·4-59·1) for subarachnoid haemorrhage. Corresponding figures for poor functional outcome at 1-year, defined by scores of 3-6 for death or dependency on the mRS, were 61·6% (95% CI 59·8-63·4), 47·5% (44·7-50·3), 77·0% (74·5-79·5), and 61·8% (57·0-66·5), respectively. The urban population of Ulaanbaatar, Mongolia, has a high incidence of stroke, particularly for intracerebral haemorrhage and subarachnoid haemorrhage, from which half of patients die within 1 month and more than two-thirds are either dead or dependent at 90 days. Although the overall incidence of stroke is similar to other countries, it occurs at a mean age of 60 years, which is at least 10 years younger than in high-income countries. These epidemiological data can inform the implementation of future programmes and scale-up activities for the primary and secondary prevention of stroke, and in the organisation of systems of care. Science and Technology Foundation of the Ministry of Education, Culture, and Science of Mongolia and The George Institute for Global Health.

The relationship of income on stroke incidence in Finland and China.

Stroke incidence has continued to increase recently in most countries. The roles of individual-level income on the incidence of overall stroke and its subtypes are still unknown, especially in low- and middle-income countries and the cross-national evidence is also limited. We explored the association between individual-level income and stroke incidence in Finland and China. Changde Social Health Insurance Database (N=571843) and Finnish population register (N=4046205) data were used to calculate standard stroke incidence rates, which were employed to assess the absolute incidence difference between income quintiles. Cox regression was used to compare income differences in first-ever stroke incidence. The highest income quintile had lower overall and subtype stroke incidence when compared to lower-income quintiles. The relative difference was more evident in hemorrhagic stroke incidence. After adjusting for age and employment status, the disparity of stroke incidence between the lowest and highest income quintiles was high among both men and women and in Finland and China. The disparity was particularly notable among men: in Finland, the hazard ratio (HR) for hemorrhagic stroke was 0.633 [95% confidence interval (95% CI) 0.576-0.696] and HR 0.572 (95% CI 0.540-0.606) for ischemic stroke. The respective figures were HR 0.452 (95% CI 0.276-0.739) and HR 0.633 (95% CI 0.406-0.708) for China. Individual-level income is related to overall and subtype stroke incidence. Future studies should explore the causal relationship between individual-level income and stroke incidence.

Incidence and case-fatality rate of stroke in General Villegas, Buenos Aires, Argentina. The EstEPA population study

ObjectivesStroke epidemiology varies among different populations. The burden of stroke is high in low- and middle-income countries. Reliable population data is needed to assess the impact of stroke and to develop policies aimed to improve stroke care in our region. EstEPA is a population-based project assessing prevalence, incidence, mortality and burden of stroke in General Villegas Department, Buenos Aires, Argentina (pop=30,864 inhabitants). We determined incidence of stroke (first-ever and recurrent stroke) and stroke case-fatality rate from 2017 to 2020. MethodsFirst-ever strokes, recurrent strokes and transient ischemic attacks were ascertained and case-fatality rate was obtained. Diagnoses were based on standard AHA/WHO definitions. Study population included all persons residing in General Villegas during the three-year period. Hospitals, households, nursing homes, death certificates and several overlapping sources were surveyed. ResultsWe assessed 92,592 person-years. There were 155 cerebrovascular events aged 70 years (SD ± 13 years), of which 115 were first-ever strokes (74%), 21 recurrent strokes (13.5%) and 19 transient ischemic attacks (12.5%). The crude overall incidence rate of first-ever strokes was 124.2 per 100,000 population (86.9 per 100,000 [95% CI 58.5-115.2] when standardized by WHO World population and 109.7 per 100,000 [95% CI 89.7-129.8] when standardized by Argentine population) and 317.0 per 100,000 population in subjects older than 40 years. Case fatality rate at 30 days of first-ever strokes was 27%. ConclusionIn this population-based comprehensive stroke epidemiological study in Argentina, first-ever stroke incidence in an urban population was 124.2 per 100,000 population (86.9 per 100,000 adjusted by the WHO World population). This is lower than the incidence in other countries in the region and similar to a recent incidence study in Argentina. It is also comparable to reported incidence in most middle- and high-income countries. Stroke case-fatality rate was comparable to other population-based Latin-American studies.

