(Stroke. 1996;27:825-832.)
© 1996 American Heart Association, Inc.
Articles |
Ten-Year Trends in Stroke Incidence and Mortality in the FINMONICA Stroke Study
From the Department of Epidemiology and Health Promotion, National Public Health Institute of Helsinki (J. Tuomilehto, D.R., C.S., K.K., V.S., J. Torppa), the University Hospital of Kuopio (J.S.), the City Hospital of Turku (P.I.-R., E.V.N.), the District Hospital of Loimaa (E.K.), and the Central Hospital of North Karelia (K.S.), Finland.
Correspondence to Prof Jaakko Tuomilehto, Department of Epidemiology and Health Promotion, National Public Health Institute, Mannerheimintie 166, FIN-00300 Helsinki, Finland.
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Abstract |
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Background and Purpose The trends in stroke incidence reported so far have not been entirely consistent, although declining trends in mortality from stroke have been reported from a number of studies around the world. This study aims to evaluate the 10-year trends (from 1983 through 1992) in incidence, attack rate, and mortality of stroke in the Finnish population.
Methods A population-based stroke register was set up in the early 1980s to collect data on all suspected events of acute stroke that occurred in the population aged 25 to 74 years permanently residing in three geographic areas of Finland: the provinces of Kuopio and North Karelia in eastern Finland and the Turku-Loimaa area in southwestern Finland. Trends in age-standardized attack rates, incidence, and mortality were calculated for the period studied.
Results During the 10-year study period, 11 392 acute stroke events occurred in the monitored populations. A statistically significant decline was observed in the pooled FINMONICA data, both in the incidence of stroke (-1.7% with 95% confidence interval [CI], -3.0% to -0.5% per year in men; -2.2% with 95% CI, -3.6% to -0.7% per year in women) and in mortality from stroke (-5.2% with 95% CI, -8.2% to -2.2% per year; -4.7% with 95% CI, -8.2% to -1.2% per year). The attack rate of stroke also declined significantly in both sexes. When the areas were considered separately, the declining trends were observed within each area. The decline in incidence of stroke was, however, statistically significant only among men and women in Kuopio and among women in Turku/Loimaa. Mortality declined significantly in all three areas among men but among women only in Kuopio. The incidence to mortality rate ratio increased during the study period, indicating a steeper fall in mortality than in incidence.
Conclusions A substantial decline in both stroke incidence and mortality was observed in the adult and elderly population in the FINMONICA study areas. Part but not all of the decline in stroke mortality, observed also in the official mortality statistics, can be attributed to the decline in stroke incidence during this 10-year period.
Key Words: epidemiology • Finland • incidence • mortality
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Introduction |
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The trends in stroke incidence reported so far have not been entirely consistent, but most studies have described a steady trend or even an increase in stroke incidence during the 1970s and 1980s.1 2 3 4 5 6 7 8 However, declining trends in mortality from stroke were reported from a number of studies around the world during the last two decades, except those from eastern Europe.4 9 10 11 12 13 14 15 16 Assessing stroke occurrence is more difficult than assessing mortality (in particular, nonhospitalized mild strokes may escape registration), and it is even more arduous to gather data that are comparable at an international level, both because of the differences among countries in diagnostic procedures and acute-care methods and because of the methodological differences among registers set up independently.
The World Health Organization (WHO) MONICA (Multinational MONItoring of Trends and Determinants in CArdiovascular Disease) project was launched in the early 1980s with the aim to relate the trends in incidence and mortality of myocardial infarction and stroke to secular trends in population risk-factor levels during the 10-year study period.17 As part of the Finnish contribution to the WHO MONICA study, called FINMONICA, a stroke register was set up to monitor the occurrence of stroke in the populations of three geographic areas of Finland. This article presents the main results of the 10-year trends in incidence, attack rates, and mortality of stroke in the adult population of the FINMONICA areas.
