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(Stroke. 2004;35:1254.)
© 2004 American Heart Association, Inc.

Original Contributions

Incidence and Case Fatality Rates of First-Ever Stroke in a Black Caribbean Population

The Barbados Register of Strokes

David O.C. Corbin, FRCP; Vishal Poddar, DM; Anselm Hennis, PhD, MRCP; Angela Gaskin, BASc; Cecil Rambarat, DM; Rainford Wilks, FRCP; Charles D.A. Wolfe, MD Henry S. Fraser, PhD, FRCP

From Chronic Disease Research Centre/Tropical Medicine Research Institute and School of Clinical Medicine and Research (D.O.C.C., V.P., A.H., A.G., C.R., H.S.F.), University of the West Indies, Barbados; Epidemiology Research Unit (R.W.), Tropical Medicine Research Institute, University of the West Indies, Mona, Jamaica; and Department of Public Health Sciences (C.D.A.W.), Guy’s, King’s, and St Thomas’ Hospital School of Medicine, London, UK.

Correspondence to Dr David O.C. Corbin, Chronic Disease Research Centre/Tropical Medicine Research Institute and School of Clinical Medicine and Research, University of the West Indies, Barbados. E-mail doccpec{at}caribsurf.com

	Abstract

Top Abstract Introduction Subjects and Methods Results Discussion Conclusions References

 
Background and Purpose— Estimation of stroke incidence among black populations outside the USA and the UK has been hampered by the lack of community-based studies. We aimed to document the incidence of first-ever stroke in Barbados, a Caribbean island with a population of 268 000 people.

Methods— A national community-based prospective register of first-ever strokes, using multiple overlapping sources of notification, was established.

Results— During the first year, 352 patients (95.2% black) were registered, 142 males and 210 females (59.7%), with a mean age of 72.5 years (range 24 to 104; SD 14.8). Cerebral infarction (IS) occurred in 81.8%, intracerebral hemorrhage (ICH) in 11.9%, subarachnoid hemorrhage (SAH) in 2.0%, whereas 4.3% of strokes were unclassified (UC). The crude annual incidence rate for the black population was 1.40 (95% CI: 1.25,1.55) per 1000 (1.35 standardized to the European population) for all strokes, 1.20 (1.07,1.34) for IS, 0.18 (0.12,0.23) for ICH, and 0.03 (0.01,0.05) for SAH. Lacunar infarction (LACI) accounted for 50.7% of IS among the black population, whereas 15.6% and 26.8% were caused by total anterior circulation infarction (TACI) and partial anterior circulation infarction (PACI), respectively. At 7 and 28 days, respectively, case fatality rates for blacks were 13.1% and 27.8% for all strokes, 46.3% and 58.5% for ICH, 7.6% and 21.7% for IS, 32.6% and 65.1% for TACI, and 2.1% and 9.0% for LACI.

Conclusions— Stroke incidence among the black population of Barbados is lower than among African-origin populations in the USA and UK. Lacunar infarction is the predominant stroke subtype.

Key Words: cerebral infarction • epidemiology • ethnic groups • incidence • stroke

	Introduction

Top Abstract Introduction Subjects and Methods Results Discussion Conclusions References

 
The estimation of stroke incidence among black populations in countries outside the USA and the UK has been hampered by the lack of community-based studies.^1–3 In the USA, comparative stroke incidence rates show a 2-fold greater incidence in black subjects than in whites.^3–8 In the South London multiethnic population, incident stroke rates were significantly higher in blacks compared with whites for all stroke types and across all ages, with a standardized rate ratio of 2.21. The higher rates in blacks were not explained by variation in social class, age, or sex.⁹

Previous studies have shown that well-recognized risk factors for stroke, namely hypertension, diabetes, and obesity, are highly prevalent among adult black Barbadians.^10–17 Furthermore, there has been a rapid shift in age distribution such that 12.5% of the population is now older than 65.¹⁸ Stroke is one of the leading causes of death and disability on the island, but no population-based incidence data are available that might assist health care planners with effective allocation of scarce resources on the island.

The Barbados Register of Strokes (BROS) was established in October 2001 to ascertain prospectively all cases of first-ever stroke on the island, whether managed in or out of hospital. This article presents the first year’s results of BROS.