Abstract 10248: Incidence and Case-Fatality Rate of Stroke in Argentina: The EstEPA Population Study

Introduction: Stroke epidemiology varies among different populations. The burden of stroke is high in low- and middle-income countries. Reliable population data is needed to assess the impact of stroke and to develop policies aimed to improve stroke care in our region. Objectives: EstEPA is a population-based project assessing prevalence, incidence, mortality and burden of stroke in General Villegas, Buenos Aires, Argentina (pop=30,864 inhabitants). We determined incidence of stroke (first-ever and recurrent stroke) and stroke case-fatality rate from 2017 to 2020. Methods: First-ever strokes, recurrent strokes and transient ischemic attacks were ascertained and case-fatality rate was obtained. Diagnoses were based on standard AHA/WHO definitions. Study population included all persons residing in General Villegas in the three-year period. Hospitals, households, nursing homes, death certificates and several overlapping sources were surveyed. Results: We assessed 92,592 person-years. There were 155 cerebrovascular events, of which 115 were first-ever strokes (74%), 21 recurrent strokes (13·5%) and 19 transient ischemic attacks (12·5%). The annual crude incidence rate of first-ever strokes was 124·2 per 100,000 person-years, while it was 109·7 per 100,000 (95% CI 89·7-129·8), 72·4 per 100,000 (95% CI 47·8-97·0) and 86·9 per 100,000 (95% CI 58·5-115·2) when standardized by the Argentine population, Segi's World population and WHO World population, respectively. The crude incidence rate according to the different subtypes of stroke was 93·4 per 100,000 person-years for ischemic stroke, 18·4 per 100,000 person-years for hemorrhagic stroke and 10·8 per 100,000 person-years for subarachnoid hemorrhage. Incidence increased after age 70. Case fatality rate at 30 days of first-ever strokes was 19·4%. Conclusions: In this first population-based comprehensive stroke epidemiological study in Argentina, first-ever stroke incidence in an urban population was 124·2 per 100,000 person-years. This is lower than the incidence in other countries in the region. It is similar to reported incidence in Western developed countries. Stroke case-fatality rate was comparable to other population-based Latin-American studies and most developed countries.

Epidemiology of First and Recurrent Ischemic Stroke in Sweden 2010–2019: A Riksstroke Study