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Methods |
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The registration methods used in the FINMONICA stroke register have been described in detail elsewhere.18 19 20 In brief, FINMONICA followed the protocol and quality control procedures of the WHO MONICA project17 21 and has been operating in three geographic areas of Finland: the provinces of North Karelia and Kuopio in eastern Finland and the Turku/Loimaa area in southwestern Finland. The FINMONICA stroke register started in North Karelia and the Turku-Loimaa area in 1982; it started in the province of Kuopio in 1983. Because stroke registration was stopped after the 10-year study period in North Karelia was completed, data for the period from 1982 through 1991 are presented for North Karelia, whereas data for the time period from 1983 through 1992 are given for Kuopio and Turku-Loimaa. The event registration covered the age group of 25 to 74 years in all three areas. The FINMONICA stroke study has been approved by the National Public Health Institute and the Ministry of Health of Finland.
The main sources of information for the registration of stroke events in the FINMONICA stroke register were admission diagnoses to the hospitals and wards of health centers; hospital discharge diagnoses and diagnoses from death certificates were also checked routinely. In Finland, only occasional patients with stroke do not have contact with a hospital: patients with an acute symptomatic cerebrovascular disease are admitted to the hospital, and this was the practice throughout the entire study period.18 19 20 All patients with symptoms and signs suggesting acute cerebrovascular disease, aged 25 to 74 years, and permanently residing in the target areas were evaluated for the registration. The data were collected and coded by nurses specially trained for the registration of stroke events. After 28 days from the onset of the attack, the stroke record form was filled in for information concerning the 28-day attack period. For fatal cases, the causes of death, duration of survival, and possible autopsy findings were recorded. Finally, the local stroke-register physician (a neurologist in Kuopio, North Karelia, and Turku and an internist in Loimaa) checked the forms and assigned the diagnostic category of stroke and the type of stroke according to the criteria of the WHO MONICA study. During the entire registration period, all cases within each area were reviewed and classified by one physician only. The physicians of the three areas met regularly to discuss the coding problematics and other cases to make sure that the coding practices among them were consistent. At the National Public Health Institute, the FINMONICA stroke register data were annually cross-checked with the computerized National Death Register for completeness. Routine stroke mortality data (International Classification of Diseases, 8th and 9th Revision [ICD-8 and -9], codes 430 through 438) for the FINMONICA population were obtained from the National Statistical Office after the underlying cause of death had been established.
In this report, the numerators for mortality from stroke based on the FINMONICA stroke register are cases that were fatal at 28 days after the onset of symptoms of stroke. We also present mortality data for the FINMONICA areas derived directly from the National Death Register, in which the numerators for the annual mortality rates are the subjects who died of stroke during that year regardless of the date of stroke onset.
According to the definition of the WHO MONICA project, the diagnosis of stroke was based on "sudden onset of clinical signs of focal or global disturbance of cerebral function lasting more than 24 hours (except in cases of sudden death or if the development of symptoms is interrupted by a surgical intervention) with no apparent cause other than a vascular origin." The stroke was classified as a first-ever event if there was no evidence of a previous stroke event in the patient's history. If the patient suffered from another acute cerebrovascular attack within 28 days from the onset of the first event, the recurrent attack was considered to belong to the same event; if the first episode had occurred more than 28 days before the onset of the new attack, the event was classified as recurrent stroke and a new register form was filled in.
Each event was assigned to one of the three diagnostic categories by the local physician: definite stroke, no stroke, or unclassifiable. The category unclassifiable was used for fatal events, especially for cases of sudden death without necropsy but sometimes also for suspected stroke cases with insufficient supporting evidence of stroke for which the diagnosis of stroke could not be entirely excluded. Nonfatal events could be classified into this category if it was impossible to say whether the symptoms were from stroke or some other disease or whether the patients had symptoms and/or clinical findings otherwise typical of a stroke but for which information on duration was not available. Because the category of insufficient information represented less than 1% of all registered events, events classified as definite stroke and unclassifiable were both included in the calculation of rates.
Statistical Methods
The source of the population data is the National Population
Register, which is updated continuously. Data are available for each
administrative unit (city, town, and province). Midyear populations for
a particular year were computed by dividing the sum of the populations
as of January 1st and December 31st and were used as the denominator in
the calculation of event rates.
