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(Stroke. 1995;26:919-923.)
© 1995 American Heart Association, Inc.

Articles

Community-Based Stroke Incidence Trends From the 1970s Through the 1980s in East Germany

Dorothea Eisenblätter, MD, DSc; Lothar Heinemann, MD, DSc Elvira Claßen, DiplOec

From the Centre for Epidemiology and Health Research Berlin, Zepernick, Germany.

Correspondence to Dr Dorothea Eisenblätter, Centre for Epidemiology and Health Research Berlin, Schönerlinder Straße 11-12, D-16341 Zepernick, Germany.

	Abstract

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Background and Purpose Stroke mortality has declined in most industrialized countries, but incidence rates have increased in some populations while they remained stable or even decreased in others. This study reports stroke incidence trends in East Germany over the past decades.

Methods Prospective community-based stroke registers were run in East Germany over two different time periods: 1972 through 1973 in the Berlin-Lichtenberg district and 1985 through 1988 in 14 districts in the central and southern part of the country. Stroke cases were collected and validated in a uniform way using both the World Health Organization (WHO) recommendations for community stroke registers and the guidelines of the WHO MONICA protocol.

Results Annual age-adjusted incidence rates of first-ever strokes rose among men aged 25 to 64 years from 48.4 per 100 000 in 1972 through 1973 to 88.0 per 100 000 in 1985 through 1988 (P<.05); incidence rates remained unchanged among women in this age range (52.6 and 52.5 per 100 000, respectively). Age-specific incidence rates increased among men in all age groups up to 74 years. Rising stroke rates were also observed in women under 55 years and between the ages of 65 and 74 years, whereas in women aged 55 to 65 years incidence rates declined by more than a third (P<.05). During the period from 1985 through 1988, stroke rates did not change.

Conclusions An increase in stroke incidence was detected that can be associated with a deteriorating risk factor profile in the East German population and, in particular, with hypertension in men.

Key Words: East Germany • epidemiology • incidence

	Introduction

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Official vital statistics indicate a remarkable decline in the rate of cerebrovascular mortality over the past decades in most industrialized countries. Only a few East European countries exhibit rising stroke death rates.^{1 2} The reasons for the observed mortality changes are not fully explained.³ So far it is not known to what extent the falling mortality rates reflect a decline in stroke incidence or a reduction in case fatality due to improved treatment, or both. Trend analyses based on data drawn from community-based stroke incidence studies in the United States, some European countries, Japan, and New Zealand gave conflicting results.^{4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22} There has been no clear evidence of a general decline in stroke incidence that parallels the reduction in mortality rates. Although a decline in stroke incidence has been reported in Finland,^{10 11 12} Japan,^{18 19 20 21} and the United States,^{4 5 6 7 8} in some of the populations under consideration no changes could be observed,^{9 12 14 16} and in others increasing rates have been found in women,^{15 22} in men,¹³ or in both sexes.⁴

In East Germany, stroke registration was carried out during two separate time periods (1972 through 1973 and 1985 through 1988), applying nearly identical methods. During the 1970s, other stroke registers were established in several smaller communities,²³ but they did not always use highly standardized methods of case finding and data collection. Therefore, these results have not been considered in this trend analysis. We have used the data from the two aforementioned, well-designed, community-based registers to assess the trends of stroke incidence in the East German population between the ages of 25 to 74 years and to verify official hospital discharge statistics that suggested a possible increase in stroke rates in the 1970s and 1980s. Stroke mortality data from the official vital statistics of East Germany cannot be used to assess temporal trends because of erroneous coding and selection practices, which changed only after the introduction of the ninth revision of the International Classification of Diseases in 1979.²⁴ No reliable data on stroke deaths are available in the official statistics.

