(Stroke. 1995;26:1707-1712.)
© 1995 American Heart Association, Inc.
Articles |
Epidemiology of Stroke in Hispanic Americans
From the Centers for Disease Control and Prevention, Hyattsville, Md.
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Abstract |
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 Top Abstract IntroductionStroke MortalityStroke MorbidityStroke Risk FactorsConclusionsReferences |
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Background and Purpose In 1990 cerebrovascular disease was the fourth leading cause of death in Hispanics in the United States. However, little information has been published about the epidemiology of stroke in US Hispanic populations.
Methods Data from the National Center for Health Statistics were examined to characterize the pattern of stroke occurrence and risk factors among Hispanics in the United States.
Results In 1989 through 1991, stroke death rates were similar in Hispanics and whites aged 45 to 64 years; at ages 65 and over, Hispanics had rates that were substantially lower than those of whites. Data from national surveys suggest that the ethnic differences in stroke mortality may be due in part to lower blood pressure in Hispanics than non-Hispanics.
Conclusions Cohort studies, well-designed case-control studies, and continued oversampling of Hispanics in national surveys are needed to further define the epidemiological patterns of stroke in US Hispanics and to guide stroke prevention efforts.
Key Words: cerebral hemorrhage • cerebral infarction • cerebrovascular disorders • cigarette smoking • diabetes mellitus • hypertension • lipoproteins
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Introduction |
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TopAbstractIntroductionStroke MortalityStroke MorbidityStroke Risk FactorsConclusionsReferences |
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Little information has been published about the epidemiology of stroke in Hispanic populations of the United States.1 2 However, a few reports have suggested differences in stroke death rates between Hispanics and non-Hispanic whites. In New Mexico, Hispanics had lower age-adjusted death rates from cerebrovascular disease than non-Hispanic whites in 1958 through 1983 but higher rates in 1983 through 1987.3 Age-adjusted rates declined for Hispanics. Age-specific comparisons are largely lacking. Data from the NCHS were examined and results of population-based studies reviewed to characterize the pattern of stroke occurrence and risk factors among Hispanics in the United States.
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Stroke Mortality |
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TopAbstractIntroductionStroke MortalityStroke MorbidityStroke Risk FactorsConclusionsReferences |
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Deaths from cerebrovascular disease were enumerated using published and unpublished data from the NCHS4 5 6 for International Classification of Diseases, 9th Revision, codes 430 to 438. Cerebrovascular disease was the fourth leading cause of death in US Hispanics in 1990.4 It was the third leading cause in Hispanics aged 65 and over. Disease of the heart was the leading cause overall and at ages 65 years and over.
Fig 1
shows age-specific death rates for cerebrovascular
disease in 1989 through 1991. Three years' data were pooled to ensure
stable rates for each age, sex, and ethnicity group. Under 65 years of
age, death rates were similar in Hispanics and whites. At ages 65 and
over, Hispanics had rates that were substantially below those of
whites, especially at ages 85 and over. Rates in Hispanic men and women
were similar below age 65 years, higher in men than women at ages 65 to
74 and 75 to 84, and higher in women at ages 85 and over. Age-adjusted
death rates were lower for Hispanics (84.4 and 68.5 per 100 000
population for men and women, respectively) than for blacks and whites
aged 45 years and over for 1989 through 1991.5 The pattern
of Hispanic compared with white age-specific death rates was remarkably
similar for cerebrovascular disease and heart disease (Fig 2); the most notable difference was that for heart
disease rates were substantially lower for Hispanics than for whites at
ages 55 to 64 years as well as at older ages.5
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Proportional Mortality
In 1990, there were 3655 deaths from cerebrovascular disease in
Hispanics, 5.32% of total Hispanic deaths.4 Deaths from
cerebrovascular disease constituted 6.90% of total deaths in
non-Hispanic whites. At ages 65 years and over, cerebrovascular deaths
were 7.74% of Hispanic deaths and 8.19% of deaths in non-Hispanic
whites. The percentage of cerebrovascular deaths occurring at age 65
and over was 71.7% for Hispanics and 90.2% for non-Hispanic whites,
reflecting the differing population age structures and stroke death
rates.
