Donate Help Contact The AHA Sign In Home
American Heart Association
Stroke
Search: search_blue_button Advanced Search
Table of Contents | Next Article »
Stroke. 1999;30:1501-1505

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow Request Permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Wein, T. H.
Right arrow Articles by Morgenstern, L. B.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Wein, T. H.
Right arrow Articles by Morgenstern, L. B.
Related Collections
Right arrow Epidemiology
Right arrow Cerebrovascular disease/stroke

(Stroke. 1999;30:1501-1505.)
© 1999 American Heart Association, Inc.

Original Contributions

Race/Ethnicity and Location of Stroke Mortality

Implications for Population-Based Studies

Theodore H. Wein, MD, FRCPC; Melinda A. Smith, MPH Lewis B. Morgenstern, MD

From the Stroke Program, Department of Neurology, The University of Texas, Houston, Medical School (T.H.W., M.A.S., L.B.M.), and the Epidemiology Research Center, The University of Texas, Houston, School of Public Health (L.B.M.).

Correspondence to Lewis B. Morgenstern, MD, Department of Neurology, Stroke Program, University of Texas Medical School–Houston, 6431 Fannin 7.044 MSB, Houston, TX 77030. E-mail lmorgens{at}neuro.med.uth.tmc.edu


*    Abstract
up arrowTop
 *Abstract
down arrowIntroduction
 down arrowSubjects and Methods
 down arrowResults
 down arrowDiscussion
 down arrowReferences
 
Background and Purpose—Stroke community surveillance projects often focus on hospital data rates. We hypothesized that not including strokes which occurred in nursing homes or at home would differentially affect race/ethnic stroke rates.

Methods—Texas vital statistics data were studied to compare age-specific (45 to 59, 60 to 74, and >=75 years) location of stroke death for African Americans (AAs), Hispanic Americans (HAs), and non-Hispanic whites (NHWs). Rate ratios are reported with 95% CIs; NHW is used as the referent group.

Results—During 1991 to 1996, there were 52 996 stroke deaths in Texas for individuals aged 45 years and older. HAs in the oldest age group (>=75 years) were 33% more likely than NHWs to die in the hospital, and HAs aged 45 to 59 and 60 to 74 years were 4% and 10%, respectively, more likely to die in the hospital. AAs aged >=75 years were 19% more likely to die in the hospital. HAs aged 60 to 74 years were 35% less likely to die in a nursing home, whereas HAs aged >=75 years were 43% less likely than NHWs to die in a nursing home. AAs aged >=75 were 33% less likely to die in a nursing home. Death at home was 19% more likely in HAs aged 60 to 74 years. Significant gender differences are also reported.

Conclusions—Using hospital data alone would overestimate stroke mortality in the HA and AA groups. Stroke community surveillance projects should account for ethnic and gender differences in location of death to avoid bias in race/ethnic and gender comparisons.


Key Words: blacks • Hispanic Americans • mortality • population surveillance • stroke


*    Introduction
up arrowTop
 up arrowAbstract
 *Introduction
down arrowSubjects and Methods
 down arrowResults
 down arrowDiscussion
 down arrowReferences
 
At the change of the new millennium, more than 25% of the US population will be composed of ethnic minorities.1 An increasing need exists to understand race/ethnic differences in stroke for the purpose of designing effective public health intervention strategies. Only a handful of studies2 3 4 5 6 have addressed race/ethnic differences in stroke mortality in the United States. In these studies, stroke mortality is consistently higher in African Americans (AAs) relative to non-Hispanic whites (NHWs). There is a relative paucity of information on Hispanic Americans (HAs), and their relative stroke burden remains unclear. Community-based stroke surveillance affords the most rigorous means by which to ascertain and validate stroke incidence, hospitalization, and mortality. Screening for stroke cases may occur in hospitals, nursing homes, and personal residences. Many projects focus on hospital records alone for race/ethnic comparisons in stroke. Examining stroke hospitalization and case fatality rates alone, however, may be subject to bias, because minority groups may be less likely to seek immediate medical attention.7 Similarly, more affluent race/ethnic groups may use nursing homes, requiring the inclusion of these institutions in population-based surveillance studies.