	Subjects and Methods

Top Abstract Introduction Subjects and Methods Results Discussion Conclusions References

 
Location
Barbados is an island of 166 square miles and a population of 268 792, comprising 95.6% black and 3.2% white persons.¹⁸ Health care facilities include 1 large general hospital, 1 private hospital, 1 nursing home, 5 district hospitals, 8 outpatient centers (polyclinics), and many private doctors’ offices. There are 2 computed tomography (CT) scan units: 1 located at the general hospital and the other in the private sector, along with a single magnetic resonance imaging (MRI) unit. An excellent road network and strategically placed polyclinics (providing free comprehensive care) across the parishes make it easy for residents to access health care.

Case Assessment
All residents on the island with first-ever stroke according to the World Health Organization (WHO) clinical definition were eligible for registration. The methods used have been previously reported for the South London Stroke Register.⁹ The research physician or the neurologist performed all initial assessments and obtained details of the clinical presentation, previous medical history, drug therapy, and demographic details from the patient or caregiver, supplemented, when necessary, by information extracted from medical records.

Patients were examined within 48 to 72 hours of notification in almost all cases, either in hospital or at home, and neuroimaging, if not already available, arranged at no cost to the patient or caregiver.

Each incident case of stroke was given a clinical diagnosis according to the Oxfordshire Community Stroke Study (OCSP) classification as lacunar syndrome, total anterior circulation syndrome, partial anterior circulation syndrome, or posterior circulation syndrome.^19,20

Case Ascertainment
All medical practitioners were informed of the study by a combination of letters, visits by the research team, and ongoing seminars. Principal notification sources, which were the emergency department, wards, and the radiology department of the general hospital, were visited on a daily basis throughout the study. Other notification sources such as general practitioners, district hospitals, the private CT unit, polyclinics, and all rehabilitation therapists were contacted by telephone on a monthly basis. Cases identified through the national registry by reviewing deaths registered as ICD-9 (international classification of diseases, 9th revision) codes 430 to 434 and 436 were registered only if antemortem clinical findings, confirmed by contacting the relevant medical practitioner or by reviewing the hospital records, were consistent with the diagnosis of stroke.

Statistical Analysis
The 2000 national census data were used to calculate incidence rates. Gender-specific incidence rates by stroke type were age-adjusted to standard European and world populations for comparative purposes and were calculated for the entire population and black subgroups.²¹ Age-specific case fatality rates were calculated at 7 and 28 days after stroke.

The Medical Research Ethics Committee of the Barbados Ministry of Health approved the study. Informed consent was obtained from each patient or next of kin.

	Results

Top Abstract Introduction Subjects and Methods Results Discussion Conclusions References

 
BROS registered 352 patients with a first-ever stroke over the 1-year period commencing October 15, 2001; 142 (40.3%) were males and 210 (59.7%) females, 335 (95.2%) were black, 16 (4.5%) were white, and 1 (0.3%) was of Asian ethnic origin. The major sources of notification were hospital doctors (141 cases, 40.1%), routine register team surveillance (71 cases, 20.2%), and private doctors (67 cases, 19%). Sixty-nine percent or 242 patients were admitted to hospital. There was no difference in the rate of neuroimaging between hospital and community patients; 326 (92.6%) scans were performed within 30 days (median 1 day, mean 5 days) of the onset of the stroke.

Pathological stroke subtype was confirmed by neuroimaging in 338 (96.0%) cases: 335 by CT and 3 by MRI scans; cerebral infarction occurred in 288 (81.8%) cases, intracerebral hemorrhage (ICH) in 42 (11.9%), subarachnoid hemorrhage in 7 (2.0%), and 15 (4.3%) cases were unclassified. Postmortem examinations were performed in 12 cases; the results confirmed the clinical and radiological stroke subtype diagnosis in each case.

Incidence Rates
The overall crude incidence rate of stroke for the entire population was 1.31 per 1000 (95% CI: 1.2, 1.4), or 0.80 and 1.22 per 1000 standardized to the world and European populations, respectively. Age- and gender-specific annual stroke incidence rates for the black population are presented in Table 1. The mean age of stroke for black patients was 72.4 (SD 15.0) years. The crude incidence rates (per 1000) in black patients for all types of stroke combined was 1.40 (1.25, 1.55), 1.15 (0.95, 1.35) for males, and 1.63 (1.41, 1.87) for females [or 0.88 (0.70, 1.06) and 1.35 (1.12, 1.58)], standardized to the world and European populations, respectively. Among the black patients, there was a previous physician diagnosis of hypertension and diabetes in 68.1% and 38.2%, respectively. Obesity, defined as body mass index >30 kg/m², was recorded in 22.2%.

