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The Current State and Future of Stroke

Temporal and Geographic Trends in the Global


Stroke Epidemic
Anthony S. Kim, MD, MAS; S. Claiborne Johnston, MD, PhD

The Burden of Stroke in the United States incidence rates seen in most high-income countries.7 So not only
Stroke continues to present a significant public health challenge is the overall disease burden of stroke higher in the developing
for the United States. Stroke is a leading cause of adult disabil- world but stroke also accounts for a greater relative proportion of
ity1; race-ethnic and geographic disparities in stroke incidence total deaths in low- and middle-income countries as well.
and outcomes have remained stubbornly persistent,2 and the There is substantial variation in the distribution of stroke burden
total number of deaths from stroke is projected to increase in by geographic region and by country—the level that may be most
the coming decades as the population ages.3 However, there is relevant for policy and program development. These regional and
also reason for optimism. During the last 40 years, there has national hot spots constitute a global stroke belt that parallels the
been a >60% decline in the age-adjusted mortality rate from well-documented geographic variations of stroke burden within
stroke in the United States,4 and stroke has recently moved the stroke belt of the southeastern United States.11 The burden of
from its prior position as the third leading cause of death to stroke is particularly high in Eastern Europe, North Asia, Central
become the fourth leading cause of death overall.5 Africa, and the South Pacific with a 10-fold difference in stroke
Although there are multiple factors to help to explain this mortality and morbidity rates between the most affected and least
trend, improvements in blood pressure control at the population affected countries.12 For example, Russia’s standardized stroke
level are likely to be playing a major role. During the last few mortality rate is 251 per 100 000 compared with a rate of 32 per
decades, each successive national health survey has recorded 100 000 in the United States.10 The pattern is quite similar for dis-
improvements in population systolic blood pressure and ability adjusted life year loss rates—a measure of overall disease
hypertension control. For example, the median systolic blood burden that takes into account both years of potential life lost from
pressure among aged 60 to 74 years in 1960–1962 was ≈150 premature deaths and long-term disability from stroke.12
mm Hg.6 In subsequent surveys, the median systolic blood pres- Once again, the reasons for this geographic variation in the
sure has consistently declined and by the 1988–1991 National burden of stroke globally are quite complex. However, national
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Health and Nutrition Examination Survey III, the median sys- income has emerged as a particularly strong predictor of stroke
tolic blood pressure had decreased to 130 mm Hg.6 burden.12 The association between lower national income per
Improvements in blood pressure have been particularly pro- capita and higher burden of stroke persists even after adjustment
nounced among those with very high blood pressure, which for national measures of typical cardiovascular risk factors,
confers a disproportionately higher risk for stroke. For instance, such as physical inactivity, hypertension, diabetes mellitus,
during the same period, the 90th percentile for systolic blood pres- tobacco use, alcohol use, and dyslipidemia.12 The strong
sure decreased from >190 mm Hg to <160 mm Hg.6 This pattern association of stroke with national income is consistent with an
of improved hypertension control has also been demonstrated in overall shift from communicable diseases to noncommunicable
other high-income countries, which have experienced a 42% diseases, such as heart disease and stroke, with rising income
decrease in stroke incidence overall during the past 40 years.7 in what has been termed the epidemiological transition.13
Infection, nutrition, and perinatal disease accounted for 34%
The Ongoing Global Epidemic of Stroke of deaths in 1990 but are projected to account for just 15%
From the global prospective, the outlook for stroke is quite dis- of total deaths in 2020.14 In contrast, the proportion of deaths
tinct. The conventional wisdom is that heart disease and stroke from cardiovascular diseases, including stroke, is projected to
are primarily diseases of the developed world, although in point increase from 28% to 34% during that same period.14
of fact most of the burden of cardiovascular disease and stroke is A similar geographic pattern is also seen for the burden of
borne by countries in the developing world.8,9 Stroke continues to ischemic heart disease worldwide which is not surprising given
be the second leading cause of death worldwide (second only to that these 2 forms of vascular disease have overlapping ath-
cardiovascular disease) and accounts for ≈1 in 10 deaths or 5.7 erosclerotic disease mechanisms and have major modifiable
million deaths a year.10 This mortality burden has come with a risk factors in common. But although ischemic heart disease
more than doubling of the stroke incidence in low- and middle- is the predominant form of vascular disease burden overall,
income countries with incidence rates that commonly surpass the stroke is the predominant form of vascular disease for many

Received November 6, 2012; accepted April 4, 2013.