In 1990, of 3655 deaths attributed to cerebrovascular disease in
Hispanics, 761 (20.8%) were coded intracerebral and
other intracranial hemorrhage, 406 (11.1%) cerebral thrombosis
and unspecified occlusion of cerebral arteries, 18 (0.5%) cerebral
embolism, and 2470 (67.6%) other diagnoses and late effects of
cerebrovascular diseases (Table 1). An age-specific
comparison at ages 65 to 74 years revealed a similar pattern. Although
the diagnosis of hemorrhage was slightly more common in
Hispanics than in non-Hispanic whites living in the 45 reporting states
as well as New York State (excluding New York City) and the District of
Columbia, population-based studies using uniform criteria and methods
are required to assess ethnic differences in stroke pathology.
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Limitations of Vital Statistics
Mortality data for Hispanics are based on information from states
with 90% complete data on Hispanic origin on death certificates, the
number of states increasing from 44 in 1989 to 47 in
1991.4 5 6 Data from New York were excluded for the 3-year
period of 1989 through 1991 because Hispanic origin of descent was not
stated or was unknown in a substantial percentage of deaths in New York
City in 1990 to 1991.5 Analyses of 1989 data
indicated that exclusion of New York likely changed age- and
sex-specific rates by less than 5%.5 However, in these
analyses, rates for whites and blacks are based on available
data from 50 states and the District of Columbia. Hence, geographic
differences may confound comparisons of ethnic groups. Bias in
comparisons of death rates for Hispanics and whites due to ethnic
classification errors is unlikely because persons identified as
Hispanic by self report in data from the US census (denominator of
death rates) are similarly classified by persons completing the death
certificate in a high percentage of cases.7 Hispanics may
be of any race. The death certificate has specific items requesting
both race and Hispanic origin.6 Furthermore, patterns of
stroke death by age and Hispanic status similar to those reported above
were reported from the National Longitudinal Mortality Study, which
followed a cohort that included 12 527 Hispanics who experienced 46
stroke deaths.8 However, interpretation of comparisons of
death rates for Hispanics is complicated by the possibility that the
population of Hispanics may be undercounted in the census to a greater
extent than that of non-Hispanic whites. In the 85+ age group, a lower
average age for Hispanics (29.5% 
90 years) than for non-Hispanic
whites (33.2% 90 years) might produce a greater difference in rates
than would be seen with closed aged intervals.
The numbers of deaths and population-based rates are not subject to
sampling error.6 When the number of events is large
(>100), approximate CIs for rates are extremely narrow. In 1989
through 1991 in the reporting states, 9982 Hispanics aged 45 years and
over died of stroke. All the rates shown in Fig 1
are based on large
numbers of deaths (eg, 1352 deaths in Hispanic men and 1769 deaths in
Hispanic women aged 75 to 84 years). However, examination of trends in
mortality rates was not possible because of the many limitations of the
vital statistics data (eg, only 15 states reported Hispanic origin in
1980 through 1984).
Hispanic Subgroups
Age-adjusted death rates for Mexican Americans or other US
mainland Hispanic subgroups based on data from 18 states and the
District of Columbia in 1986 through 1988 showed higher rates for
stroke in men among Puerto Ricans (49.2) than Cubans (30.2) or Mexican
Americans (21.7); rates for women were 41.3, 24.2, and 22.6,
respectively.9 Unpublished analyses of
cerebrovascular death after 12 years follow-up in the Puerto Rico Heart
Health Program revealed the following10 : over a 12-year
follow-up, cerebrovascular death occurred in 54 rural and 129 urban men
in the cohort aged 35 to 79 years; age-adjusted rates per 10 000 were
168 in rural and 193 in urban men (P. Sorlie, personal communication,
1994). It is interesting to note that the age-specific US stroke death
rates in Hispanic men above age 45 years were nearly identical to those
for American Indians.5 Among women, rates were nearly
identical below age 85 but much higher in Hispanics than American
Indians at ages 85 years and over. It is unclear whether this is a
chance occurrence or a result of American Indian ancestry of Mexican
Americans.