Introduction: Ischemic stroke incidence appears to have decreased during the last decades, but most studies focus on the first-ever events and epidemiological data on recurrent stroke are scarce. The aim of our study was to investigate trends in incidence, risk factors, and medication in patients with first-ever and recurrent ischemic stroke between 2010 and 2019 in Sweden. Methods: We included patients (≥18 years old) with ischemic stroke registered in the hospital-based Swedish Stroke Register (Riksstroke) 2010–2019. The coverage of Riksstroke was consistently high (about 90%) during this period. Data were stratified by first-ever and recurrent ischemic stroke in three different time periods (2010–2012, 2013–2016, and 2017–2019) and shown as crude and age-specific incidence rates per 100,000 person-years. Statistics Sweden provided census data on the Swedish population in different age groups. Results: During the study period, 201,316 cases of ischemic stroke were registered in Riksstroke, including 153,865 (76.4%) cases of first-ever ischemic stroke and 46,248 (23.0%) cases of recurrent ischemic stroke (0.6% of cases unclassified). The crude incidence of first-ever ischemic stroke decreased by 17% from 216 (95% CI 214–218) to 179 (95% CI 177–181) between 2010–2012 and 2017–2019, whereas recurrent ischemic stroke decreased by 33% from 72 (95% CI 71–73) to 48 (95% CI 47–49). Between these time periods, diminishing ischemic stroke incidence was seen in all age groups with highest decline noted in those aged 75–84 years (928 [95% CI 914–943] to 698 [95% CI 686–709]; −25% in first-ever ischemic stroke and 361 [95% CI 351–370] to 219 [95% CI 213–226]; −39% in recurrent ischemic stroke) and ≥85 years (1,674 [95% CI 1,645–1,703] to 1,295 [95% CI 1,270–1,320]; −23% in first-ever ischemic stroke and 683 [95% CI 664–702] to 423 [95% CI 409–437]; −38% in recurrent ischemic stroke). Treatment with anticoagulants in patients with atrial fibrillation and lipid-lowering drugs increased considerably in patients with first-ever and recurrent ischemic stroke both at admission and discharge during the study period. Conclusion: Whereas both first-ever and recurrent ischemic stroke rates declined in Sweden between 2010 and 2019, the proportional decline was almost double for recurrent ischemic stroke than for first-ever ischemic stroke and most pronounced in the elderly. Increased use of secondary preventive drugs, in particular anticoagulants in atrial fibrillation, appears to have contributed, but further studies on precise causes for the decline in recurrent ischemic stroke are needed.

Declining first-ever stroke incidence rates in 15- to 54-year-old residents of Tartu, Estonia, from 1991 to 2017.

Having a stroke at a young age has a huge socioeconomic impact. Data on the trends of stroke incidence in young adults from prospective population-based studies are scarce. The aim of this study was to analyze the trends in stroke incidence in 15- to 54-year-old residents of Tartu, Estonia from 1991 to 2017. Three population-based studies with identical study protocols determining the incidence of first-ever stroke have previously been conducted in Tartu, Estonia (1991-1993, 2001-2003, and 2013-2017). All residents of Tartu with first-ever stroke (ischemic stroke, spontaneous intracerebral hemorrhage, and subarachnoid hemorrhage) who were hospitalized to the Department of Neurology, Tartu University Hospital in respective study periods were included prospectively. Overlapping data sources for case ascertainment were used to include both hospitalized and non-hospitalized cases. Trends in first-ever stroke incidence in 15- to 54-year-old residents of Tartu were calculated and compared using rate ratio (RR). Altogether 259 strokes were identified. From 1991 to 2017, the proportion of women increased from 38.3% to 43.6%. Mean age at onset in women decreased from 46.9 (standard deviation (SD): 7.3) to 42.6 (SD: 8.9). Overall crude incidence rates per 100,000 decreased significantly from 1991 to 2003 (from 57.2 (95% confidence interval (CI): 46.9-69.1) to 35.7 (95% CI: 25.7-48.3)); RR: 0.62 (95% CI: 0.44-0.89). While also present in women, the decrease was most notable in 45- to 54-year-old men (RR: 0.55 (95% CI: 0.30-0.99)). In 35- to 44-year-old men, the incidence rates decreased significantly from 2001 to 2017 (RR: 0.37 (95% CI: 0.14-0.99)). The overall first-ever stroke incidence rates decreased from 1991 to 2003 and remained stable thereafter.

Temporal trend of first-ever ischaemic stroke incidence from 2010 to 2019 in South Korea: a nationwide retrospective cohort study

ObjectiveIschaemic stroke incidence is on the decline globally, but the trend in South Korea is unknown. In this study, the 10-year incidence trends of first-ever ischaemic stroke in South Korea...

Income and outcomes of patients with incident atrial fibrillation

BackgroundSocioeconomic disparities can be associated with adverse outcomes in patients with cardiovascular diseases. The impact of personal income on the outcomes of patients with atrial fibrillation (AF) is unclear.MethodsNationwide observational...

