(Stroke. 1997;28:1527-1529.)
© 1997 American Heart Association, Inc.
Articles |
The End of the Long-term Decline in Stroke Mortality in the United States?
From the Centers for Disease Control and Prevention, Hyattsville (R.F.G.), and the National Heart, Lung, and Blood Institute, Bethesda (C.T.S.), Md.
Key Words: cerebrovascular disorders • mortality • racial differences • stroke prevention
 |
Introduction |
|---|
 Top Introduction References |
|---|
Stroke is the third leading cause of death in the United States.1 2 3 4 A decline in the age-adjusted death rate for nonwhite women began in 1924, for nonwhite men in 1930, and for whites by 1918.5 The rate of decline accelerated in the 1970s, probably because of improved hypertension control, but slowed in the 1980s for reasons that remain unclear.6 Recently published statistics suggest that the long-term decline in stroke mortality rates in the United States may have ceased.
There is unmistakable evidence for a marked slowdown in the decline in
stroke mortality.6 The age-adjusted US stroke mortality
rate increased between 1992 and 1993; a recent report documented
another rise in the preliminary rate for 1995 (percent change from 1994
to 1995, +0.8).7 Age-adjusted rates per 100 000 for 1991
to 1995 were 26.8, 26.2, 26.5, 26.5, and 26.7, respectively (Table 1
). It is important to view these
increases in proper perspective while in no way diminishing the serious
impact of the slowdown in the decline of stroke mortality in the United
States since 1978.6 To this end, we tested the hypotheses
(1) that the rate of decline of age-adjusted mortality rates in 1987 to
1994, the period since the previous report,6 has returned
to that seen in the 1960s before the widespread availability of
antihypertensive therapy, and (2) that this occurred in each sex/race
group.
|
In 1987 to 1994, the mean annual absolute and percent decline in
age-adjusted death rates for stroke was less than observed in 1979 to
1986 for each sex/race group (Table 2).6 It was comparable to
that observed in the 1960s, before the rapid decline of the 1970s that
was commonly attributed to marked improvements in hypertension
detection and treatment.2 This further deceleration in the
decline affected all four sex/race groups. Although not included in
calculations in Table 2, preliminary age-adjusted rates per 100 000 by
sex and race for 1995 based on 80% of deaths were as follows: white
men, 26.5; white women, 23.2; black men, 51.1; and black women, 39.3. A
continuing deceleration of the decline in mortality rates has also been
noted for ischemic heart disease, especially in
blacks.8 9
|
It might be hypothesized that declining levels of hypertension detection and control or increases in prevalence of other risk factors have led to the slowdown in the mortality decline and a possible upturn in stroke incidence. However, data from the most recent national examination survey offer no evidence of a deterioration in hypertension detection and control.10 Rather, modest further improvements were seen through 1991. Data collected through 1994 will soon be available to indicate whether improvements continued. Furthermore, data from Rochester, Minn, suggest that despite proven efficacy in lowering stroke incidence and mortality in clinical trials, improved hypertension control at the community level does not explain some recent trends in stroke incidence.11 12 For example, between 1975 to 1979 and 1980 to 1984, stroke incidence declined among persons without hypertension but increased among persons with hypertension.12
Rates of smoking and hypercholesterolemia have continued to decline in adults.1 However, the prevalence of diabetes and obesity has been increasing, especially in blacks.1 13 14 In 1976 to 1980, 26% of blacks and 18% of whites were diabetic at age 65 to 74 years.14
Although there is no evidence for increased prevalence of hypertension, the prevalence of congestive heart failure has risen to 10% in those aged 70 years and older, perhaps indicating an expanding pool of stroke-prone patients with severe heart disease.15 The prevalence of atrial fibrillation, an important risk factor for stroke,11 might also be increasing.16 17 These trends may be related to improved long-term survival in persons with ischemic heart disease.18 Increases in stroke incidence in Rochester occurred mainly among survivors of ischemic heart disease.19 In persons aged 65 years or older, the national prevalence of self-reported ischemic heart disease increased from 114/1000 in 1979 to 1981 to 148/1000 in 1990.16
Current efforts to control stroke risk factors must clearly continue, particularly in high-risk and underserved subpopulations. In the nation as a whole, trends in hypertension and smoking do not seem related to the slowdown in the decline of stroke mortality. However, adverse trends in the prevalence of diabetes, obesity, ischemic heart disease, and heart failure should be evaluated as possible causes of the slowdown.
