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(Stroke. 1995;26:924-929.)
© 1995 American Heart Association, Inc.

Articles

Stroke Incidence and 30-Day Case-Fatality Rates in Novosibirsk, Russia, 1982 Through 1992

Valery L. Feigin, MD, DSc; David O. Wiebers, MD; Jack P. Whisnant, MD W. Michael O'Fallon, PhD

From the Department of Health Sciences Research (D.O.W., J.P.W., W.M.O'F.) and the Division of Cerebrovascular Diseases (D.O.W., J.P.W.), Mayo Clinic and Mayo Foundation, Rochester, Minn. V.L.F., a visiting scientist at the Department of Health Sciences Research and the Division of Cerebrovascular Research, is from the Cerebrovascular Disease Center, Institute of Internal Medicine, Siberian Branch of the Russian Academy of Medical Science, Novosibirsk, Russia.

	Abstract

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Background and Purpose The present study was conducted to investigate the incidence of stroke and 30-day case-fatality rates for stroke in a defined Russian population.

Methods This is a population-based study that was established in 1982. All residents of an administratively defined and typical district of Novosibirsk (approximately 150 000 subjects) who had an incident (first-ever) stroke from January 1, 1982, through December 31, 1992, were registered.

Results During an 11-year study period, 3406 incident stroke patients were registered, for an overall crude average annual incidence rate of 202/100 000 population. The rates were higher with increasing age and were significantly higher for men than for women. The age- and sex-adjusted annual incidence rate of stroke declined from 271/100 000 in 1982 to 232/100 000 in 1992. Slowing of the decline in stroke incidence was observed after 1988, and stroke incidence increased slightly in 1992. No significant differences in 30-day stroke case-fatality rates were noted from 1982 through 1992, but a slight trend toward decreasing rates was observed after 1988. There was no major change in patient age at stroke onset.

Conclusions Stroke incidence rates in Novosibirsk are among the highest in the world. We observed a decline in stroke incidence but little change in 30-day case-fatality rates in Novosibirsk from 1982 through 1992.

Key Words: epidemiology • morbidity • mortality • Russia

	Introduction

Top Abstract Introduction Subjects and Methods Results Discussion References

 
A lack of prolonged population-based studies on stroke morbidity and mortality over a long period of time does not allow validation of observed secular trends in stroke mortality rates in different populations or accurate assessment of the probability of stroke occurrence.^{1 2} Although stroke mortality rates have declined significantly over many decades in the United States,^{3 4 5 6 7 8 9} Canada,¹⁰ Norway,¹¹ France,¹² Finland,^{13 14 15} Israel,¹⁶ Japan,^{17 18 19} New Zealand,²⁰ Australia,^{21 22} China,²³ and Taiwan,²⁴ there is evidence for recent stabilization of¹³ or even increases in stroke incidence^{25 26} and mortality rates during the 1980s in some western nations, including the United States. Reports from eastern European countries (eg, Hungary, Poland, Bulgaria, Yugoslavia, Romania, and Czechoslovakia) have noted increases in stroke mortality in recent decades.^{27 28 29} No report has been published on stroke incidence and case-fatality rate trends in Russia.

	Subjects and Methods

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For the determination of incidence and 30-day case-fatality rates, all incident strokes (first-ever), whether hospitalized or not, occurring from January 1, 1982, through December 31, 1992, in residents of the Oktiabrsky District of Novosibirsk were registered. Immediate notification of and information about all cases of stroke or alleged stroke and stroke mortality came to the Stroke Registry Department (SRD) of the studied region on an ongoing basis. These notifications came from primary care physicians, neurologists, inpatient and outpatient clinics, pathologists, and forensic medicine experts. The completeness of the information was verified by three specially trained research nurses of the SRD by (1) daily review of death certificates for all deaths in the study area to identify those with stroke (for those with a diagnosis of stroke, the clinical records were reviewed); (2) weekly review of hospital registration, hospitalization refusals (stroke patients could only be hospitalized in two hospitals in the study area), and all autopsy protocols (patients with old stroke at brain autopsy were not included in this study); (3) weekly review of outpatient clinic data; and (4) daily review of all ambulance call registrations within and just outside the study area. Additionally, information regarding documentation of the history of a previous stroke was checked through all medical documentation available, including the patient's recall.

On the basis of these sources of information, all patients with stroke or suspected stroke were examined and interviewed by a specially trained cerebrovascular neurologist of the SRD at the hospital or at home as soon as possible after the episode of stroke or alleged stroke became known to the SRD. In addition, one of the authors reviewed all the records and classified the patients in diagnostic categories according to the best information available. One hundred seventy-five subjects for whom stroke was listed on the death certificate were presumed to have died of nonstroke causes and were excluded. Exclusion was based on one of the following: (1) a short time had elapsed between onset of symptoms and death (<2 hours); (2) the time that had elapsed before death occurred was unknown, and an autopsy was not performed; (3) the clinical records did not support the diagnosis; or (4) no clinical record indicating stroke was available.