Epidemiology of atrial fibrillation in ischaemic stroke patients: a population-based study in Auckland, New Zealand

This oral presentation aims to discuss the results of my research on the incidence and attack rates of first-ever ischaemic stroke in patients with atrial fibrillation. Stroke is one of the most prevalent causes of death and debilitating neurological conditions. Globally, the absolute number of stroke patients is rising, with high-income countries showing a higher stroke prevalence than low- and middle-income countries. Atrial fibrillation is one of the most common cardiac arrhythmia and a well-known risk factor for ischaemic stroke. It is associated with a five-fold increase in ischaemic stroke risk, more likely to be severe or fatal. In New Zealand, there have been no previous population-based incidence studies of ischaemic stroke in patients with atrial fibrillation. The design of this study allowed, for the first time, an accurate estimation of the frequency of ischaemic stroke in patients with atrial fibrillation, identifying knowledge gaps specific to New Zealand and providing essential information for health policy development. In this study, the pre-stroke prevalence of atrial fibrillation appeared to be very high and was strongly associated with established cardiovascular risk factors. During the study period, the crude incidence rate of first-ever ischaemic stroke in atrial fibrillation patients in the Auckland population was higher than that reported in other population-based studies. The aging of the population could partlyexplain the increasing incidence of ischaemic stroke associated with atrial fibrillation in developed countries, including New Zealand. The atrial fibrillation detection at the time of stroke onset was significantly improved by using historical hospital archives. Moreover, a longer post-stroke duration of electrocardiographic monitoring was associated with higher newly diagnosed atrial fibrillation detection, demonstrating that prolonged monitoring should be considered for all stroke survivors.

Population-based stroke incidence estimates in Peru: Exploratory results from the CRONICAS cohort study

SummaryBackgroundLimited information exists about the incidence of first-ever stroke at the population level, particularly in low- and middle-income countries (LMIC). Longitudinal data from the CRONICAS Cohort Study includes both altitude and urbanization and allows a detailed assessment of stroke incidence in resource constrained settings. The aim of this study was to estimate the incidence and explore risk factors of first-ever stroke at the population level in Peru.MethodsStroke was defined using a standardised approach based on information from cohort participants or family members. This information was adjudicated centrally by trained physicians using common definitions. Time of follow-up was calculated as the difference between date of enrolment and the reported date of the stroke event. Unstandardised and age-standardised, first-ever stroke incidence rate and 95% confidence intervals (95% CI) were calculated. Generalized linear models, assuming Poisson distribution and link log, were utilized to determine potential factors to develop stroke.Findings3,601 individuals were originally enrolled in the cohort and 2,471 provided data for the longitudinal analysis. The median time of follow-up was 7.0 (range: 1 - 9) years, accruing a total of 17,308 person-years. During followup, there were 25 incident cases of stroke, resulting in an age-standardised incidence of stroke of 98.8 (95% CI: 63.8 – 154.0) per 100,000 person-years. After adjustment by age and sex, stroke incidence was higher among people with hypertension (incidence risk ratio (IRR) = 5.18; 95% CI: 1.89 – 14.16), but lower among people living at high altitude (IRR = 0.09; 95% CI: 0.01 – 0.63).InterpretationOur results indicate a high incidence of first-ever strokes in Peruvian general population. These results are consistent with the estimates found in previous LMIC reports. Our study also found a contributing role of hypertension, increasing the risk of having a first-ever stroke. This work further advances the field of stroke epidemiology by identifying high altitude as a factor related to lower incidence of stroke in a longitudinal study. However, this information needs to be considered with cautions because of the study limitations.

Long-Term Trends in Stroke Management and Burden Among Low-Income Women in a Rural Area From China (1992-2019): A Prospective Population-Based Study.