Could wider application of any medical or surgical interventions available for patients with symptomatic or asymptomatic cerebrovascular disease effect a nationwide acceleration in the decline in stroke mortality? In recent decades, survival after stroke has improved even in studies reporting increases in incidence.20 Currently available antiplatelet agents might affect mortality trends if they were used more widely in secondary prevention of ischemic heart disease and stroke.21 22 23 24 In persons aged 45 to 64 years in 1987 to 1989, the percentage of persons with a history of stroke taking aspirin ranged from only 17% of black women to 54% of white men.21 In persons aged 65 years and older in 1990, only 30.5% of women and 14.7% of men with coronary or cerebrovascular disease reported taking aspirin daily.22 The low rates of patient-reported aspirin use contrast sharply with much higher rates of physician-reported advice, suggesting difficulty with patient compliance and patient education.23 25 Several studies indicate that neither aspirin nor warfarin is prescribed for many patients with atrial fibrillation, despite proven efficacy of antithrombotic therapy in prevention of stroke in this condition.26 27 Newer trials of carotid endarterectomy have demonstrated benefits in certain patient groups but were unable to detect a significant difference in mortality from stroke or all causes because of limits of sample size.28 29 30 Hence, the impact of increasing use of carotid endarterectomy on mortality at the population level remains unknown. Meta-analyses and statistical modeling approaches might provide estimates of potential effects.
A stroke initiative similar to the National Heart Attack Alert Program will seek to ensure that most eligible patients with acute ischemic stroke are able to receive thrombolytic therapy within 3 hours after onset of stroke, as proposed at recent national conferences convened by the National Institute of Neurological Disorders and Stroke (NINDS), the American Academy of Neurology, the American Heart Association, and six other national medical organizations in coalition. Since the NINDS rt-PA Stroke Study did not show a significant difference in mortality at 3 months between the tissue plasminogen activator group and the placebo group, we must assess the effects of the emerging therapy acute thrombolysis on total stroke mortality rates in larger clinical trials and/or in a nationwide registry.31 32 Since it is unlikely that more that 20% of stroke patients could receive recombinant tissue plasminogen activator therapy even with an effective stroke alert program according to presentations made at the aforementioned conferences, an impact on national stroke mortality trends cannot be assumed without empirical evidence.
The currently available data suggest that the rate of decline in stroke mortality will continue at the low level seen in the 1960s until a new widely applicable and highly effective innovation in prevention or treatment is introduced. Among the lowest in the world, stroke mortality rates in US whites outside rural areas of the southeastern states may be nearing the best achievable with current technology.33 34 However, rates in blacks remain higher than those in many countries and should be susceptible to further reduction.2 35 Further research is needed on the following: (1) the influence of increasing obesity, diabetes, ischemic heart disease, and heart failure prevalence on stroke mortality and morbidity; (2) trends in the prevalence of atrial fibrillation and use of aspirin and other antithrombotic agents; (3) statistical modeling approaches to provide estimates of the potential effect of trends in medical care on stroke mortality and morbidity trends; and (4) the potential costs and benefits for primary and secondary prevention programs to reduce diabetes and obesity prevalence, increase use of antiplatelet agents in high-risk patients, and promote more widespread use of early stroke care, including thrombolysis. Even though national surveys have not shown a deterioration in hypertension treatment and control in the early 1990s, the best chance to increase the rate of decline in stroke mortality rates may be to redouble efforts to achieve the goal for the year 2000 of increasing "to at least 50% the proportion of people with high blood pressure whose blood pressure is under control (less than 140 mm Hg systolic and 90 mm Hg diastolic)."35 36 Increasing utilization of antithrombotic agents in high-risk patients may require increased patient as well as physician education efforts.