International Comparisons
It is interesting to compare cerebrovascular disease mortality
rates for US Hispanics and US whites with rates in the countries of
origin of most US Hispanic immigrants. In 1985 through 1988,
age-adjusted stroke mortality rates per 100 000 in males were highest
in Cuba (33.9), followed by Mexico (23.7) and the United States
(20.2).11 In females, rates were higher in Mexico (23.0)
and Cuba (32.0) than in the United States. (18.8). Between 1968 to 1970
and 1985 to 1988, rates declined more in US males (-54.3%) and
females (-50.3%) than in Mexican males (-24.3%) or females
(-33.9%) or Cuban males (-26.1%) or females (-30.9%). These data
must be interpreted with caution.11 12 Thus, in recent
years rates of death from cerebrovascular disease were lower in the US
than in the countries of origin of most US Hispanic immigrants, with
the exception of Puerto Rico. However, in 1968 through 1970, rates in
the United States were similar to those in Cuba and higher than those
in Mexico, indicating a much greater reduction in death rates in the
United States, presumably in part due to improved hypertension
control.11 13 14 15
The current pattern in the United States of lower stroke death rates for Hispanics compared with non-Hispanic whites aged 65 years and over resembles the international pattern of 1968 through 1970 (death rates lower in Mexico than in the United States). The current pattern of similar stroke death rates for middle-aged US Hispanics compared with non-Hispanic whites resembles the current international pattern of similar or somewhat higher death rates in Mexico compared with the United States. Perhaps, like persons in Mexico, middle-aged US Hispanics have benefited less than elderly Hispanics from improvements in US lifestyles and medical care because of more recent immigration or lower socioeconomic status.13 Among Hispanics in the 1990 US census, 6.4% were recent (<10-year) immigrants at ages 85+ compared with 11.9% at ages 45 to 54 years. Perhaps older US Hispanics have been able to share in improvements in US lifestyles and medical care because of longer US residence, enhanced socioeconomic status, and Medicare eligibility.
Another possible contributor to mortality patterns is the possibility that some elderly Mexican Americans and Puerto Ricans suffering from cerebrovascular disease might return to the communities in Mexico and Puerto Rico from which they emigrated decades earlier. This would tend to lower death rates among elderly US Mexican Americans. Further demographic and epidemiological research is needed to elucidate causes of mortality patterns.
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Stroke Morbidity |
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TopAbstractIntroductionStroke MortalityStroke MorbidityStroke Risk FactorsConclusionsReferences |
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Incidence, Hospitalization, and Case Fatality
Currently, studies of stroke incidence in US Hispanics are lacking. A study of a cohort of Puerto Rican men, the Puerto Rico Heart Health Program, did not have nonfatal stroke as an end point.10 Data by Hispanic origin or descent were not available for hospitalization data from the National Hospital Discharge Survey.14 However, New York State discharge data for 1983 through 1986 were used to compute acute stroke hospitalization rates among residents of an area of north Manhattan in New York City, defined by four zip codes.16 Age-adjusted rates at age 40 and over were 361 in Hispanics, 326 in white non-Hispanics, and 716 in black non-Hispanics among women and 306, 235, and 567, respectively, among men. Rates were higher in whites than Hispanics aged 80 and over but similar at ages 40 to 79 years. Fatality rates in the hospital for Hispanics (18.8% at ages 40 to 69, 16.1% at age 70 and over) were higher than for whites but lower than for blacks.16 Among survivors, 1- and 2-year readmission rates were similar among groups. Consistent with national proportional mortality data (Table 1
),
the percentage of strokes coded intracranial hemorrhage was
higher in Hispanics than whites, similar to observations in blacks and
Native Americans.16 17 18 A subsequent study of a series of patients with cerebral infarction in north Manhattan indicated a greater proportion with intracranial atherosclerotic stroke and lacunar stroke in Hispanics and non-Hispanic blacks compared with whites.19 Few published case series reported findings for Hispanics.20 21 In New York City, Hispanic patients (n=82) hospitalized with cerebral infarct had significantly lower risk of death or recurrent stroke after 1 year than whites or blacks because of their lower prevalence of nonlacunar stroke and coexisting heart disease (abnormal first electrocardiogram).20 Cohort and surveillance studies of Hispanic populations are needed to determine rates of stroke incidence, hospitalization, case fatality, stroke subtypes, and long-term survival in Mexican Americans, Puerto Ricans, and Cuban Americans.