Although an increasing number of studies are considering sex-related differences in stroke burden, the trends in stroke burden and management among women in China, especially among low-income women, remain unclear. This study evaluated the long-term trends in stroke management and burden among low-income Chinese women during the period between 1992 and 2019. Stroke burden was assessed using the age-adjusted incidence of first-ever stroke, whereas stroke management was assessed using the rates of neuroimaging diagnoses, hospitalizations, case fatalities, and stroke recurrence. Stroke burden and management were analyzed during four study periods: 1992–1998, 1999–2004, 2005–2012, and 2013–2019. During the 193,385 person-years of surveillance in this study, 597 female stroke patients were identified. The stroke incidences per 100,000 person-years were 88.1 cases during 1992–1998, 145.4 cases during 1999–2004, 264.3 cases during 2005–2012, and 309.8 cases during 2013–2019 (P < 0.001). Between 1992 and 2019, the incidence of stroke significantly increased (6.4% annually) as did the incidence of ischemic stroke (7.8% annually; both, P < 0.001). The rates of neuroimaging diagnoses and hospitalizations significantly increased during the four periods, while the case fatality rates and 1-year recurrence rates decreased significantly for both overall strokes and ischemic strokes, especially among patients ≥45 years old (all, P < 0.001). Among low-income women in China, stroke management is gradually improving, despite the increasing stroke burden. Thus, improved healthcare coverage is needed to further reduce the stroke burden among low-income Chinese women.

Tissue-Based Stroke Definition Impacts Stroke Incidence but not Ethnic Differences

ObjectivesWe explored how the new, tissue-based stroke definition impacted incidence estimates, including an ethnic comparison, in a population-based study. MethodsStroke patients, May, 2014-May, 2016 in Nueces County, Texas were ascertained and validated using source documentation. Overall, ethnic-specific and age-specific Poisson regression models were used to compare first-ever ischemic stroke and intracerebral hemorrhage (ICH) incidence between old and new stroke definitions, adjusting for age, ethnicity, sex, and National Institutes of Health Stroke Scale score. ResultsAmong 1308 subjects, 1245 (95%) were defined as stroke by the old definition and 63 additional cases (5%) according to the new. There were 12 cases of parenchymal hematoma (PH1 or PH2) that were reclassified from ischemic stroke to ICH. Overall, incidence of ischemic stroke was slightly higher under the new compared to the old definition (RR 1.07; 95% CI 0.99–1.16); similarly higher in both Mexican Americans (RR 1.06; 95% CI 1.00–1.12) and Non Hispanic whites (RR 1.09, 95% CI 0.97–1.22), p(ethnic difference)=0.36. Overall, incidence of ICH was higher under the new definition compared to old definition (RR 1.16; 95% CI 1.05–1.29), similarly higher among both Mexican Americans (RR 1.14; 95% CI 1.06–1.23) and Non Hispanic whites (RR 1.20, 95% CI 1.03–1.39), p(ethnic difference)=0.25. ConclusionModest increases in ischemic stroke and ICH incidence occurred using the new compared with old stroke definition. There were no differences between Mexican Americans and non Hispanic whites. These estimates provide stroke burden estimates for public health planning.

Temporal trends in stroke incidence and case-fatality rates in Arcadia, Greece: A sequential, prospective, population-based study.

Stroke incidence and case-fatality are reported to decline in high-income countries during the last decades. Epidemiological studies are important for health services to organize prevention and treatment strategies. The aim of this population-based study was to determine temporal trends of stroke incidence and case-fatality rates of first-ever stroke in Arcadia, a prefecture in southern Greece. All first-ever stroke cases in the Arcadia prefecture were ascertained using the same standard criteria and multiple overlapping sources in three study periods: from November 1993 to October 1995; 2004; and 2015-2016. Crude and age-adjusted to European population incidence rates were compared using Poisson regression. Twenty-eight days case fatality rates were estimated and compared using the same method. In total, 1315 patients with first-ever stroke were identified. The age-standardized incidence to the European population was 252 per 100,000 person-years (95% CI 231-239) in 1993/1995, 252 (95% CI 223-286) in 2004, and 211 (192-232) in 2015/2016. The overall age- and sex-adjusted incidence rates fell by 16% (incidence rates ratio 0.84, 95% CI: 0.72-0.97). Similarly, 28-day case-fatality rate decreased by 28% (case fatality rate ratio = 0.72, 95% CI: 0.58-0.90). This population-based study reports a significant decline in stroke incidence and mortality rates in southern Greece between 1993 and 2016.