|
Footnotes |
|---|
Reprint requests to Richard F. Gillum, MD, Centers for Disease Control and Prevention, Office of Analysis, Epidemiology, and Health Promotion, National Center for Health Statistics, 6525 Belcrest Rd, Hyattsville, MD 20782.
The opinions expressed in this editorial are not necessarily those of the editors or of the American Heart Association.
Received March 24, 1997; revision received May 5, 1997; accepted May 20, 1997.
|
References |
|---|
|
TopIntroductionReferences |
|---|
1. National Center for Health Statistics. Health, United States, 1995. Hyattsville, Md: Public Health Service; 1996.
2.
Gillum RF. Stroke in blacks.
Stroke. 1988;19:1-9.
3.
Gillum RF. The
epidemiology of stroke in Hispanics in the
United States. Stroke. 1995;26:1707-1712.
4.
Gillum RF. The
epidemiology of stroke in Native
Americans. Stroke. 1995;26:514-521.
5. Moriyama IM, Krueger DE, Stamler J. Cardiovascular Diseases in the United States. Cambridge, Mass: Harvard University Press; 1971:175-229.
6.
Cooper R, Sempos C, Hsieh SC, Kovar MG.
Slowdown of the decline of stroke mortality in the United States,
1978-1986. Stroke. 1990;21:1274-1279.
7. Centers for Disease Control and Prevention. Preliminary data on births and deaths: United States, 1995. MMWR Morb Mortal Wkly Rep. 1996;45:914-919.[Medline] [Order article via Infotrieve]
8. Centers for Disease Control and Prevention. Trends in ischemic heart disease mortality: United States, 1990-1994. MMWR Morb Mortal Wkly Rep. 1997;46:146-150.[Medline] [Order article via Infotrieve]
9.
Sempos C, Cooper R, Kovar MG, McMillen M.
Divergence of the recent trends in coronary mortality for the
four major race-sex groups in the United States. Am
J Public Health. 1988;78:1422-1427.
10.
Burt VL, Cutler JA, Higgins M, Horan MJ, Labarthe D,
Whelton P, Brown C, Roccella EJ. Trends in prevalence,
awareness, treatment, and control of hypertension in the adult US
population: data from the Health Examination Surveys,
1960-1991. Hypertension. 1995;26:60-69.
11.
Whisnant JP, Wiebers DO, O'Fallon WM, Sicks JD, Frye
RL. A population-based model of risk factors for
ischemic stroke: Rochester, Minnesota.
Neurology. 1996;47:1420-1428.
12.
Whisnant JP. Effectiveness versus efficacy of
treatment of hypertension for stroke prevention.
Neurology. 1996;46:301-307.
13. Kenny SJ, Aubert RE, Geiss LS. Prevalence and incidence of non-insulin dependent diabetes. In: Diabetes in America. 2nd ed. Bethesda, Md: National Institutes of Health, 1995:47-68.
14. Harris MI. Noninsulin-dependent diabetes mellitus in black and white Americans. Diabetes Metab Rev.. 1990;6:71-90.[Medline] [Order article via Infotrieve]
15. Congestive Heart Failure in the United States: a New Epidemic. Bethesda, Md: National Heart, Lung, and Blood Institute, National Institutes of Health; 1996.
