Background and Purpose In 1990 cerebrovascular disease was the fourth leading cause of death in Hispanics in the United States. However, little information has been published about the epidemiology of stroke in US Hispanic populations.
Methods Data from the National Center for Health Statistics were examined to characterize the pattern of stroke occurrence and risk factors among Hispanics in the United States.
Results In 1989 through 1991, stroke death rates were similar in Hispanics and whites aged 45 to 64 years; at ages 65 and over, Hispanics had rates that were substantially lower than those of whites. Data from national surveys suggest that the ethnic differences in stroke mortality may be due in part to lower blood pressure in Hispanics than non-Hispanics.
Conclusions Cohort studies, well-designed case-control studies, and continued oversampling of Hispanics in national surveys are needed to further define the epidemiological patterns of stroke in US Hispanics and to guide stroke prevention efforts.
- cerebral hemorrhage
- cerebral infarction
- cerebrovascular disorders
- cigarette smoking
- diabetes mellitus
Little information has been published about the epidemiology of stroke in Hispanic populations of the United States.1 2 However, a few reports have suggested differences in stroke death rates between Hispanics and non-Hispanic whites. In New Mexico, Hispanics had lower age-adjusted death rates from cerebrovascular disease than non-Hispanic whites in 1958 through 1983 but higher rates in 1983 through 1987.3 Age-adjusted rates declined for Hispanics. Age-specific comparisons are largely lacking. Data from the NCHS were examined and results of population-based studies reviewed to characterize the pattern of stroke occurrence and risk factors among Hispanics in the United States.
Deaths from cerebrovascular disease were enumerated using published and unpublished data from the NCHS4 5 6 for International Classification of Diseases, 9th Revision, codes 430 to 438. Cerebrovascular disease was the fourth leading cause of death in US Hispanics in 1990.4 It was the third leading cause in Hispanics aged 65 and over. Disease of the heart was the leading cause overall and at ages 65 years and over.
Fig 1⇓ shows age-specific death rates for cerebrovascular disease in 1989 through 1991. Three years’ data were pooled to ensure stable rates for each age, sex, and ethnicity group. Under 65 years of age, death rates were similar in Hispanics and whites. At ages 65 and over, Hispanics had rates that were substantially below those of whites, especially at ages 85 and over. Rates in Hispanic men and women were similar below age 65 years, higher in men than women at ages 65 to 74 and 75 to 84, and higher in women at ages 85 and over. Age-adjusted death rates were lower for Hispanics (84.4 and 68.5 per 100 000 population for men and women, respectively) than for blacks and whites aged 45 years and over for 1989 through 1991.5 The pattern of Hispanic compared with white age-specific death rates was remarkably similar for cerebrovascular disease and heart disease (Fig 2⇓); the most notable difference was that for heart disease rates were substantially lower for Hispanics than for whites at ages 55 to 64 years as well as at older ages.5
In 1990, there were 3655 deaths from cerebrovascular disease in Hispanics, 5.32% of total Hispanic deaths.4 Deaths from cerebrovascular disease constituted 6.90% of total deaths in non-Hispanic whites. At ages 65 years and over, cerebrovascular deaths were 7.74% of Hispanic deaths and 8.19% of deaths in non-Hispanic whites. The percentage of cerebrovascular deaths occurring at age 65 and over was 71.7% for Hispanics and 90.2% for non-Hispanic whites, reflecting the differing population age structures and stroke death rates.
In 1990, of 3655 deaths attributed to cerebrovascular disease in Hispanics, 761 (20.8%) were coded intracerebral and other intracranial hemorrhage, 406 (11.1%) cerebral thrombosis and unspecified occlusion of cerebral arteries, 18 (0.5%) cerebral embolism, and 2470 (67.6%) other diagnoses and late effects of cerebrovascular diseases (Table 1⇓). An age-specific comparison at ages 65 to 74 years revealed a similar pattern. Although the diagnosis of hemorrhage was slightly more common in Hispanics than in non-Hispanic whites living in the 45 reporting states as well as New York State (excluding New York City) and the District of Columbia, population-based studies using uniform criteria and methods are required to assess ethnic differences in stroke pathology.