The definition of stroke was based on standard criteria.³ Stroke was considered to include cerebral infarction, intracerebral hemorrhage, and subarachnoid hemorrhage (classification of stroke subtypes was based on the results of clinical examination, including autopsy findings when available^{30 31} ). However, because CT scanning became available in Novosibirsk only in 1992, it was thought that defining stroke subtypes (cerebral infarction, intracerebral hemorrhage, and subarachnoid hemorrhage) was unreliable. Thus, the data presented herein were not stratified by subtypes of stroke.

The population of Novosibirsk was relatively stable (the migration rate is <1%/y) and predominantly white (>95% in 1989 census). The population size of the Oktiabrsky District of Novosibirsk was determined with All-Union census estimates in 1979 and 1989 and, in all intermediate years, by linear interpolation. The estimated population was 147 680 in 1982 (81 230 females and 66 450 males; male-to-female ratio, 0.8) and 158 234 in 1992 (86 660 females and 71 574 males; male-to-female ratio, 0.8).

The number of persons with an incident stroke occurring during the period 1982 through 1992 was expressed each year as an annual rate per 100 000 population adjusted for age and sex. To assess early case-fatality rates for 1982 through 1992, death that occurred within 30 days from the onset of the incident stroke was noted (total number of strokes by age and sex was used to directly adjust case-fatality rates). The 1970 white population of the United States was used to directly adjust incidence rates, so that these "adjusted" rates could be compared with published rates from Rochester, Minn. Poisson regression was used to model the incidence rates as a function of sex, age (10-year age groups), and calendar year (linear) with the use of generalized linear models³² and SAS procedure.³³ The log link function was used with the natural logarithm of the population as an offset variable. We also examined plots of observed versus predicted incidence rates to assess the adequacy of specific models.

	Results

Top Abstract Introduction Subjects and Methods Results Discussion References

 
The crude incidence rate of stroke for the period 1982 through 1992 was 202/100 000, and the age- and sex-adjusted rate was 219/100 000 (Table 1). The age-specific incidence rate of stroke was higher in men than in women in each group aged older than 44 years. Although the crude stroke incidence rate in men (168/100 000) was lower than in women (231/100 000), the age-adjusted rate in men (244/100 000 [95% confidence interval (CI), 228 to 259]) was significantly higher than that in women (201/100 000 [95% CI, 192 to 210]). The annual hospitalization rate, averaging 60% of all first-ever stroke patients, was not significantly different throughout the 11-year period studied.

View this table: [in this window] [in a new window]   Table 1. Annual Age- and Sex-Specific Incidence Rates of First Stroke per 100 000 Population of Novosibirsk, Russia, 1982-1992

View this table: [in this window] [in a new window]   Table 1B. Continued

Age- and sex-adjusted stroke incidence rates declined by 14.4%, from 271/100 000 in 1982 to 232/100 000 in 1992. A comparison of overlapping 3-year average annual incidence rates for men and women is shown in Fig 1. Age-specific incidence rates are shown in Fig 2.

View larger version (13K): [in this window] [in a new window]   Figure 1. Line graph shows running 3-year average annual age-adjusted incidence rates of stroke in Novosibirsk, Russia, 1982 through 1992. The data points are labeled according to the middle year of each 3-year period.

View larger version (18K): [in this window] [in a new window]   Figure 2. Line graph shows running 3-year average annual age-specific incidence rates of stroke in Novosibirsk, Russia, 1982 through 1992. The data points are labeled according to the middle year of each 3-year period.

Using Poisson regression, we investigated the effects of sex, age group, and calendar year on the natural log of the incidence rates. Each effect contributed significantly to the model (P<.0001 for each effect). The mean age (±SD) at stroke onset was 64.8±13.1 years (62.7±12.6 years in men and 66.9±13.3 years in women). The mean age of women with stroke was higher than that in men in each year of the study but was not changed significantly (P>.05) in either men or women during the 11-year period under review.

Of the 3406 incident stroke patients, 1044 (384 men and 660 women) died during the first 30 days after stroke (overall age-adjusted rate, 30.6%: 32.4% in men and 29.7% in women; P>.05). Age-specific 30-day stroke case-fatality rates increased with increasing age in both men and women (Fig 3). Thirty-day case-fatality rates decreased from 31.9% in 1982 to 19.1% in 1992 in women but increased from 24.9% to 29.1% in men. These year-to-year variations in 30-day case-fatality rates were not significantly different, as determined by Poisson regression (Table 2).

View larger version (11K): [in this window] [in a new window]   Figure 3. Line graph shows age- and sex-specific 30-day stroke case-fatality rates in Novosibirsk, Russia, 1982 through 1992.