16. Higgins M, Thom T. Trends in stroke risk factors in the United States. Ann Epidemiol. 1993;3:550-554.[Medline] [Order article via Infotrieve]
17. Wolf PA, Benjamin EJ, Belanger AJ, Kannel WB, Levy D, D'Agostino RB. Secular trends in the prevalence of atrial fibrillation: the Framingham Study. Am Heart J. 1996;131:790-795.[Medline] [Order article via Infotrieve]
18. Gillum RF. Trends in acute myocardial infarction and coronary heart disease death in the United States. J Am Coll Cardiol. 1994;23:1273-1277.[Abstract]
19. Whisnant JP, O'Fallon WM, Sicks J, Ingall T. Stroke incidence with hypertension and ischemic heart disease in Rochester, Minnesota. Ann Epidemiol. 1993;3:480-482.[Medline] [Order article via Infotrieve]
20. Brown RD Jr, Whisnant JP, Sicks JD, O'Fallon WM, Wiebers DO. Stroke incidence, prevalence, and survival: secular trends in Rochester, Minnesota, through 1989. Stroke. 1996;27:373-380.
21. Shahar E, Folsom AR, Romm FJ, Bisgard KM, Metcalf PA, Crum L, McGovern PG, Hutchinson RG, Heiss G. Patterns of aspirin use in middle-aged adults: the Atherosclerosis Risk in Communities (ARIC) Study. Am Heart J. 1996;131:915-922.[Medline] [Order article via Infotrieve]
22. Psaty BM, Lee M, Savage PJ, Rutan GH, German PS, Lyles M. Assessing the use of medications in the elderly: methods and initial experience in the Cardiovascular Health Study. J Clin Epidemiol. 1992;45:683-692.[Medline] [Order article via Infotrieve]
23.
Goldstein LB, Bonito AJ, Matchar DB, Duncan PW, Samsa
GP. US National Survey of Physician Practices for the Secondary
and Tertiary Prevention of Ischemic Stroke: medical therapy in
patients with carotid artery stenosis.
Stroke. 1996;27:1473-1478.
24. Hennekins CH, Jonas MA, Buring JE. Antiplatelet therapy and risk of stroke. Ann Epidemiol. 1993;3:568-570.[Medline] [Order article via Infotrieve]
25.
Goldstein LB, Bonito AJ, Matchar DB, Duncan PW,
DeFriese GH, Oddone EZ, Paul JE, Akin DR, Samsa GP. US National
Survey of Physician Practices for the Secondary and Tertiary Prevention
of Ischemic Stroke: design, service availability, and common
practices. Stroke. 1995;26:1607-1615.
26.
O'Connell JE, Gray CS. Atrial fibrillation and
stroke prevention in the community. Age Ageing. 1996;25:307-309.
27. Singer DE. Overview of the randomized trials to prevent stroke in atrial fibrillation. Ann Epidemiol. 1993;3:563-567.[Medline] [Order article via Infotrieve]
28. North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med. 1991;325:445-453.[Abstract]
29.
Moore WS, Barnett HJM, Beebe HG, Bernstein EF, Brener
GJ, Brott T, Caplan LR, Day A, Goldstone J, Hobson RW II. Guidelines
for carotid endarterectomy: a multidisciplinary
consensus statement from the Ad Hoc Committee, American Heart
Association. Stroke. 1995;26:188-201.
30. Kuntz KM, Kent KC. Is carotid endarterectomy cost-effective? An analysis of symptomatic and asymptomatic patients. Circulation. 1996;94(suppl II):II-194-II-198.
31.
The National Institute of Neurological Disorders and
Stroke rt-PA Stroke Study Group. Tissue plasminogen
activator for acute ischemic stroke. N
Engl J Med. 1995;333:1581-1587.
32.
Furlan AJ, Kanoti G. When is
thrombolysis justified in patients with acute
ischemic stroke? A bioethical perspective.
Stroke. 1997;28:214-218.
33. Zarate AO. International Mortality Chartbook: Levels and Trends, 1955-91. Hyattsville, Md: Public Health Service; 1994.
34.
Gillum RF, Ingram DI. The relation between
residence in the southeast region of the United States and stroke
incidence and death: the NHANES I Epidemiologic Follow-up
Study. Am J Epidemiol.. 1996;144:665-673.
