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(Stroke. 2003;34:1615.)
© 2003 American Heart Association, Inc.

Original Contributions

Editorial Comment—Decline in Stroke Mortality: Splitters and Lumpers

Stroke Critical Care Program, Neurointensive Care Unit, Department of Neurology and Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin

An extract of the first 250 words of the full text is provided, because this article has no abstract.

Over the last 3 decades, it has been rewarding to observe the steep decline in stroke mortality in many countries. In part, epidemiologists have attributed this decline to improvements in treatment of hypertension.² Unfortunately, during the last several years some of these countries have experienced a slowdown of the declining trend. A plethora of studies have been published since attempting to explain this phenomenon.

It seems unlikely that flattening of the stroke mortality curve is an indication of a floor effect of primary and secondary prevention efforts.³ Rather, it seems more likely to be masking a relapse in hypertension prevention. Although screening for high blood pressure has increased in the 1980s, still only half of hypertensive patients received treatment from their physicians in the 1990s,⁴ and only 69% are even aware that they have elevated blood pressure.⁵ It is also possible that the increase in incidence of other stroke risk factors, such as diabetes,⁶ obesity,⁷ and alcohol drinking,⁸ may be contributing to the slowdown in mortality decline.

In the accompanying article, Peeters and colleagues focused on a more optimistic hypothesis. The investigators tested the hypothesis that the increase in CHD cases, secondary to improvement in survival, could lead to an increase in stroke mortality that will eliminate the previously observed decline. First, they estimated the annual rate of decline in stroke mortality in the United States during 1981–1991 on the basis of ICD-9 codes data from the Compressed Mortality Database.⁹ Probability models were used to identify whether improvements in survival . . . [Full Text of this Article]