View this table: [in this window] [in a new window]   TABLE 1. Age- and Gender-Specific Annual Stroke Incidence Rates (per 1000) for the BROS Black Population

Age-specific annual stroke rates in blacks by subtype are presented in Table 2. The incidence rates (per 1000) for the different subtypes of stroke were 1.20 (1.07 to 1.34) for ischemic (IS), 0.18 (0.12 to 0.23) for ICH, 0.03 (0.01 to 0.05) for subarachnoid hemorrhage, and 0.06 (0.03 to 0.09) for unclassified stroke. The distribution and crude incidence rates for the different subtypes of IS by gender in blacks are presented in Table 3. Of a total of 276 IS, 43 (15.6%) were caused by total anterior circulation infarction (TACI), 74 (26.8%) to partial anterior (PACI), 15 (5.4%) to posterior, and 144 (50.7%) to lacunar infarction (LACI). The incidence rate of LACI in blacks standardized to the European population was 0.59, compared with 0.17 per 1000 for TACI.

View this table: [in this window] [in a new window]   TABLE 2. Age-Specific Annual Stroke Incidence Rates (per 1000) by Subtype for the BROS Black Population

View this table: [in this window] [in a new window]   TABLE 3. Distribution and Incidence Rates (per 1000) for Ischemic Stroke Subtypes in the BROS Black Population

Case Fatality Rates
Case fatality rates in the black population by stroke type at 7 and 28 days are presented in Table 4. The 7-day case fatality rate was 13. 7% for all strokes, 46.3% for ICH, and 2.1% for LACI. Particularly high fatality rates (65.1%) were observed for TACI at 28 days.

View this table: [in this window] [in a new window]   TABLE 4. Case Fatality Rates (%) at 7 and 28 Days for the BROS Black Population by Stroke Subtype (n=335)

	Discussion

Top Abstract Introduction Subjects and Methods Results Discussion Conclusions References

 
BROS provides the first population-based stroke incidence data in the black English-speaking Caribbean. Census data provided a detailed population profile, based on ethnic origin. Thus, stroke estimates could be calculated using a reliable denominator for the entire population and for the majority black subgroup. The increase in incidence of stroke with increasing age has been observed in other similar studies.²² Pathological subtyping was achieved in >96% of hospital and community cases despite the low hospital admission rate of 69%. Eighty-two percent of strokes in BROS were ischemic compared with proportional frequencies varying from 67.3% to 80.5% in 10 published studies in which CT scan rate exceeded 70%.²² Intracerebral hemorrhage was observed in 11.9% of strokes in BROS compared with 6.5% to 19.6% in these studies.²²

When compared with the reported rates for other black populations in the USA and the UK, incident stroke rates observed among the black population of Barbados are relatively low. Thus, standardized to the European population, the annual rate per 1000 of all types of first-ever stroke among black Barbadians was 1.35 compared with 2.6 for blacks living in South London, UK²³ and 2.72 for blacks living in Cincinnati, Ohio.⁷

By contrast, the incidence rate of stroke in Barbados is closer to reported rates from Europe and Australia. The incidence rate for first-ever strokes in the Belluno province, North East Italy was 1.7 per 1000, after adjusting to the European population.²⁴ In Erlangen, the corresponding rate was 1.34 per 1000,²⁵ and in Melbourne, the rate of first-time strokes was 1.0 per 1000 standardized to the world population,²⁶ which compares with a rate of 0.88 for the black population in BROS.