We studied the race/ethnic and gender differences in location of stroke death in the state of Texas. We hypothesized that HAs and AAs are more likely to die at home than in a nursing home and that future community-based racial/ethnic surveillance projects should account for location of stroke death.


*    Subjects and Methods
up arrowTop
 up arrowAbstract
 up arrowIntroduction
 *Subjects and Methods
down arrowResults
 down arrowDiscussion
 down arrowReferences
 
In the state of Texas, the health department generates computer files on death certificate data for research purposes. Texas law requires that a death certificate include the race/ethnicity of the deceased. This information was used to distinguish HAs, AAs, and NHWs. Those HAs coded as black Hispanic were considered AAs for the purpose of this study. Age was calculated from the date of birth reported on the death certificate. Texas vital statistics data for 1991 through 1996 were analyzed with use of the computer statistical package SPSS version 8 for Windows (SPSS Inc). Stroke mortality was defined as the underlying cause of death by the International Classification of Diseases, Ninth Revision (ICD-9), codes 430 to 438 (cerebrovascular disease).8

In the 6-year period between January 1, 1991, and December 31, 1996, 52 996 stroke deaths occurred in the state of Texas, with 39 407 (74.4%) of these in NHWs, 7057 (13.3%) in AAs, and 6119 (11.5%) in HAs. The remaining 413 (0.8%) for other races/ethnicities were excluded for the purpose of this analysis. The stroke mortality rate was evaluated for location of death for each racial/ethnic group. Texas death certificates record location of death in the following categories: personal residence, hospital, nursing home, other, or not classifiable. Stroke deaths occurring in the hospital, nursing home, or personal residence accounted for 99.2% of the locations of stroke death. The 0.8% for other locations were omitted for the purposes of this analysis.

After calculating the age at time of death for each individual, data were categorized into the following age-specific groups: 45 to 59, 60 to 74 and >=75years, because these age-specific categories have been used in prior comparative studies for these 3 ethnic groups.2 4 9 To prevent masking the interaction between age and ethnicity for stroke mortality, age adjustment was not used.2 4

The stroke mortality rate for each race/ethnic group was calculated for the age-specific groups and by location. Rate ratios were calculated with NHW as the referent group, and 95% CIs were calculated by the Katz method.10 Rates are reported as a percentage of all stroke deaths. The gender race/ethnic rate ratios in location of death are also reported.


*    Results
up arrowTop
 up arrowAbstract
 up arrowIntroduction
 up arrowSubjects and Methods
 *Results
down arrowDiscussion
 down arrowReferences
 
In the period between January 1, 1991, and December 31, 1996, HAs in Texas in all age groups were more likely to die of stroke in the hospital than AAs or NHWs (Table 1Down). The greatest difference was seen in the >=75 years age group, in which HAs were 33% more likely to die in a hospital than NHWs. HAs aged 45 to 49 and 60 to 74 years were slightly more likely than NHWs to die in the hospital (4% and 10%, respectively). In contrast, only AAs in the oldest age group (>=75 years), were found to be more likely (19%) than NHWs to die in the hospital. Table 2Down demonstrates that HAs at older ages (60 to 74 and >=75 years) were 35% and 43% less likely, respectively, to die in nursing homes than NHWs in the same age group. Nursing home death was also found to be 23% less frequent in the oldest (>=75 years) AA group. When exploring death at home (Table 3Down), HAs aged 60 to 74 years were 19% less likely than NHWs to die at home.


View this table:
[in this window]
[in a new window]
  		Table 1. Race/Ethnic Differences in the Percentage of Stroke Deaths Occurring in Texas Hospitals, 1991–1996


View this table:
[in this window]
[in a new window]
  		Table 2. Race/Ethnic Differences in the Percentage of Stroke Deaths Occurring in Texas Nursing Homes, 1991–1996


View this table:
[in this window]
[in a new window]
  		Table 3. Race/Ethnic Differences in the Percentage of Stroke Deaths Occurring at Home in Texas, 1991–1996