A Sharp Decline in Burden of Stroke in Rural China During COVID-19 Pandemic.

This study aimed to explore trends in the burden from stroke associated with home quarantine during the COVID-19 pandemic. Patients with a first-ever stroke registered between January 1 and April 20 from 2010 to 2020 were included in this study. We compared the incidence and the rates of mortality, hospitalization, and diagnosis by neuroimaging for first-ever stroke among a low-income population in rural China during the study periods. Overall, 377 first-ever stroke patients were analyzed in this study period; men accounted for 59.2%. Compared with 2019, the incidence of first-ever stroke was 73.5% lower in 2020 (P < 0.001). The incidence of first-ever stroke was lower by 64.18% in 2020 than in the previous 5 years (P = 0.002) and by 65.42% in 2020 than in the previous 10 years (P = 0.001). Mortality from first-ever stroke in 2020 was not significantly different from that in 2019, but it was noticeably lower than that for the previous 5 and 10 years. However, rates of hospitalization and diagnosis by neuroimaging remained stable across the study period. These findings suggest that the home quarantine helped reduce outdoor activities at low temperatures, restrict gatherings, reduce alcoholism and high-fat diet, and lower pollution caused by factories. These changes were advantageous for helping high-risk groups to reduce the burden of stroke.

Macroeconomic Development and Dramatic Increase in Stroke Burden in Rural China: A 25-Year Population-Based Study.

Low socioeconomic status is associated with a high stroke risk. However, few studies have quantitatively assessed the relationship between stroke burden and national economic development indicators. We explored the quantitative association between macroeconomic development and stroke burden in rural China. In this population-based, prospective study (1992–2016), we collected data on annual registrations of stroke events and deaths in Tianjin, China. Economic development over the period was represented by gross domestic product annually adjusted for purchasing power parity (PPP-aGDP) and per capita net income (PCNI) of rural residents in China. We assessed the association of first-ever stroke incidence with PPP-aGDP and PCNI. During the 25-year study period, there were 1,185 stroke events and 362,296 person years of surveillance. First-ever stroke incidence increased by an average of 10.7% per 1,000 USD increase in overall PPP-aGDP and by 12.0% per 1,000 Yuan increase in PCNI; respectively, the mean increases were 9.6 and 10.8% in men and 13.0 and 14.4% in women (all, P < 0.001). These same changes in PPP-aGDP and PCNI also resulted in increases in the incidence of ischemic stroke (12.6 and 14.3%, respectively; P < 0.05), and intracerebral hemorrhage (both, 6.2%; P < 0.05). Similarly, in men, the age of onset of intracerebral hemorrhage decreased by 0.96-years (P = 0.002) for each 1,000 USD increase in PPP-aGDP and by 1.08-years (P = 0.003) for each 1,000 Yuan increase in PCNI. Macroeconomic development was positively associated with stroke incidence in rural China. Thus, enhancing health-care investments is crucial for containing the stroke burden during this remarkable economic development in China. Our findings could guide other developing countries with information regarding the timely control of stroke risk factors and reductions in stroke burden during the initial stages of economic development.

Effect of 5-Minute Movies Shown via a Mobile Phone App on Risk Factors and Mortality After Stroke in a Low- to Middle-Income Country: Randomized Controlled Trial for the Stroke Caregiver Dyad Education Intervention (Movies4Stroke).