View this table: [in this window] [in a new window]   Table 2. Thirty-Day Case-Fatality Rates for Stroke in Novosibirsk, Russia, 1982-1992

	Discussion

Top Abstract Introduction Subjects and Methods Results Discussion References

 
The study area was chosen to ensure maximal case ascertainment. The population received care at only two hospitals in this region. In addition, other sources of medical care were easily identified. Attempts to ensure completeness of ascertainment were augmented by reviewing official mortality statistics from the Novosibirsk Bureau of Statistics; by retrospectively reviewing death certificates for all deaths, hospital registrations, hospitalization refusals, outpatient clinic data, and all ambulance calls; and by performing a standardized neurological examination on all patients with stroke or suspected stroke at the hospital or at home within and just outside the study area. The result was a comprehensive record of all new cases of stroke in residents of Novosibirsk.

These overlapping sources of information and the close liaison with general practitioners added to the reliability of the case-ascertainment and neurological observations (97% of the patients were examined by a neurologist of the SRD). Furthermore, the symptoms at onset and the clinical course of the stroke were well documented. Patients with poorly documented stroke were not included in the analysis. Because the addition of CT scanning only marginally sharpens the diagnosis of all stroke (by <2%),³⁴ the study data, based on standardized clinical observations, should be reliable for incidence and case-fatality rates (for all strokes). However, CT scanning was not available in Novosibirsk until 1992; thus, designation of stroke subtype is unreliable.

The decline in stroke incidence shown in Fig 1 was most prominent in the older age groups (Fig 2). For example, during the period 1982 through 1992, men aged 65 to 74 years and women aged 75 to 84 years experienced the fastest average annual rate of decline in stroke incidence (5.6% for men and 6.7% for women, compared with 1.7% and 4.0% for men and women aged 55 to 64 years and 65 to 74 years, respectively). Stroke incidence rates increased in 1992 in both men and women, particularly in the groups aged 65 to 74 years and 75 to 84 years. There was no major change in age at stroke onset.

The average age-adjusted incidence rates for stroke in Novosibirsk (201/100 000 in women and 244/100 000 in men) were 83% higher in women and 45% higher in men than the similar age-adjusted incidence rates in Rochester, Minn, in the period 1980 through 1984. The Novosibirsk rates were quite comparable to the rates in Rochester, Minn, from 1945 through 1949.²⁵ In Söderhamn, Sweden, the stroke incidence in women increased by 38% between 1975 and 1978 and between 1983 and 1985.²⁶ This increase was most notable in women aged 85 years or older.²⁶

In contrast to findings in Rochester, Minn,²⁵ and other studies,^{14 35 36} in which the decrease started earlier or was more prominent for women than for men, the incidence of stroke in Novosibirsk in our observation period declined in both men and women, and the decline was even more substantial in men than in women. Differences in medical care, in the proportion of patients with hypertension who received effective treatment, and in other risk factors before stroke may have had a role. A decrease in stroke incidence rates during the last few decades has been observed in other community- and population-based studies.^{15 19 22}

The identification of cases for the stroke incidence study coincided with the beginning of a special program for the detection and management of patients with hypertension, which continued throughout the incidence study. However, the number of persons in the population with unidentified and uncontrolled hypertension was still substantial in 1985 and 1986.³⁷ In 1989, of all stroke patients with underlying hypertension, approximately 45% had not been identified and treated before stroke, and among those with previously identified hypertension, good control with treatment had been achieved in only 25%. The lack of effective measures of primary prevention of stroke in Russia may explain why overall stroke incidence was so high in our period of observation.

The average 30-day case-fatality rate for stroke was 30.6% from 1982 through 1992, and it increased significantly with increasing age in both men and women. No information was available for this study about the proportion of nonfatal events managed out of hospital. A trend toward improved early survival after stroke, although not statistically significant, has been noted since 1987 in women and since 1988 in both men and women. The average age-adjusted early 30-day case-fatality rates for incident stroke in Novosibirsk (32.4% in men and 29.7% in women) are similar to those in Italy,³⁸ the Netherlands,³⁹ New Zealand,⁴⁰ China,²³ and Finland (women)¹³ but higher than the rates in the United States,⁴¹ Sweden,⁴² Finland (men),¹³ and Australia.⁴³ A pattern of decreased 30-day case-fatality rates for stroke was observed in Rochester, Minn,^{44 45} where the rates decreased from 33% to 17% between the periods 1945 through 1949 and 1980 through 1984. These data are consistent with the results from other studies.^{6 15 19 23 46 47}

Stroke incidence is still high in Russia compared with that of other countries.³⁷ On the basis of the present study, it seems likely that the decline in stroke incidence in Novosibirsk could be greatly enhanced by the implementation of primary stroke prevention strategies.

	Acknowledgments

 
This study was supported in part by research grants 1 F05 TWO4644-01 NSS, NS 06663, and AR 30582 from the National Institutes of Health. The authors would like to express their gratitude to all the physicians and nurses of Novosibirsk for supporting the local data collection. We also thank Chu-Pin Chu (data analyst), Mayo Clinic, Rochester, Minn, for her valuable assistance.

	Footnotes

 
Reprint requests to David O. Wiebers, MD, Division of Cerebrovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN 55905.

Received November 7, 1994; revision received February 24, 1995; accepted February 27, 1995.

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