Tables 4 through 6DownDownDown depict gender differences in location of death, with NHWs used as the referent group. HA men at younger ages (45 to 59 and 60 to 74 years) were slightly more likely (6%) than NHW males to die in the hospital. In the oldest age group (>=75 years), HA males were 20% more likely to die in the hospital (Table 4Down). HA women aged 60 to 74 and >=75 years were 12% and 40%, respectively, more likely to die in the hospital than their NHW counterparts. AA men and women in the >=75 years age group were 10% and 24%, respectively, more likely to die in the hospital than NHW women. With respect to nursing home deaths (Table 5Down), gender differences revealed that young (45- to 59-year-old) AA males were 49% more likely than NHW males to die in a nursing home. This difference was not found in AA women in the respective age group compared with NHW women. In the oldest age group, >=75 years, AA men and women were 14% and 25%, respectively, less likely to die in a nursing home. HA men and women aged 60 to 74 and >=75 years were 21% to 47%, respectively, less likely than NHWs to die in nursing homes (see Table 5Down). Stroke death at home (Table 6Down) was 61% more likely in HA women aged 45 to 59 years, while the oldest group of HA women (>=75 years) were 30% less likely to die at home. In the 60- to 74-year age group, AA and HA males were 22% and 30%, respectively, less likely to die at home than were their NHW counterparts.


View this table:
[in this window]
[in a new window]
  		Table 4. Gender Differences in the Percentage of Stroke Deaths Occurring in Texas Hospitals, 1991–1996


View this table:
[in this window]
[in a new window]
  		Table 5. Gender Differences in the Percentage of Stroke Deaths Occurring in Texas Nursing Homes, 1991–1996


View this table:
[in this window]
[in a new window]
  		Table 6. Gender Differences in the Percentage of Stroke Deaths Occurring at Home in Texas, 1991–1996


*    Discussion
up arrowTop
 up arrowAbstract
 up arrowIntroduction
 up arrowSubjects and Methods
 up arrowResults
 *Discussion
down arrowReferences
 
This study suggests that focusing on hospital surveillance alone would overestimate AA and HA stroke mortality relative to that for NHWs. HAs in all age groups and AAs in the oldest age group are more likely to die in hospitals, whereas NHWs are relatively more likely to die in nursing homes. This has important implications for population-based surveillance projects that examine stroke mortality in multiethnic communities. Our data suggest that comparing stroke mortality among HAs, AAs, and NHWs should focus on hospital and nursing home stroke mortality. Few race/ethnic differences exist in stroke mortality at home. Although gender differences in stroke death at home were found among HA women in the oldest and youngest age groups, residence surveillance for stroke death is not cost effective.

Explanations for our findings may be related not only to ethnicity but also to issues of severity of stroke at presentation, access to care, acculturation, social support, and shortcomings of ICD-9 codes and/or vital statistics. A greater number of HAs may be dying in the hospital because they may present with more-severe strokes than NHW patients, and they may have a greater number of cerebrovascular risk factors, which may predispose them to a poor recovery from stroke. Diabetes, for example, has been documented to be more common in HAs than NHWs.11 12 13 Several studies have shown that diabetes or hyperglycemia after acute stroke predicts a poor prognosis.14 15 Social support may also be a key factor in determining location of stroke death: HAs live alone less often than NHWs.16

Race/ethnic and gender differences in location of stroke death may also be related to access to care and issues of acculturation. Acculturation refers to the process in which an immigrant group acquires the language and culture of their new country and feels part of their new country rather than outsiders.17 18 19 HAs are likely to identify themselves as being from another country and do not embrace the culture and language of the United States, which results in an under utilization or even lack of awareness of healthcare resources, namely, social and preventative health services.20 In the state of Texas, 30% of HAs, 25% of AAs, and 10% of NHWs lack health insurance.5 21 22 23 Language barriers may also result in an underutilization or even a lack of awareness of healthcare resources. Monolingual HAs have been documented to be less likely to have a usual source of health care or seek preventative healthcare treatment when compared with bilingual HA who tend to be more acculturated.24 25 Differing beliefs regarding the impact of an illness will also influence the need to present to the health care system.26 Furthermore, if an individual does not feel entitled to use the healthcare system and use of healthcare services is not the cultural norm, such a population will result in a greater disease burden and more advanced or critical disease.27 28 Additional impediments to the access of quality medical care are education level, socioeconomic status, health insurance, and availability of health care in the region.7 These issues may account for stroke recurrence being found more frequently in AAs and HAs.28 Access to care may effect length of hospital stay, a potentially important determinant of location of stroke death. NHWs with insurance may be transferred from the hospital quickly to nursing homes, where they die, while uninsured minorities may die in the hospital waiting for placement.