	Subjects and Methods

Top Abstract Introduction Subjects and Methods Results Discussion References

 
The first East German community-based stroke register was established for 13 months beginning December 1, 1972, in the Berlin-Lichtenberg district using WHO standardized methods for community stroke registers.²⁵ Lichtenberg is one of the 10 administrative districts of the former capital of the German Democratic Republic, Berlin. According to official statistics, the study area covered a population of 107 377 men and women aged 25 to 74 years. The second registration period under consideration in this article began on January 1, 1984, within the framework of the Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA) East Germany program. This report includes only results from the years 1985 through 1988. The year 1984 was a pilot phase during which the standardized registration procedures were established and the register teams were trained in how to find cases, verify stroke diagnoses, and subsequently categorize them into different stroke subtypes according to the specifications of the WHO program. The study area comprised 14 officially defined administrative districts (reporting units) in the central and southern part of the country and included a general population of 803 979 men and women aged 25 to 64. In six of the districts, stroke events in persons up to the age of 74 years were included. The study population in the age range of 65 to 74 years totaled 62 373 persons. Detailed demographic data for both study periods are shown in Table 1. The comparison between the two different areas at these different points in time seems justifiable; the target population studied during the first period lived in a large city, and in the second period six reporting units were also in large cities, whereas another eight were in mixed urban/rural areas. Access to the medical services network was comparatively good; all districts had central hospitals because of the density of their populations. No significant differences of social class existed among the study areas or between the two time periods (ie, educational level). Thus, there is no evidence of systematic differences between the two areas where the population-based stroke registers were run.

View this table: [in this window] [in a new window]   Table 1. Age and Sex Distribution of the Study Population (Age Range, 25-74 Years) of the East German Stroke Registers: Berlin-Lichtenberg (1972-1973) and MONICA East Germany (1985-1988)

Case recruitment and validation, as well as uniform data collection and coding, were carried out in the monitoring areas by physicians trained in the application of standardized study methods. Since 1984, the instructions and guidelines used were taken from the WHO MONICA protocol²⁶ and were similar to the recommendations taken as the basis for WHO stroke registers in the early 1970s.²⁵ For each study period, the principles of stroke registration were described in a manual that took into account the local conditions in East Germany.

Cases were collected by the "hot-pursuit" technique, a method involving identifying and following up suspected cases during the actual event, as well as retrospectively by "cold pursuit," ie, abstracting information from medical records, death certificates, and other possible sources without seeing the patient. Main sources for the identification of likely events were records kept by the emergency services, hospital admission records, hospital discharge records, and death certificates. In the mid 1980s as well as in the early 1970s, most of the stroke patients were examined and questioned about previous strokes during their period of acute illness by a register doctor. If a patient had already died, had been treated outside the study area, or could not be traced within 28 days after the event, data were collected from hospital records or other medical records by attending general practitioners or occasionally gleaned from interviews with relatives. General practitioners were contacted regularly (at least once per month) by telephone and asked to report stroke events in patients not referred for hospital treatment. Moreover, all of the doctors in charge of the stroke registers in the different reporting units were usually working in the study districts, mostly at regional hospitals. In the course of their routine duties, they were in close contact with doctors treating stroke patients at first hand in the districts.

Standardized record forms completed by register doctors were sent to the East German Coordinating Center for quality checks on the data and for data processing. To maintain uniform registration procedures and standardized diagnostic classification, regular working meetings of the register doctors were held twice a year. At these meetings, results of the coding of several series of test case histories sent out by the Coordinating Center in Berlin and by the MONICA Quality Control Center for Event Registration in Dundee, Scotland, were discussed, as well as problems arising from the classification and coding of particular cases.

The diagnosis of stroke was made on the basis of "rapidly developed, clinical signs of focal (or global) disturbance of cerebral function lasting more than 24 hours (unless interrupted by surgery or death), with no apparent cause other than a vascular origin."^{25 26} Global symptoms applied to patients with subarachnoid hemorrhage or deep coma but excluded coma of systemic vascular origin such as shock, Stokes-Adams syndrome, or hypertensive encephalopathy. Cases without clinical symptoms or signs were not included.

The stroke definition included cases of subarachnoid hemorrhage, intracerebral hemorrhage, and cerebral infarction (embolic, atherothrombotic). Because the criteria for the classification of stroke type varied between the two study periods, only data for all strokes are presented here.

During the second registration period, information on reported symptoms, clinical signs, and diagnostic procedures was obtained within 28 days of onset to validate clinical stroke diagnosis. An event was defined as fatal if the patient died within 28 days. In 1972-1973 the follow-up was only 21 days. Thus, case fatality and mortality rates are not comparable between the two periods and could not be used for this analysis.

Events were categorized as either "definite stroke," "not stroke," or "unclassifiable." Unclassifiable referred to cases that showed insufficient evidence of stroke but in which the diagnosis of stroke could not be entirely excluded or to cases with otherwise typical stroke symptoms but in which the duration remained uncertain.

To estimate the coverage rate of the register, the following variables were calculated: the proportion of stroke patients traced by review of death certificates only; the proportion of patients suffering several stroke events during the registration period and the previous event(s) not recorded in the register; and the ratio of the number of fatal stroke events covered by the register each year to the number of strokes in the routine mortality statistics.