In this report, the incidence rate refers to the rate of first-ever events, ie, those that occur without evidence of a previous stroke. The attack rate refers to the rate of all episodes of stroke (first and recurrent events together). Fatal events were those in which the survival time after the onset of the attack was less than 28 days. Twenty-eight-day mortality from stroke was calculated for all events and for first-ever events separately. The direct method was used for age standardization in the calculation of rates. The age distribution of Segi's truncated world population was used as the standard.22 The 95% confidence intervals were calculated assuming Poisson distribution for the events within each stratum. The trends in the incidence, attack rate, and mortality of stroke were estimated from the logarithms of the annual age-standardized event rates using ordinary linear regression, and the confidence interval of trends was obtained in the usual manner from the standard error of the regression coefficient. Regression coefficient multiplied by 100 is given as the average yearly change in percentages.
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Results |
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During the 10-year study period, 11 392 acute stroke events were registered, of which 6442 (56.5%) occurred in men and 4950 (43.5%) in women. Of all strokes, 1426 (22%) were fatal within 28 days among men and 1223 (25%) among women. Of all strokes, 77% among men and 79% among women were first strokes. Recurrent events occurred slightly more often in Turku-Loimaa (27% of all strokes in men and 24% in women) than in Kuopio (22% in men and 21% in women) or North Karelia (18% in both men and women). The lowest proportion of fatal strokes was found in Kuopio (19% among men and 21% among women), whereas they accounted for 27% and 28% of all strokes in North Karelia and 23% and 27% in Turku-Loimaa, respectively.
Average annual age-standardized incidence (first-ever
strokes), attack rate (first and recurrent events together), and
mortality of stroke in men and women aged 25 to 74 years in the
FINMONICA stroke register for the 3 years at the beginning and end of
the study period are given in Table 1
. Trends in
age-standardized incidence of stroke during 1983 through 1992 in
the FINMONICA areas are shown in Figs 1 and 2. Annual percentage changes and their 95% confidence
intervals are given in Tables 2 through 4. During the study period, incidence of stroke
decreased by 1.7% per year among men and by 2.2% per year among women
in the pooled FINMONICA data. At the end of the study period, in
1990 to 1992, the annual incidence of stroke in the pooled FINMONICA
data was 241/100 000 among men and 129/100 000 among women, 10% and
14% lower than that at the beginning of the study period, respectively
(Table 1). The steepest decrease in incidence of stroke in both men
(-2.5% per year) and women (-3.5% per year) was observed
in Kuopio. Among both men and women aged 35 to 64 years, the largest
decline in stroke incidence was observed in Kuopio (-2.6% and
3.9% per year, respectively), whereas in men aged 65 to 74 years the
decline was largest in Turku-Loimaa (-2.1% per year) (Table 2).
The changes in stroke incidence in North Karelia were not
significant.
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indicates Kuopio; 
, North Karelia; and 
, Turku-Loimaa.
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Trends similar to those in incidence were also observed in attack
rate of stroke in all FINMONICA areas (Table 3
, Figs 1 and 2). No
changes were observed in the attack rate of recurrent stroke in the
pooled FINMONICA data, whereas in Kuopio it decreased
significantly among men aged 35 to 64 years (-3.6% per year) and
among women aged 25 to 74 years (data not shown).
During the 10-year period, mortality from stroke declined by 5.2% per
year among men and by 4.7% per year among women in the pooled
FINMONICA data (Table 4). At the end of the study period, in 1990 to
1992, age-standardized mortality from all strokes was 60/100 000
among men and 34/100 000 among women, 27% and 29% lower than at the
beginning of the study, respectively (Table 1). In men, mortality from
stroke decreased significantly in all areas, whereas in women the
declining trend observed was statistically significant only in Kuopio.
Among men, the decline in stroke mortality was more pronounced among
those aged 35 to 64 years than 65- to 74-year-olds, whereas among
women the trend was almost the same in different age groups.