Our study found that HA women were 60% more likely at young age (45 to 59 years) to die at home from stroke, while those aged >=75 years were 32% less likely to die at home. In comparison, HA men in all age groups were more likely to die in the hospital and 30% less likely to die in the hospital in the 60- to 74-year age group. We also reported that AA men are 50% more likely to die in a nursing home at younger ages. These findings may be accounted for by various psychosocial norms within a culture that may promote women to be traditional caregivers and not recipients.7 12 25 These psychosocial and cultural differences may also foster a distrust of a NHW-run healthcare system, which may also explain both gender and race/ethnic differences.4 18 Markedly increased delay times in hospital arrival and in evaluation by an emergency department physician was found in HA women presenting to the emergency room with acute stroke symptoms.7 Similarly, these psychosocial norms may explain why women in New Mexico have a decreased knowledge of stroke risk factors.29

Thus, the differences found in our study may also be accounted for in part by acculturation and access to care. These issues raise important concerns regarding the interpretation of hospital based stroke mortality which would overestimate minority stroke mortality. Access to care and acculturation may also influence whether individuals will present to the hospital, present to their primary care physician, or not present to the hospital for their stroke evaluation.

We recognize some of the inherent difficulties in analyzing vital statistics data when exploring race/ethnicity. In comparing death certificate data with the National Mortality Followback Survey (NMFS), Poe et al30 found that 19.6% of the time the NMFS questionnaire stated the decedent was of Hispanic origin; however, this was not found on the death certificate. Thus, HA deaths may be underestimated by as much as 20% by the use of vital statistics. In addition, the specificity and positive predictive value of stroke ICD-9 codes have been subject to criticism.31

We also recognize that HAs are a heterogeneous group of individuals and that the term Hispanic is a sociodemographic one referring to the common social and cultural characteristics of the population. Nationally, 63% of Hispanic Americans are Mexican American32 and have a genetic heritage of 16th century Spanish Europeans and Native American Indian tribes. Our data are based on Texas vital statistics, in which 95% of this population is Mexican American.33 While the Hispanic American population of Texas is relatively homogenous, this is not true of other Hispanic American populations in the United States. In New York, for example, the Hispanic American population is composed predominantly of individuals from the Caribbean and Puerto Rico.13 The process of acculturation may be quite different between these Hispanic groups, and further study is required to compare the different Hispanic American subpopulations.

Mortality in hospitals, nursing homes, and personal homes accounts for 99.2% of all stroke deaths. Further population-based stroke surveillance studies should consider these 3 locations of stroke death to obtain accurate race ethnic and gender differences in stroke mortality. Although no significant race/ethnic differences in stroke mortality at home were found, gender differences were significant. A prospective cohort study would account for patients dying at home and ensure that stroke deaths were correctly validated. A prospective cohort study would also allow examination of the interaction of race/ethnicity and stroke severity, risk factors, family support, and time from stroke onset in determining location of stroke mortality.


*    Acknowledgments
 
This study was supported by an American Heart Association Clinician Scientist Award (to Dr Morgenstern).

Received April 1, 1999; revision received May 3, 1999; accepted May 11, 1999.