35. Gillum RF. The epidemiology of hypertension in African American women. Am Heart J. 1996;131:385-395.[Medline] [Order article via Infotrieve]
36. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington DC: US Dept of Health and Human Services, Public Health Service; 1991. US Dept of Health and Human Services publication PHS 91-50212.
This article has been cited by other articles:
 |
|
 |
|
  M. M. Glymour and M. Avendano Can Self-Reported Strokes Be Used to Study Stroke Incidence and Risk Factors?: Evidence From the Health and Retirement Study Stroke, March 1, 2009; 40(3): 873 - 879. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. J. Goldacre, M. Duncan, M. Griffith, and P. M. Rothwell Mortality Rates for Stroke in England From 1979 to 2004: Trends, Diagnostic Precision, and Artifacts Stroke, August 1, 2008; 39(8): 2197 - 2203. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D. C. Goff Jr, L. Brass, L. T. Braun, J. B. Croft, J. D. Flesch, F. G.R. Fowkes, Y. Hong, V. Howard, S. Huston, S. F. Jencks, et al. Essential Features of a Surveillance System to Support the Prevention and Management of Heart Disease and Stroke: A Scientific Statement From the American Heart Association Councils on Epidemiology and Prevention, Stroke, and Cardiovascular Nursing and the Interdisciplinary Working Groups on Quality of Care and Outcomes Research and Atherosclerotic Peripheral Vascular Disease Circulation, January 2, 2007; 115(1): 127 - 155. [Full Text] [PDF]
|
|
|
|
 |
|
 D. G. Jamieson, A. Parekh, and M. D. Ezekowitz Review of Antiplatelet Therapy in Secondary Prevention of Cerebrovascular Events: A Need for Direct Comparisons Between Antiplatelet Agents Journal of Cardiovascular Pharmacology and Therapeutics, July 1, 2005; 10(3): 153 - 161. [Abstract] [PDF]
|
|
|
|
|
|
N. F. Gordon, M. Gulanick, F. Costa, G. Fletcher, B. A. Franklin, E. J. Roth, and T. Shephard Physical Activity and Exercise Recommendations for Stroke Survivors: An American Heart Association Scientific Statement From the Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention; the Council on Cardiovascular Nursing; the Council on Nutrition, Physical Activity, and Metabolism; and the Stroke Council Stroke, May 1, 2004; 35(5): 1230 - 1240. [Full Text] [PDF]
|
|
|
|
|
|
N. F. Gordon, M. Gulanick, F. Costa, G. Fletcher, B. A. Franklin, E. J. Roth, and T. Shephard Physical Activity and Exercise Recommendations for Stroke Survivors: An American Heart Association Scientific Statement From the Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention; the Council on Cardiovascular Nursing; the Council on Nutrition, Physical Activity, and Metabolism; and the Stroke Council Circulation, April 27, 2004; 109(16): 2031 - 2041. [Full Text] [PDF]
|
|
|
|
 |
|
 D. W. Jones, L. E. Chambless, A. R. Folsom, G. Heiss, R. G. Hutchinson, A. R. Sharrett, M. Szklo, and H. A. Taylor Jr Risk Factors for Coronary Heart Disease in African Americans: The Atherosclerosis Risk in Communities Study, 1987-1997 Arch Intern Med, December 9, 2002; 162(22): 2565 - 2571. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R.F. Gillum and H. B. Bosworth New Considerations in Analyzing Stroke and Heart Disease Mortality Trends: The Year 2000 Age Standard and the International Statistical Classification of Diseases and Related Health Problems, 10th Revision Stroke, June 1, 2002; 33(6): 1717 - 1722. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Billings-Gagliardi, N. M. Fontneau, M. K. Wolf, S. V. Barrett, G. Hademenos, K. M. Mazor, and G. Ghilardi Educating the Next Generation of Physicians About Stroke: Incorporating Stroke Prevention into the Medical School Curriculum Editorial Comment: Incorporating Stroke Prevention into the Medical School Curriculum Stroke, December 1, 2001; 32(12): 2854 - 2859. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. Howard, V. J. Howard, C. Katholi, M. K. Oli, S. Huston, and K. Asplund Decline in US Stroke Mortality: An Analysis of Temporal Patterns by Sex, Race, and Geographic Region Editorial Comment: An Analysis of Temporal Patterns by Sex, Race, and Geographic Region Stroke, October 1, 2001; 32(10): 2213 - 2220. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. B. Goldstein, R. Adams, K. Becker, C. D. Furberg, P. B. Gorelick, G. Hademenos, M. Hill, G. Howard, V. J. Howard, B. Jacobs, et al. Primary Prevention of Ischemic Stroke : A Statement for Healthcare Professionals From the Stroke Council of the American Heart Association Circulation, January 2, 2001; 103(1): 163 - 182. [Full Text] [PDF]
|
|
|
|
|
|
L. B. Goldstein, R. Adams, K. Becker, C. D. Furberg, P. B. Gorelick, G. Hademenos, M. Hill, G. Howard, V. J. Howard, B. Jacobs, et al. Primary Prevention of Ischemic Stroke : A Statement for Healthcare Professionals From the Stroke Council of the American Heart Association Stroke, January 1, 2001; 32(1): 280 - 299. [Full Text] [PDF]
|
|
|
|
|
|
R. Cooper, J. Cutler, P. Desvigne-Nickens, S. P. Fortmann, L. Friedman, R. Havlik, G. Hogelin, J. Marler, P. McGovern, G. Morosco, et al. Trends and Disparities in Coronary Heart Disease, Stroke, and Other Cardiovascular Diseases in the United States : Findings of the National Conference on Cardiovascular Disease Prevention Circulation, December 19, 2000; 102(25): 3137 - 3147. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. Sarti, D. Rastenyte, Z. Cepaitis, and J. Tuomilehto International Trends in Mortality From Stroke, 1968 to 1994 Stroke, July 1, 2000; 31(7): 1588 - 1601. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. O. Obisesan, C. M. Vargas, and R. F. Gillum Geographic Variation in Stroke Risk in the United States : Region, Urbanization, and Hypertension in the Third National Health and Nutrition Examination Survey Stroke, January 1, 2000; 31(1): 19 - 25. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. F. Gillum Stroke Mortality in Blacks : Disturbing Trends Stroke, August 1, 1999; 30(8): 1711 - 1715. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 U. Agnarsson, G. Thorgeirsson, H. Sigvaldason, and N. Sigfusson Effects of Leisure-Time Physical Activity and Ventilatory Function on Risk for Stroke in Men: The Reykjavik Study Ann Intern Med, June 15, 1999; 130(12): 987 - 990. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
W. D. Rosamond, A. R. Folsom, L. E. Chambless, C.-H. Wang, P. G. McGovern, G. Howard, L. S. Copper, and E. Shahar Stroke Incidence and Survival Among Middle-Aged Adults : 9-Year Follow-Up of the Atherosclerosis Risk in Communities (ARIC) Cohort Stroke, April 1, 1999; 30(4): 736 - 743. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. B. Gorelick Cerebrovascular Disease in African Americans Stroke, December 1, 1998; 29(12): 2656 - 2664. [Full Text] [PDF]
|
|
|
|
|
|
J. Zeng, Y. Zhang, J. Mo, Z. Su, R. Huang, and H. A. Kontos Two-Kidney, Two Clip Renovascular Hypertensive Rats Can Be Used as Stroke-prone Rats • Editorial Comment Stroke, August 1, 1998; 29(8): 1708 - 1714. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. Fisher and J. Bogousslavsky Further Evolution Toward Effective Therapy for Acute Ischemic Stroke JAMA, April 22, 1998; 279(16): 1298 - 1303. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
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]
|
|
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||