From the Departments of Neurology (A.S.K., S.C.J.) and Epidemiology and Biostatistics (S.C.J.), University of California, San Francisco, CA.
Correspondence to Anthony S. Kim, MD, MAS, Department of Neurology, University of California, San Francisco, 675 Nelson Rising Lane, Room
411B, San Francisco, CA 94158. E-mail akim@ucsf.edu
(Stroke. 2013;44[suppl 1]:S123-S125.)
© 2013 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org DOI: 10.1161/STROKEAHA.111.000067

S123
S124  Stroke  June 2013

lower income countries.15 For example, ischemic heart disease expected increases in coronary artery disease and stroke incidence,
mortality rates are slightly higher than stroke mortality rates in trends in virtually all the major vascular risk factors, including
North America, Western and Northern Europe, and Australia.15 systolic blood pressure, cholesterol, diabetes mellitus, and smok-
In contrast, stroke mortality rates are substantially higher than ing, are unfavorable and will account for a substantial proportion
ischemic heart disease mortality rates in much of Africa and of the expected excess burden of stroke moving forward.17 Mean
Asia (Figure 1). In South Korea and China, for example, 17% population body mass index has been increasing for decades; mean
to 18% of all deaths are from stroke compared with just 6% cholesterol, mean systolic blood pressure, and mean blood glucose
to 8% for ischemic heart disease. This concentration of stroke have been steadily increasing since the early 1990s (Figure 2); and
burden in low-income countries and in Asia and Africa sug- the prevalence of smoking has remained persistently high during
gests that a targeted approach for addressing stroke in the the past 20 years.18 In contrast, the United States and Japan have
developing world may be warranted.10 seen steady improvements in population-level measures of choles-
terol, systolic blood pressure, and smoking prevalence, although
The Case of China obesity and mean body mass index, as well as mean serum glucose
In this global epidemic, the recent experience of China is continue to trend upward.18
deserving of special attention. Not only is China an outlier in
terms of its substantial absolute stroke burden but also China Limitations
is an outlier in terms of its high relative burden of stroke com- As we move forward to meet these challenges, the limited avail-
pared with ischemic heart disease.15 The sobering projections ability of high-quality epidemiological data on stroke and the
of stroke incidence for the coming decades provide a case challenge of integrating heterogeneous data sources will con-
study of the current challenges in addressing this epidemic. tinue to make an accurate transnational picture of the global
Stroke is the leading cause of death in China with an esti- stroke epidemic a challenging task. Country-level analyses do
mated 2.5 million incident strokes and 1.6 million deaths from not take into account the joint distribution of risk factors in
stroke each year.16 As previously described, stroke is the pre- important subnational groupings (e.g., by region or by urban/
dominant form of vascular disease in China. The stroke mortal- rural area) and may be subject to the ecological fallacy, whereby
ity rate far exceeds the ischemic heart disease mortality rate in an inference made at the population level is falsely assumed
a pattern that is shared by many low- and middle-income coun- to apply at the individual level. However, together as a whole,
tries.15 Hemorrhagic strokes also make up a larger proportion available data do provide a hint of the magnitude and scope of
of incident strokes as well.17 In fact, the incidence of hemor- the challenge and will help to inform public health priorities and
rhagic stroke alone exceeds the incidence of myocardial infarc- policy planning moving forward.
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tion. This pattern of hemorrhage stroke subtypes and a higher


relative burden of stroke compared with heart disease contrib- Conclusions
utes to substantial societal costs since each stroke is associated Stroke is the second leading cause of death worldwide. In the
with upward of 10 times the cost of myocardial infarction.16 ongoing global epidemic of cardiovascular disease, stroke has
On the basis of current demographic and population-level vascu- emerged as a major cause of preventable death and morbidity, par-
lar risk factor trends, current projections are for an unprecedented ticularly in the developing world where stroke is the predominant
50% increase in stroke incidence in China during the next 20 subtype of vascular disease. Demographic and vascular risk factor
years.17 Although demographic changes do account for some of the trends suggest that there will be an even greater burden of disease

Figure 1. The Global Stroke-Belt. Relative mortality rate from stroke compared with ischemic heart disease, 2004 (based on WHO Global
Burden of Disease data).15
Kim and Johnston   The Global Stroke Epidemic   S125

Figure 2. Trends in major vascular risk factors at the population level in the United States, China, and Japan, 1980–2008 (based on WHO
Global Burden of Disease data).
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from stroke in coming years and will represent a major public in the adult US population. Data from the health examination surveys, 1960
to 1991. Hypertension. 1995;26:60–69.
health challenge moving forward.
7. Feigin VL, Lawes CM, Bennett DA, Barker-Collo SL, Parag V.
Worldwide stroke incidence and early case fatality reported in
Sources of Funding 56 population-based studies: a systematic review. Lancet Neurol.
None. 2009;8:355–369.
8. Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ. Global and
regional burden of disease and risk factors, 2001: systematic analysis of
Disclosures population health data. Lancet. 2006;367:1747–1757.
None. 9. Strong K, Mathers C, Bonita R. Preventing stroke: saving lives around
the world. Lancet Neurol. 2007;6:182–187.
10. Mathers C, Fat DM, Boerma JT, World Health O. The Global Burden of
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Trends in the prevalence, awareness, treatment, and control of hypertension health

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