*    References
up arrowTop
 up arrowAbstract
 up arrowIntroduction
 up arrowSubjects and Methods
 up arrowResults
 up arrowDiscussion
 *References
 

  1. United States Bureau of the Census. Current Population Reports, Series P25–1130. Population projections of the United States by age, sex, race, and Hispanic origin: 1995 to 2050. Available at: http//www:census.gov/population/projection/projections/nation/nsrh/nprh9600.txt. Accessed February 1999.
  2. Howard G, Anderson R, Sorlie P, Andrews V, Backlund E, Burke GL. Ethnic differences in stroke mortality between non-Hispanic whites, Hispanic whites, and blacks. Stroke. 1994;24:2120–2125.
  3. Gillum RF. Epidemiology of stroke in Hispanic Americans. Stroke. 1995;26:1707–1712.[Abstract/Free Full Text]
  4. Morgenstern LB, Spears WD, Goff DC, Grotta JC, Nichaman MZ. African Americans and women have the highest stroke mortality in Texas. Stroke. 1997;28:15–18.[Abstract/Free Full Text]
  5. Morgenstern LB, Spears WD. A triethnic comparison of intracerebral hemorrhage mortality in Texas. Ann Neurol. 1997;42:919–923.[Medline] [Order article via Infotrieve]
  6. Sacco RL, Hauser WA, Mohr JP. Hospitalized stroke in blacks and Hispanics in northern Manhattan. Stroke. 1991;22:1491–1496.[Abstract/Free Full Text]
  7. Menon SC, Pandey DK, Morgenstern LB. Critical factors determining access to acute stroke care. Neurology. 1998;51:427–432.[Abstract/Free Full Text]
  8. International Classification of Diseases, 9th Revision, Clinical Modification. Los Angeles, Calif: Practice Management Information Corporation; 1995.
  9. Bruno A, Carter S, Qualls C, Nolte KB. Incidence of spontaneous intracerebral hemorrhage among Hispanics and non-Hispanic whites in New Mexico. Neurology. 1996;47:405–408.[Abstract/Free Full Text]
  10. Kahn HA, Sempos CT. Statistical Methods in Epidemiology. New York, NY: Oxford University Press; 1989:62.
  11. Self-reported prevalence of diabetes among Hispanics: United States, 1994–1997. MMWR Morb Mortal Wkly Rep. 1999;48:8–12.[Medline] [Order article via Infotrieve]
  12. Harris MI. Epidemiological correlates of NIDDM in Hispanics, whites and blacks in the US population. Diabetes Care. 1991;14:639–648.[Abstract]
  13. Sacco RL, Kargman DE, Qiong G, Zamanillo MC. Race-ethnicity and determinants of intracranial atherosclerotic cerebral infarction. Stroke. 1995;26:14–20.[Abstract/Free Full Text]
  14. Weir CJ, Murray GD, Dyker AG, Lees KR. Is hyperglycemia an independent predictor of poor outcome after acute stroke? Results of a long-term follow up study. BMJ. 1997;314:1303–1306.[Abstract/Free Full Text]
  15. Asplund K, Hagg E, Helmers C, Lithner F, Strand T, Wester PO. The natural history of stroke in diabetic patients. Acta Med Scand. 1980;207:417–424.[Medline] [Order article via Infotrieve]
  16. Sacco RL, Kargman DE, Zamarillo MC. Race-ethnic differences in stroke risk factors among hospitalized patients with cerebral infarction: the Northern Manhattan Stroke Study. Neurology. 1995;45:659–663.[Abstract/Free Full Text]
  17. Estrada AL, Trevino FM, Ray LA. Health care utilization barriers among Mexican Americans: evidence from HHANES 1982–84. Am J Public Health. 1990;80:27–31.
  18. Solis JM, Marks G, Garcia M, Shelton D. Acculturation, access to care, and use of preventative services by Hispanics: findings from HHANES 1982–84. Am J Public Health. 1990;80(suppl):11–19.
  19. Andersen RM, Giachello AL, Aday LA. Access of Hispanics to health care and cuts in services: a state of the art overview. Public Health Rep. 1986;101:238–252.[Medline] [Order article via Infotrieve]
  20. Polednak A. Reported pap test use by Hispanic women in Connecticut and Long Island. Conn Med. 1996;60:3–8.[Medline] [Order article via Infotrieve]
  21. Valdez RB, Morgenstern H, Brown R, Wyn R, Wang C, Cumberland W. Insuring Latinos against the costs of illness. JAMA. 1993;269:889–894.[Abstract]
  22. Texas Department of Health. Texas behavioral risk factor surveillance study. Available at: http//www.tdh.state.tx.us/chronicd/test1.htm. Accessed May 1, 1997.
  23. Trevino FM, Moyer ME, Valdez RB, Stroup-Benham CA. Health insurance coverage and utilization of health services by Mexican Americans, mainland Puerto Ricans, and Cuban Americans. JAMA. 1991;265:233–237.[Abstract]
  24. Schur CL, Albers LA. Language, sociodemographics, and health care use of Hispanic adults. J Health Care Poor Underserved.. 1996;7:140–158.[Medline] [Order article via Infotrieve]
  25. O'Malley AS, Kerner J, Johnson AE, Mandelblatt J. Acculturation and breast cancer screening among Hispanic women in New York City. Am J Public Health. 1999;89:219–227.[Abstract/Free Full Text]
  26. Hubbel FA, Chavez LR, Mishra SI, Valdez RB. Differing beliefs about breast cancer among Latinas and Anglo women. West J Med. 1996;164:405–409.[Medline] [Order article via Infotrieve]
  27. Valdez R, Giachello A, Rodriguez-Trias H, Gomez P, De La Rocha C. Improving access to health care in Latino communities. Pub Health Rep. 1993;108:534–539.[Medline] [Order article via Infotrieve]
  28. Sheinart KF, Tuhrim S, Horowitz DR, Weinberger J, Godbold JH. Stroke recurrence is more frequent in blacks and Hispanics. Neuroepidemiology. 198;17:188–198.
  29. Kattapong VJ, Longstreth WT, Kukull WA, Howard DB, Bowes JI, Wilson BE, Bigney JB, Becker TM. Stroke risk factor knowledge in Hispanic and non-Hispanic white women in New Mexico: implication for targeted prevention strategies. Health Care Women Int. 1998;19:313–325.[Medline] [Order article via Infotrieve]
  30. Poe GS, Powell-Griner E, McLaughlin JK, Placek PJ, Thompson GB, Robinson K. Comparability of the death certificate in the 1986 National Mortality Followback Survey. Vital Health Stat 2.. 1993;118:1–53.
  31. Benesch C, Witter DM, Wilder AL, Duncan PW, Samsa GP, Matchar DB. Inaccuracy of the International Classification of Disease (ICD-9-CM) in identifying the diagnosis of ischemic cerebrovascular disease. Neurology. 1997;49:660–664.[Abstract/Free Full Text]
  32. United States Bureau of the Census. 1997 current population survey summary. Table 1Up.1: age by race-ethnicity: both sexes—values. Available at: http//www:census.gov/population/socdemo/hispanic/cps97/tab 01–1Up.txt. Accessed March 1997.
  33. Plan and Operation of the Hispanic Health and Nutrition Examination Survey, 1982–84. Hyattsville, Md: US Public Health Service; 1985. DHHS publication (PHS) 85-1321.