Prevalence
Table 2 shows the estimated prevalence of
self-reported stroke in the civilian noninstitutionalized population by
age and ethnicity using data from the NHIS.22 In 1989
through 1991, an estimated annual average of 139 556 (95% CI,
111 880 to 167 232) Hispanics had a history of stroke. Of these, an
estimated 82 982 were aged 65 years or over. At age 65 and over, the
rate was 73 per 1000 (95% CI, 54 to 93). Unfortunately, despite
pooling data from 3 years, the small number of Hispanics with stroke in
the NHIS sample resulted in wide CIs, precluding meaningful comparison
with the rates in non-Hispanics. Further analyses of aggregated
years of NHIS data are needed for the years following 1992, in which
Hispanics are being oversampled. Also needed are studies of the
validity of self-reported stroke diagnoses in US Hispanics. If
confirmed in subsequent studies of persons aged 65 years and over, a
pattern of lower death rates, similar proportional mortality, similar
hospitalization rates below age 80, and greater prevalence rate of
stroke survivors in Hispanics compared with non-Hispanic whites might
be explained by greater survivorship after stroke in Hispanics. Greater
survivorship may be due to a lower occurrence of large nonlacunar
strokes and coexisting ischemic heart
disease.20
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Stroke Risk Factors |
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TopAbstractIntroductionStroke MortalityStroke MorbidityStroke Risk FactorsConclusionsReferences |
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Almost no published data are available from prospective cohort studies relating risk variables to stroke incidence or mortality in US Hispanics. Unpublished univariate and multivariate logistic regression analyses from the Puerto Rico Heart Health Program10 indicated that the following variables were directly related to 12-year occurrence of cerebrovascular death in both urban and rural men aged 35 to 79 years (Table 3
) (P. Sorlie, personal communication, 1994):
systolic blood pressure, diastolic blood pressure, definite
hypertension, electrocardiogram left
ventricular hypertrophy (urban only). Levels of
serum cholesterol, triglycerides, and blood
glucose, diabetes mellitus, glucose intolerance, relative weight,
cigarette smoking, hematocrit level, physical activity, and alcohol
intake were not significantly associated with risk of cerebrovascular
death. However, the small number of events limited statistical power to
detect associations. Vital capacity and education were inversely
associated with cerebrovascular death rates in urban and rural men.
Further prospective cohort and case-control studies are needed of these
and other risk factors in various Hispanic populations.
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Are differences in stroke risk factor prevalence between Hispanics and non-Hispanic whites consistent with observed differences in stroke mortality and morbidity? Data from national surveys suggest that the ethnic differences in stroke may be due in part to lower blood pressure in Hispanics. However, patterns of smoking, diabetes, and obesity prevalence are not consistent with mortality patterns. A comprehensive review of all published studies of risk factors in Hispanics is beyond the scope of this article. NCHS data on stroke risk factors in Hispanics may be summarized briefly as follows.
Blood Pressure
Compared with whites or blacks in the second NHANES of 1976
through 1980, the prevalence of hypertension at ages 18 to 74 years was
significantly lower in Mexican Americans (16.8% of men, 14.1% of
women), Cuban Americans (22.8% of men, 15.5% of women), and Puerto
Ricans (15.6% of men, 11.5% of women) in the HHANES of 1982 through
1984.23 The differences persisted after adjusting for age
(Fig 3). Mean blood pressure levels were also lower in
Mexican Americans compared with non-Hispanic whites or with blacks,
even after adjusting for age and body mass.24
Unfortunately, age-specific comparisons have not been presented
because of limited sample size within Hispanic subgroups. For
hypertension and other risk factors, estimates of levels and
differences between Hispanics and non-Hispanics from NCHS surveys may
vary from results of surveys of local populations.23 24 25
Data from the third NHANES of 1988 to 1994 will provide updated results
for Mexican Americans.