According to the official mortality statistics, mortality from stroke
(ICD codes 430 through 438) also declined in both sexes and in all
FINMONICA areas during the 1980s through the early 1990s (Figs 1 and 2). In general, these trends were slightly less steep than those
obtained from the FINMONICA stroke register. In the official mortality
statistics for the three FINMONICA areas, significant decreases were
observed only among both men (-4.0% per year; P<.05)
and women (-6.2% per year; P<.01) in Kuopio.
To compare trends in incidence with trends in mortality, we calculated
the age-specific and age-standardized incidence to mortality
rate ratio, which also can serve as an indicator of the severity of
stroke (Table 5). During the 10-year study period, the
incidence to mortality rate ratio increased among both men
(P=.02) and women (P=.08) in the pooled FINMONICA
data. This increasing trend in rate ratio tended to be more pronounced
among persons aged 35 to 64 years than among older persons. The highest
rate ratios in both men and women were found in Kuopio, reflecting the
lowest case fatality and possibly less severe strokes than in North
Karelia and Turku-Loimaa.
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Discussion |
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The present data demonstrated a substantial decrease in the incidence, attack rate, and mortality of stroke in Finland in both men and women aged 25 to 74 years during the 10-year period from the early 1980s to the early 1990s. In the past, mortality from stroke in Finland was the highest in western Europe and one of the highest in the world.23 24 In general, the incidence of stroke in this study was lower than previously reported in Finland25 26 27 and is now approaching the level found in western European countries. Nevertheless, the incidence of stroke in Finland is still higher than that reported for Sweden,8 28 Denmark,28 29 Italy and Germany,30 or even for some eastern European countries.16 30 31 Interestingly, although stroke mortality has been decreasing markedly in most western European countries,5 6 8 9 32 thus far no declining trends in incidence of stroke have been observed in these countries, except in one study from the Netherlands that used predictive models rather than real validated data.33 Outside Europe, the Honolulu Heart Program recently reported a decrease in stroke incidence of all types among a cohort of Hawaiian Japanese men aged 45 to 68 years at entry during a prospective follow-up from 1969 through 1988.4 Studies from Japan have also reported a decreasing trend in incidence of stroke.34 On the other hand, data from the Framingham study,7 the Minnesota Heart Survey,11 Canada,2 and New Zealand35 suggested no change or even an increase in stroke incidence during the last decade.
The findings from this study confirm earlier observations on the geographic differences in the incidence of stroke in Finland: lower rates were observed in southwestern Finland compared with eastern Finland. The substantial difference in incidence of stroke between North Karelia and Kuopio seen at the beginning of the study period in both men and women almost disappeared during the study. This occurred mainly because of the steeper decline in incidence of stroke observed in Kuopio during this 10-year period. Furthermore, in North Karelian men, the incidence of stroke declined only in those younger than 65 years, and thus the trend for the entire range of 25 to 74 years was flat; among North Karelian women, a small decline in stroke incidence was observed in all age groups.
A decline in mortality and case fatality of stroke during the 1970s and 1980s has been observed in most European and many other industrialized countries, excluding eastern Europe. The declining trend in mortality from stroke has been reported both from official mortality statistics and population-based stroke register studies. A recent report from the WHO MONICA stroke study showed a very good agreement between mortality rates reported by the official statistics and the stroke registers.30 This suggests that the routine mortality statistics may be used for comparisons and trend analyses of stroke mortality, at least in populations where diagnostic validation of the routine mortality data has been undertaken. Previous reports have suggested that the improved detection of milder stroke cases because of the widespread use of CT and nuclear MR may bias the estimates of incidence trends.7 In the present study, the decline in the incidence of stroke was larger in Kuopio, where at the beginning of the study period in the early 1980s CT was already used in diagnostic evaluation for one third of the stroke events, clearly more than in the other two areas.20 In addition, in Kuopio we also observed a fall in the incidence of nonfatal strokes similar to that in incidence of all strokes (data not shown). Nevertheless, we want to point out that the increase in CT performed in the FINMONICA stroke study did not influence the number of cases classified as "no stroke," which remained stable throughout the period studied (C. Sarti, unpublished data, 1994). Thus, it seems likely that improved diagnostic facilities did not result in spurious trends in the occurrence of stroke, mainly because we applied the strict clinical criteria for the diagnosis of stroke, which remained unchanged within each FINMONICA stroke register area. A stroke event without symptoms lasting at least 24 hours diagnosed with CT only was not registered as stroke in our study in any area. On the other hand, a possibility of varying degree of case ascertainment due to underestimation of nonfatal events among the areas and during the 10-year period cannot be fully excluded, although several quality checks we applied to the FINMONICA stroke register database did not suggest such a bias.