Annual incidence rates were calculated for patients who had suffered their first-ever stroke, ie, no history of a previous stroke. Rates presented here include definite stroke cases as well as unclassifiable events. Rates were age adjusted to Segi's truncated world population²⁷ by the direct method of age standardization. The 95% confidence intervals were calculated assuming a Poisson distribution of the events within the age groups. Significant statistical difference (P<.05) was assumed when the 95% confidence intervals did not overlap.

	Results

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Totals of 151 first-ever strokes and 62 recurrent events in the 25- to 74-year age group were recorded in Berlin-Lichtenberg in the 13-month study period of 1972-1973. During the four-year period of 1985-1988, 3854 first-ever strokes and 1260 recurrent events were identified within the MONICA East German population. The distribution of the cases by age and sex is shown in Table 2 and Table 3. Between the early 1970s and the mid 1980s, age-standardized stroke incidence rose in men aged 25 to 64 years from 48.4 per 100 000 to 88.0 per 100 000 (P<.05). Among women aged 25 to 64, no change in overall stroke rate was observed. Whereas in men similar trends have been shown in all age groups up to 74 years, a decreased incidence in women aged 55 to 64 years contrasted with increasing rates in all other age groups (Table 2). Differences in stroke incidence between the two registration periods were statistically significant for all age groups in women and for the age strata 35 to 44 years and 55 to 64 years in men. The increase in stroke incidence tended to be steeper in the youngest age groups in both sexes, but the absolute number of cases was too small to calculate statistical significance. During the 1985-1988 observation period, no significant trend in stroke incidence rates was detected in either men or women (Table 3).

View this table: [in this window] [in a new window]   Table 2. Number of First-Ever Stroke Cases and Annual Age-Specific Incidence Rates in East German Stroke Registers, 1972-1973 and 1985-1988

View this table: [in this window] [in a new window]   Table 3. Incidence Rates per 100 000 Population and Year With 95% Confidence Intervals in the MONICA East German Stroke Registers During 1985-1988

More than 80% of all registered stroke patients were treated in hospitals during the acute phase of their illness in both register periods, with the exception of the older age group in the period 1985-1988 (Table 4). During the MONICA period, 26% of stroke patients were treated either at home or in a nursing home.

View this table: [in this window] [in a new window]   Table 4. Site of First Treatment in Patients Registered in the East German Stroke Registers

CT examinations were not performed in patients registered in the 1970s, since CT scan did not come into use before 1979 in East Germany. During the 1985-1988 study period, a CT scan was performed within 28 days after the event in 18% of stroke patients aged 25 to 64 years but in only 2% of patients in the age range of 65 to 74 years. Between 1985 and 1988, the use of CT scan increased from 8% to 34% in the 25- to 64-year age group and from 1% to 6% in those aged 65 to 74 years.

	Discussion

Top Abstract Introduction Subjects and Methods Results Discussion References

 
This comparison of data from community-based stroke registers using uniform study methods during two different time periods revealed an increase in stroke incidence rates from the early 1970s to the mid 1980s in almost all age groups in the range of 25 to 74 years. Only among women aged 55 to 64 years was there a statistically significant decline in stroke incidence. During the period 1985-1988, no further change was observed. Although not directly comparable, these trends are in line with the official hospital discharge statistics that showed a marked increase in hospitalization rates for stroke between 1972 and 1986 and no change in the late 1980s.²⁸

Even though the same methods were used, the differences in stroke incidence observed between the two study periods should be interpreted with caution. We did not have a uniform study area, but we have no evidence of incompatibility either, as mentioned earlier (see "Methods"). In other words, the stroke incidence may differ between the metropolitan population of Berlin-Lichtenberg (1972-1973) and the mixed urban and urban/rural populations of the late 1980s. Even when only the urban areas across both periods are compared, the difference remains.²⁹ Moreover, in the first period the study population and the absolute number of stroke events were small, but age- and sex-specific incidence rates for 1972-1973 in the district of Dippoldiswalde (a rural area near Dresden) were comparable with those observed in the Berlin-Lichtenberg area, with no obvious regional differences.³⁰

Data from the routine mortality statistics do not indicate any remarkable differences between the Berlin-Lichtenberg district and the MONICA East Germany population.²⁹ No statistically significant differences could be demonstrated in relation to cardiovascular diseases. Stroke mortality rates are not comparable for methodological reasons.²⁴

There is no evidence to support the assumption that inequalities in medical services may be behind the varying incidence rates. In the study areas, as in the whole country, medical care facilities improved, and preventive measures were intensified after the 1970s. A countrywide hypertension-control program was launched in 1982. Thus, a decrease in stroke incidence would have been expected rather than rising rates.