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Diabetes
In Mexican Americans in HHANES, age-adjusted prevalence of
self-reported diabetes was 6.8% among men and 7.6% among women
compared with US rates of 2.9% among men and 3.8% among
women.26 At age 45 to 74 years, the prevalence of
previously diagnosed diabetes was 2.4 times as great in Mexican
Americans and Puerto Ricans and the same in Cubans as in non-Hispanic
whites.27 When results of an oral glucose tolerance test
were analyzed, the total prevalence of diabetes (World Health
Organization criteria) at ages 45 to 74 years in Mexican Americans and
Puerto Ricans was found to be more than two times as high as that for
non-Hispanic whites in NHANES II (Mexican Americans, 23.9%; Puerto
Ricans, 26.1%; Cubans, 15.8%; non-Hispanic whites,
12%).27
Smoking
Age-specific current smoking rates in the three Hispanic groups
surveyed in HHANES were generally higher than the rates observed for
non-Hispanic whites in the 1985 NHIS and were only slightly lower than
the rates for blacks.28 The age-adjusted rates for men
were Mexican American 42.5%, Cuban American 39.8%, and Puerto Rican
41.6%; those for women were 23.8%, 24.4%, and 30.3%, respectively.
Puerto Rican and Cuban male smokers were more likely and Mexican
American male smokers less likely to smoke more than 20 cigarettes per
day compared with all white men (37%). Heavy smoking was also twice as
prevalent in Puerto Rican and Cuban women compared with Mexican
American and all white women. Data from the 1992 NHIS for persons aged
18 years and over indicate a prevalence of current smokers in Hispanics
of 20.4% (95% CI, ±2.7%), which is slightly lower than the 26.2%
for all whites (95% CI, ±0.8%).29 Prevalence was
slightly higher in men (22.2%) than women (18.6%). Data from HHANES
indicate that Hispanics may underreport cigarette
smoking.30
Lipids
Among Mexican-Americans aged 20 to 74 years in the southwest
United States, 16.6% overall, 16.6% of men, and 16.5% of women had
serum total cholesterol levels of 6.20 mmol/L (240 mg/dL)
or more.31 Among Cubans in Dade County, Florida, the
percentages were 18.3% overall, 17.5% of men, and 18.8% of women.
Among Puerto Ricans in the New York metropolitan area, the percentages
were 17.7% overall, 16.8% of men, and 18.2% of women. In 1976
through 1980, 27% of white adults had serum cholesterol
levels of 6.20 mmol/L (240 mg/dL) or more. Age-adjusted mean serum
cholesterol levels for the three Hispanic origin groups
(Mexican Americans, Cubans, and Puerto Ricans) were 5.35, 5.30, and
5.25 mmol/L (207, 205, and 203 mg/dL) for men and 5.35, 5.15, and 5.40
mmol/L (207, 199, and 209 mg/dL) for women, respectively.
Among Mexican-Americans aged 20 to 74 years in the southwest United States, 38.4% overall, 46.3% of men, and 30.4% of women had ratios of total cholesterol to high-density lipoprotein cholesterol of 4.5 or more. Among Cubans in Dade County, Florida, the percentages were 40.6% overall, 56.6% of men, and 27.4% of women. Among Puerto Ricans in the New York metropolitan area, the percentages were 49.1% overall, 58.4% of men, and 43.2% of women. In 1976 through 1980, 47% of white adults had ratios of total to high-density lipoprotein cholesterol of 4.5 or more.