This article has been cited by other articles:


Home page
 Am J EpidemiolHome page
P. Piriyawat, M. Smajsova, M. A. Smith, S. Pallegar, A. Al-Wabil, N. M. Garcia, J. M. Risser, L. A. Moye, and L. B. Morgenstern
Comparison of Active and Passive Surveillance for Cerebrovascular Disease: The Brain Attack Surveillance in Corpus Christi (BASIC) Project
Am. J. Epidemiol., December 1, 2002; 156(11): 1062 - 1069.
[Abstract] [Full Text] [PDF]

Home page
 NeurologyHome page
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]

Home page
 Am J EpidemiolHome page
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]

Home page
 NeurologyHome page
L. B. Morgenstern, T. H. Wein, M. A. Smith, L. A. Moye, D. K. Pandey, and D. R. Labarthe
Comparison of stroke hospitalization rates among Mexican-Americans and non-Hispanic whites
Neurology, May 23, 2000; 54(10): 2000 - 2002.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow Request Permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Wein, T. H.
Right arrow Articles by Morgenstern, L. B.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Wein, T. H.
Right arrow Articles by Morgenstern, L. B.
Related Collections
Right arrow Epidemiology
Right arrow Cerebrovascular disease/stroke

Stroke Home | Subscriptions | Archives | Feedback | Authors | Help | AHA Journals Home | Search
Copyright © 1999 American Heart Association, Inc. All rights reserved. Unauthorized use prohibited.