BackgroundPakistan is the sixth most populous nation in the world and has an estimated 4 million stroke survivors. Most survivors are taken care of by community-based caregivers, and there are no inpatient rehabilitation facilities.ObjectiveThe objective of this study was to evaluate the effectiveness and safety of locally designed 5-min movies rolled out in order of relevance that are thematically delivered in a 3-month program to deliver poststroke education to stroke survivor and caregiver dyads returning to the community.MethodsThis study was a randomized controlled, outcome assessor–blinded, parallel group, single-center superiority trial in which participants (stroke survivor-caregiver dyads) with first-ever stroke (both ischemic and hemorrhagic) incidence were randomized within 48 hours of their stroke into either the video-based education intervention group or the control group. The video-based education intervention group had health education delivered through short videos that were shown to the participants and their caregivers at the time of admission, before discharge, and the first and third months of follow-up after discharge. The control group had standardized care including predischarge education and counseling according to defined protocols. All participants enrolled in the video education intervention and control groups were followed for 12 months after discharge for outcome assessment in the outpatient stroke clinics. The primary outcome measures were the proportion of participants achieving control of blood pressure, blood sugar, and blood cholesterol in the video intervention versus the control group. Several predefined secondary outcomes were included in this study, of which we report the mortality and functional disability in this paper. Analysis was by performed using the intention-to-treat principle.ResultsA total of 310 stroke survivors and their caregiver dyads (participant dyads) were recruited over a duration of 6 months. In total, 155 participant dyads were randomized into the intervention and control groups, each. The primary outcome of control of three major risk factors revealed that at 12 months, there was a greater percentage of participants with a systolic BP<125 mm Hg (18/54, 33% vs 11/52, 21%; P=.16), diastolic BP<85 mm Hg (44/54, 81% vs 37/52, 71%; P=.21), HbA1c level<7% (36/55, 65% vs 30/40, 75%; P=.32), and low-density lipoprotein level<100 mg/dL (36/51, 70% vs 30/45, 67%; P=.68) in the intervention group than in the control group. The secondary outcome reported is the mortality among the stroke survivors because the number of stroke-related complications was higher in the control group than in the intervention group (13/155, 8.4% vs 2/155, 1.3%), and this difference was statistically significant (P<.001).ConclusionsThe Movies4Stroke trial failed to achieve its primary specified outcome. However, secondary outcomes that directly related to survival skills of stroke survivors demonstrated the effectiveness of the video-based intervention on improving stroke-related mortality and survival without disability.Trial RegistrationClinicalTrials.gov NCT02202330; https://www.clinicaltrials.gov/ct2/show/NCT02202330

Risk Factors of Incident Total Stroke and Ischemic Stroke in China

Background: Stroke places a considerable burden on human beings. Managing risk factors is crucial to prevent stroke. However, few cohort studies have evaluated socioeconomic factors together with conventional factors affecting incident stroke, particularly ­in China. Methods: A 2014-2016 cohort of the China National Stroke Screening and Intervention Program was studied, comprised 437 318 adults aged 40 years or older without stroke at baseline from 31 provinces. Cox regression yielded adjusted hazard ratios for risk factors related to the incidence of first-ever stroke and ischemic stroke. Findings: There were 2 429 cases of first-ever stroke during a median follow-up period of 2·1 years, including 2 206 ischemic strokes and 237 hemorrhagic strokes. The multivariable Cox regression analysis indicated that age 50–59 years (vs. 40-49 years), primary school or no formal education (vs. middle school), having more than one child (vs. one child), and living in Northeast, Central, East, or North China (vs. Southwest China), fruit consumption ≤4 days/week (vs.≥5 days/week), vegetable-based diet (vs. balance portion of vegetables and meat), physical inactivity, smoking (former, current, and passive), heavy drinking, hypertension, diabetes, obesity, family history (stroke, coronary heart disease, and hypertension) were positively associated with the risk of total and ischemic stroke, whereas age 60-69 years (vs. 40-49 years), living with spouse or children (vs. living alone), and vegetable consumption 3-4 days/week (vs.≥5 days/week) were negatively associated with the risk of total and ischemic stroke. The population-attributable risk of hypertension for stroke was the highest among all modifiable risk factors, followed by physical inactivity and smoking. Interpretation: We identified socioeconomic factors that complement traditional risk factors associated with incident stroke and ischemic stroke, allowing targeting these factors to reduce stroke burden. Funding Statement: The National Natural Science Foundation of China (No. 71532014). Declaration of Interests: The authors stated: None. Ethics Approval Statement: The study was performed according to the Helsinki declaration and approved by the Ethics Committee of Xuanwu Hospital Institutional Review Board of Capital Medical University, located in Beijing, China. All participants were informed about the study and signed written informed consent.