Overweight
In HHANES and NHANES II, overweight was defined as a body mass
index equal to or greater than that at the 85th percentile of men (27.8
kg/m2) or women (27.3 kg/m2) aged 20 to 29
years from NHANES II. In HHANES at ages 20 to 74, 29.6% of Mexican
American men, 29.4% of Cuban men, and 25.2% of Puerto Rican men were
overweight compared with 24.4% of US white men in NHANES
II.32 33 In HHANES at ages 20 to 74 years, 39.1% of
Mexican American women, 34.1% of Cuban women, and 37.3% of Puerto
Rican women were overweight compared with 25.1% of US white women in
NHANES II.32 33 Skinfold-thickness data indicated a strong
tendency toward centralized distribution of body fat in
Hispanics.34
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Conclusions |
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TopAbstractIntroductionStroke MortalityStroke MorbidityStroke Risk FactorsConclusionsReferences |
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Stroke is a leading cause of death in US Hispanics. However, little published information is available about the epidemiology of stroke in Hispanics. Vital statistics data indicate similar death rates for Hispanics and non-Hispanic whites under 65 years of age, with lower rates for Hispanics at age 65 and over. Stroke accounted for a somewhat lower percentage of deaths in Hispanics than in non-Hispanic whites; hemorrhagic stroke was slightly more frequent in Hispanics. US Hispanics had higher levels of diabetes, smoking, and overweight but lower levels of blood pressure and serum cholesterol compared with non-Hispanic whites. No prospective cohort studies have published data on stroke incidence or risk factors in US Hispanics. Cohort studies, well-designed case-control studies, continued improvements in vital statistics, analyses of administrative hospitalization data, and continued oversampling of Hispanics in national surveys are needed to further define the epidemiological patterns of stroke in US Hispanics overall and in Mexican Americans, Puerto Ricans, and Cuban Americans.
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Selected Abbreviations and Acronyms |
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Footnotes |
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Reprint requests to R. F. Gillum, MD, Centers for Disease Control and Prevention, National Center for Health Statistics, 6525 Belcrest Rd, Hyattsville, MD 20782.
Received March 3, 1995; revision received June 5, 1995; accepted June 5, 1995.
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References |
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TopAbstractIntroductionStroke MortalityStroke MorbidityStroke Risk FactorsConclusionsReferences |
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 K. J. Ottenbacher, G. V. Ostir, M. K. Peek, and K. S. Markides Diabetes Mellitus as a Risk Factor for Stroke Incidence and Mortality in Mexican American Older Adults J. Gerontol. A Biol. Sci. Med. Sci., June 1, 2004; 59(6): M640 - M645. [Abstract] [Full Text] [PDF]
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H. J. Fullerton, Y. W. Wu, S. Zhao, and S. C. Johnston Risk of stroke in children: Ethnic and gender disparities Neurology, July 22, 2003; 61(2): 189 - 194. [Abstract] [Full Text] [PDF]
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C. Ayala, J. B. Croft, K. J. Greenlund, N. L. Keenan, R. S. Donehoo, A. M. Malarcher, and G. A. Mensah Sex Differences in US Mortality Rates for Stroke and Stroke Subtypes by Race/Ethnicity and Age, 1995-1998 Stroke, May 1, 2002; 33(5): 1197 - 1201. [Abstract] [Full Text] [PDF]
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A. Hartmann, T. Rundek, H. Mast, M. C. Paik, B. Boden-Albala, J. P. Mohr, and R. L. Sacco Mortality and causes of death after first ischemic stroke: The Northern Manhattan Stroke Study Neurology, December 11, 2001; 57(11): 2000 - 2005. [Abstract] [Full Text] [PDF]