The decline in stroke mortality in FINMONICA was larger than that in incidence. The larger decline in mortality may be at least partly due to the improvement in treatment and secondary prevention of stroke and/or to strokes becoming less severe. Indirect support to the first hypothesis comes from the observation that the largest decline in incidence and mortality from stroke occurred in Kuopio. Most stroke patients in this area participated throughout the study period in the European Stroke Prevention Study, a trial on secondary prevention of stroke.36 In addition to efficient therapy for study patients, the active and positive attitude regarding the possibilities of drug treatment influenced the care of patients in the whole study area.
As to the second hypothesis, a decreased severity of stroke may be related to changes in the risk-factor patterns of stroke, ie, to improved primary prevention, and/or improvements in acute-stroke care. Unfortunately, there is still no undisputed effective treatment regimen for the acute phase of stroke that can reduce case fatality, except perhaps surgical treatment for subarachnoid hemorrhage.
Hypertension is the main known risk factor for stroke.37 38 39 40 Blood pressure levels in Finland were among the highest from the MONICA centers at the beginning of the study.41 During the 1970s, when drug treatment for hypertension started to be systematically implemented in Finland, an inverse relation between mortality from stroke and effectiveness of hypertension treatment in Finland was suggested.42 43 A study on the development of hypertension care in Finnish patients showed that there was also some improvement in the control of hypertension during the years 1982 through 1987, although it was less than expected from the high proportion of subjects treated with antihypertensive drugs.44 Some studies also indicate that the decline in stroke mortality can be only partly explained by the improvement in antihypertensive therapy.4 45 46 47 There was a decrease in the mean levels of diastolic blood pressure and serum total cholesterol among both men and women and in the prevalence of smoking among men, but there was a small increase among women during 1983 to 1992.48 It seems likely, however, that changes in these classic cardiovascular risk factors explain at least half of the decline in stroke mortality observed in the official mortality statistics in Finland.48
Ten years of the WHO MONICA project are in the past. The FINMONICA study was one of the first to start and also to report the 10-year trends. Ten years can be considered a relatively long study period, and yet it is rather short when related to the natural history of stroke. Although statistically significant changes in stroke rates occurred in Finland during the last 10 years, most of the decline occurred during the second half of the study period. Keeping in mind the reported increasing or flat trends in the incidence of stroke around the world during the last decades, a 10-year period is short. Furthermore, stroke is a disease affecting elderly people in particular. In many parts of the world, the proportion of elderly populations is growing fast. Because the risk of stroke increases exponentially with age, it is necessary to have adequate data to set up programs for primary and secondary prevention of stroke. It is possible that the decrease in incidence of stroke, and particularly in stroke mortality among the middle-aged population, may postpone the onset of stroke to more advanced age. This has lead us in Finland to continue the monitoring of incidence, attack rate, and mortality of stroke even after the 10-year period of the WHO MONICA project was completed and to include age groups over 75 years in this extension.
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Acknowledgments |
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The FINMONICA stroke study has been partly supported by the Academy of Finland. We are grateful to the hospitals, primary healthcare centers, and health personnel of the registration areas for supporting the local data collection. Much of the practical work in case finding and data collection was done by the nurses Elvi Surakka in North Karelia; Anu Mononen in Turku; Hannele Kastarinen, Sinikka Roynä, Eva Talasniemi, and Markku Kalinen in Kuopio; and Aino-Maija Kantee in Loimaa.
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Footnotes |
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1 Deceased.
Received December 22, 1995; revision received January 29, 1996; accepted February 1, 1996.
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