The overall incidence of IS in blacks in BROS, age-adjusted to the standard European population, was 1.1 per 1000, exactly the same as the standardized rate reported from Belluno,²⁴ but lower than the rate among black patients (1.9 per 1000) and higher than the rate for white patients (0.8 per 1000) in the multiracial South London stroke register.²³ However, the standardized rate per 1000 for LACI in black patients in London (0.7) was similar to the rate observed in BROS (0.6). The rates for the other subtypes of IS, TACI (0.2), partial anterior circulation infarction (0.3), and posterior circulation infarction (0.1), were 50% lower than observed among black patients in South London.²³ The stroke incidence rate among the black French-speaking residents on the Caribbean island of Martinique, when adjusted to the population of Europe, was 1.51 (1.39, 1.64) per 1000, similar to the adjusted rate for the Barbadian black population of 1.35 (1.12, 1.58) per 1000.²⁷

The relatively low incidence rate of stroke among blacks in Barbados compared with USA black populations and the migrant black population of South London is worthy of comment. Recent studies have established a gradient of obesity, diabetes, and hypertension prevalence in peoples of the African Diaspora, from low levels in rural Africa through intermediate levels in the Caribbean and high levels in urban black Americans.^13,15 This gradient is thought to reflect variations in socioeconomic and environmental influences against a common genetic background. Fang et al found that Caribbean-born blacks had one fourth the mortality rate from coronary artery disease compared with Southern-born blacks.²⁸On the African continent, incidence rates of stroke of 0.7 and 0.68 per 1000 were reported from the Stroke Registry in Ibadan, Nigeria²⁹ and from a 1991 study among the black population in Harare, Zimbabwe,³⁰ respectively. Thus, the relatively low incidence of stroke in Barbados (and Martinique), compared with rates recorded for black Americans and black Caribbean migrants to Europe are high when compared with earlier studies from Africa, and suggests that black Caribbean populations may be at an earlier stage of transition to lifestyles associated with high prevalence of obesity, hypertension, and diabetes and associated chronic disease.³¹ Accordingly, incidence of stroke may be expected to increase in the near future. Affluent urbanized blacks on the African continent are already experiencing an increase in the incidence of cardiovascular diseases as they adopt a Western lifestyle.³²

In BROS, 7-day and 28-day case fatality rates for all strokes in the black population were 13.7% and 29.9%, respectively, compared with the corresponding rates for all ethnic groups of 16.6% and 25.7% in the South London register.²⁴ Worldwide, 28-day case fatality rates for all strokes average 22.9%²² and range from 17% in Japan³³ to 33% in Belluno.²⁵ For patients with IS, case fatality rates vary from 10% in the OCSP²⁰ to 15.8% in Martinique²⁷ and 20.4% in Greece.³⁴ In BROS, the corresponding 28-day case fatality rate for patients with IS was 21.7%, ranging from 65.1% for cases of TACI to 9% for cases of LACI. Patients with TACI have large vessel occlusion and often have acute cerebral edema caused by cortical ischemia.³⁵ Early deterioration is associated with a worse prognosis; Tei et al found almost 42% of Japanese patients with TACI deteriorated within the first 7 days of acute stroke and more than one third of these were dead by 7 days.³⁶ The 28-day case fatality rate for TACI in Barbados is particularly high compared with that observed in the OCSP (39%).²⁰ Patients in Barbados may have more severe neurological impairments and a greater burden of comorbid factors, particularly in the elderly population, but further analysis is needed. In BROS, high 28-day case fatality rates were also observed for ICH (58.5%) and unclassified strokes (58.3%).

	Conclusions

Top Abstract Introduction Subjects and Methods Results Discussion Conclusions References

 
The first-year results of the BROS provide data on the epidemiology of stroke in a predominantly black population outside the USA and UK. The lower incidence of stroke compared with black Americans and South London blacks suggests that the acculturation process rather than genetic factors alone may be playing a significant role in determining the incidence of stroke in a given black population. LACI is the most common stroke subtype, with a low 28-day case fatality rate compared with very high rates for TACI. Further research is needed to elucidate these findings to better inform health care planners.

	Acknowledgments

 
The project was funded by the Wellcome Trust of the UK. Sonia Connell, Senior Health Sister (loaned from the Barbados Ministry of Health), supervised surveillance of notification sources. We thank Barbados Shipping and Trading, Ltd, who loaned a car to the project, Maureen Workman for secretarial assistance, Glenda Gay for assistance with data analysis, Dr Ian Wilson for assistance with patient evaluations, and all health care personnel in Barbados who have supported the project. The authors have no conflicts of interest to declare.

Received December 24, 2003; accepted February 24, 2004.

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