Macroeconomic Development and Dramatic Increase in Stroke Burden in Rural China: A 25-Year Population-Based Study

Background: To explore the quantitative association between macroeconomic development and stroke burden in rural China. Methods: In this population-based, prospective study (1992–2016), gross domestic product annually adjusted for purchasing power parity (PPP-aGDP) and per capita net income (PCNI) in rural China were collected to assess the association with first-ever stroke incidence over 25-year prospective study. Findings: During the 25-year study period, there were 1185 stroke events and 362,296 person-years of surveillance. First-ever stroke incidence increased by an average of 10·7% per 1000 USD increase in overall PPP-aGDP and by 12·0% per 1000 Yuan increase in PCNI; respectively. These same changes in PPP-aGDP and PCNI also resulted in increases in the first-ever stroke incidences across sex and stroke types. Similarly, in men, the age of onset of intracerebral hemorrhage decreased by 0·96 years for each 1000 USD increase in PPP-aGDP and by 1·08 years for each 1000 Yuan increase in PCNI. Interpretation: These findings suggested that enhancing health-care investments is crucial for containing the stroke burden during this remarkable economic development in China. Our findings imply the guiding function for other developing countries on the timely control of stroke risk factors and reductions in stroke burden during the initial stages of economic development. Funding Statement: The authors stated: None. Declaration of Interests: The authors declare that they have no competing interests. Ethics Approval Statement: The study protocol was approved by the ethics committee of Tianjin Medical University General Hospital (TMUGH), and written informed consent was obtained from each participant.

Abstract TMP58: Preliminary Population-Based Temporal Trends in Stroke Incidence: Racial Disparity and Stroke Incidence From 1993-2015

Introduction: We previously reported that the incidence of stroke was decreasing for whites but stable for blacks from 1993/94 to 2005. We sought to describe recent temporal trends and racial disparities in stroke incidence within our large, bi-racial population, by including 2010 and preliminary data from 2015. Methods: The Greater Cincinnati/Northern Kentucky region includes two southern Ohio and three Northern Kentucky counties on the Ohio River, a population of 1.3 million representative of the US population in terms of sociodemographics and percent black race. Our study ascertained all hospitalized strokes that occurred in the population between 7/1/93 and 6/30/94 and in calendar years 1999, 2005, 2010 and 2015. For 2015, nursing review of medical records is complete but physician review is not; thus 2015 rates are preliminary. The denominator for the calculation of incidence rates (in those aged ≥20 years) was estimated from the U.S. Census Bureau website (www.census.gov). The 95% confidence intervals (CI) for the incidence rates were calculated assuming a Poisson distribution. Rates are age, sex, and race adjusted, as appropriate, and standardized to the 2010 U.S. population. Results: First-ever stroke incidence rates stratified by subtype, race, and study period are presented in the Table. We project that stroke incidence did not significantly change in 2015 vs. 2010 for either blacks or whites, regardless of stroke subtype. Blacks have a substantially higher incidence of stroke compared with whites in all study periods, without significant change in disparity over time. Discussion: In contrast to the significant decline in stroke incidence among whites from 1993-94 to 2005, we did not observe a statistically significant decrease in 2010 and 2015. This may be due to true stabilization of rates over time, or less statistical power to detect smaller declines. The substantial black/white racial disparity in stroke incidence has not changed over time.