The same registration procedures and comprehensive, sometimes overlapping, methods of case finding were used throughout the two study periods. There is no evidence of a higher coverage rate in the second period, which could have produced an artificial rise in incidence rates. On the basis of several quality-control measures, coverage rates of almost 90% were estimated for both study periods. Rising stroke rates reflecting more thorough record keeping in the registers also would have applied to all age groups and both sexes, but this was not the case.

The ascertainment of nonfatal events treated outside the hospital is critical to the case-finding process within stroke registers. In both study periods, a great effort was made to trace these cases by close contact between the responsible register doctors and the family doctors working in the study regions. The percentage of stroke case subjects aged 25 to 64 years not treated in a hospital was almost the same during the first and second registration periods. In contrast, in patients aged 65 to 74 years a higher proportion were treated at home during 1985-1988. The difference may be explained by the inclusion of some rural regions in the 1985-1988 period. In rural areas, the hospitalization rate of stroke patients still appeared to be lower than in urban populations. Also, during the 1972-1973 period, in the rural district of Dippoldiswalde 34% of all stroke patients were treated outside the hospital.³⁰

In the United States, a rise in stroke incidence rates in the late 1970s coincided with the introduction of CT, which appeared to increase the detection of less severe strokes.^{4 29 30 31 32} In East Germany, CT scanning came into use in 1979. The proportion of stroke patients undergoing CT was still less than 20% expressed as a mean for the period 1985-1988, even in those younger than 65 years. Despite a distinct increase in the use of CT scan between 1985 and 1988, no simultaneous rise in stroke incidence was observed throughout this period. Moreover, in the stroke registers only cases with clinical symptoms and signs of stroke were collected for both periods, excluding events diagnosed solely on the basis of CT scan or autopsy findings. Thus, the more frequent use of CT cannot explain the changes in stroke incidence observed since the 1970s.

Considering the same trends in the hospital discharge statistics, we believe that the changes in stroke rates found in this analysis are real. However, what are the reasons for the puzzling development whereby there is a fall in stroke incidence only among women aged 55 to 64 years and a rising trend in all other age and sex groups? To a certain degree, these temporal trends in stroke incidence are in line with unfavorable changes in the risk factor profile of the East German population during the last 20 years.^{33 34 35} This holds true especially with respect to blood pressure as the most important determinant of stroke incidence. In men aged 40 to 69 years, an increase of mean systolic and diastolic blood pressure has been observed since the late 1960s, whereas in women of all ages falling mean values of systolic blood pressure have been found with no appreciable changes in diastolic blood pressure.^{33 35} However, blood pressure is significantly higher in East Germany than in West Germany for both sexes.³⁴ Despite great efforts to control hypertension at the community level, awareness of hypertension and the proportion of successfully treated hypertensive patients did not actually improve in men. In women, hypertension-control measures were more successful; nevertheless, in the mid 1980s as many as 38% of hypertensive females still did not know that they had high blood pressure. Of those under treatment, only every fifth person had blood pressure values in the normotensive range. Again, the most favorable trend has been observed in middle-aged women, for whom declining stroke rates have been found. Cigarette smoking and serum cholesterol also have been recognized as risk factors for stroke.^{36 37 38} The prevalence of cigarette smokers in the East German population has increased since the 1970s in both sexes under 30 years of age, especially among young women,^{33 34 35} but declined in the age groups over 40 years. In contrast, during the same time the population mean values for serum cholesterol increased in both sexes for all age groups.^{33 34 35} Alcohol consumption, which also may facilitate stroke development,³⁹ likewise showed a marked increase in East Germany, particularly in men.⁴⁰

Analyzing the possible causes of the decline in stroke mortality in the United States and the role of hypertension-control measures, Casper et al⁴¹ concluded that changes in conditions at the population level that influence the occurrence of stroke may be the primary determinant of temporal trends. Our observation of rising stroke incidence rates associated with deteriorating lifestyle factors in the population of East Germany would support this view.

Received November 14, 1994; revision received February 27, 1995; accepted March 10, 1995.

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