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S. Yusuf, S. Reddy, S. Ounpuu, and S. Anand Global Burden of Cardiovascular Diseases: Part II: Variations in Cardiovascular Disease by Specific Ethnic Groups and Geographic Regions and Prevention Strategies Circulation, December 4, 2001; 104(23): 2855 - 2864. [Abstract] [Full Text] [PDF]
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 C. Ayala, K. J. Greenlund, J. B. Croft, N. L. Keenan, R. S. Donehoo, W. H. Giles, S. J. Kittner, and J. S. Marks Racial/Ethnic Disparities in Mortality by Stroke Subtype in the United States, 1995-1998 Am. J. Epidemiol., December 1, 2001; 154(11): 1057 - 1063. [Abstract] [Full Text] [PDF]
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R. L. Sacco, B. Boden-Albala, G. Abel, I-F. Lin, M. Elkind, W. A. Hauser, M. C. Paik, and S. Shea Race-Ethnic Disparities in the Impact of Stroke Risk Factors: The Northern Manhattan Stroke Study Stroke, August 1, 2001; 32(8): 1725 - 1731. [Abstract] [Full Text] [PDF]
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L. B. Morgenstern, L. Steffen-Batey, M. A. Smith, and L. A. Moye Barriers to Acute Stroke Therapy and Stroke Prevention in Mexican Americans Stroke, June 1, 2001; 32(6): 1360 - 1364. [Abstract] [Full Text] [PDF]
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 L. A. Farrer Intercontinental Epidemiology of Alzheimer Disease: A Global Approach to Bad Gene Hunting JAMA, February 14, 2001; 285(6): 796 - 798. [Full Text] [PDF]
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G. Saposnik, L. R. Caplan, L. A. Gonzalez, A. Baird, J. Dashe, A. Luraschi, R. Llinas, S. Lepera, I. Linfante, C. Chaves, et al. Differences in Stroke Subtypes Among Natives and Caucasians in Boston and Buenos Aires Stroke, October 1, 2000; 31(10): 2385 - 2389. [Abstract] [Full Text] [PDF]
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T. H. Wein, M. A. Smith, and L. B. Morgenstern Race/Ethnicity and Location of Stroke Mortality : Implications for Population-Based Studies Stroke, August 1, 1999; 30(8): 1501 - 1505. [Abstract] [Full Text] [PDF]
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 M. Pahor, M. B. Elam, R. J. Garrison, S. B. Kritchevsky, and W. B. Applegate Emerging Noninvasive Biochemical Measures to Predict Cardiovascular Risk Arch Intern Med, February 8, 1999; 159(3): 237 - 245. [Abstract] [Full Text] [PDF]
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A. Bruno Are There Differences in Vascular Disease Between Ethnic and Racial Groups? Stroke, January 1, 1998; 29(1): 2 - 3. [Full Text] [PDF]
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J. L. Frey, H. K. Jahnke, and E. W. Bulfinch Differences in Stroke Between White, Hispanic, and Native American Patients : The Barrow Neurological Institute Stroke Database Stroke, January 1, 1998; 29(1): 29 - 33. [Abstract] [Full Text] [PDF]
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A. P. Sempere, J. Duarte, C. Cabezas, and L. E. Claveria Etiopathogenesis of Transient Ischemic Attacks and Minor Ischemic Strokes : A Community-Based Study in Segovia, Spain Stroke, January 1, 1998; 29(1): 40 - 45. [Abstract] [Full Text] [PDF]
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R. F. Gillum and C. T. Sempos The End of the Long-term Decline in Stroke Mortality in the United States? Stroke, August 1, 1997; 28(8): 1527 - 1529. [Full Text]
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L. W. Pickle, M. Mungiole, and R. F. Gillum Geographic Variation in Stroke Mortality in Blacks and Whites in the United States Stroke, August 1, 1997; 28(8): 1639 - 1647. [Abstract] [Full Text]
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L. B. Morgenstern, W. D. Spears, D. C. Goff, J. C. Grotta, and M. Z. Nichaman African Americans and Women Have the Highest Stroke Mortality in Texas Stroke, January 1, 1997; 28(1): 15 - 18. [Abstract] [Full Text]
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M. Fisher, J. A. Fernandez, S. F. Ameriso, D. Xie, A. Gruber, A. Paganini-Hill, and J. H. Griffin Activated Protein C Resistance in Ischemic Stroke Not Due to Factor V Arginine506->Glutamine Mutation Stroke, July 1, 1996; 27(7): 1163 - 1166. [Abstract] [Full Text]
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