Limitations of Vital Statistics
Mortality data for Hispanics are based on information from states with 90% complete data on Hispanic origin on death certificates, the number of states increasing from 44 in 1989 to 47 in 1991.4 5 6 Data from New York were excluded for the 3-year period of 1989 through 1991 because Hispanic origin of descent was not stated or was unknown in a substantial percentage of deaths in New York City in 1990 to 1991.5 Analyses of 1989 data indicated that exclusion of New York likely changed age- and sex-specific rates by less than 5%.5 However, in these analyses, rates for whites and blacks are based on available data from 50 states and the District of Columbia. Hence, geographic differences may confound comparisons of ethnic groups. Bias in comparisons of death rates for Hispanics and whites due to ethnic classification errors is unlikely because persons identified as Hispanic by self report in data from the US census (denominator of death rates) are similarly classified by persons completing the death certificate in a high percentage of cases.7 Hispanics may be of any race. The death certificate has specific items requesting both race and Hispanic origin.6 Furthermore, patterns of stroke death by age and Hispanic status similar to those reported above were reported from the National Longitudinal Mortality Study, which followed a cohort that included 12 527 Hispanics who experienced 46 stroke deaths.8 However, interpretation of comparisons of death rates for Hispanics is complicated by the possibility that the population of Hispanics may be undercounted in the census to a greater extent than that of non-Hispanic whites. In the 85+ age group, a lower average age for Hispanics (29.5% ≥90 years) than for non-Hispanic whites (33.2% ≥90 years) might produce a greater difference in rates than would be seen with closed aged intervals.
The numbers of deaths and population-based rates are not subject to sampling error.6 When the number of events is large (>100), approximate CIs for rates are extremely narrow. In 1989 through 1991 in the reporting states, 9982 Hispanics aged 45 years and over died of stroke. All the rates shown in Fig 1⇑ are based on large numbers of deaths (eg, 1352 deaths in Hispanic men and 1769 deaths in Hispanic women aged 75 to 84 years). However, examination of trends in mortality rates was not possible because of the many limitations of the vital statistics data (eg, only 15 states reported Hispanic origin in 1980 through 1984).
Age-adjusted death rates for Mexican Americans or other US mainland Hispanic subgroups based on data from 18 states and the District of Columbia in 1986 through 1988 showed higher rates for stroke in men among Puerto Ricans (49.2) than Cubans (30.2) or Mexican Americans (21.7); rates for women were 41.3, 24.2, and 22.6, respectively.9 Unpublished analyses of cerebrovascular death after 12 years follow-up in the Puerto Rico Heart Health Program revealed the following10 : over a 12-year follow-up, cerebrovascular death occurred in 54 rural and 129 urban men in the cohort aged 35 to 79 years; age-adjusted rates per 10 000 were 168 in rural and 193 in urban men (P. Sorlie, personal communication, 1994). It is interesting to note that the age-specific US stroke death rates in Hispanic men above age 45 years were nearly identical to those for American Indians.5 Among women, rates were nearly identical below age 85 but much higher in Hispanics than American Indians at ages 85 years and over. It is unclear whether this is a chance occurrence or a result of American Indian ancestry of Mexican Americans.
It is interesting to compare cerebrovascular disease mortality rates for US Hispanics and US whites with rates in the countries of origin of most US Hispanic immigrants. In 1985 through 1988, age-adjusted stroke mortality rates per 100 000 in males were highest in Cuba (33.9), followed by Mexico (23.7) and the United States (20.2).11 In females, rates were higher in Mexico (23.0) and Cuba (32.0) than in the United States. (18.8). Between 1968 to 1970 and 1985 to 1988, rates declined more in US males (−54.3%) and females (−50.3%) than in Mexican males (−24.3%) or females (−33.9%) or Cuban males (−26.1%) or females (−30.9%). These data must be interpreted with caution.11 12 Thus, in recent years rates of death from cerebrovascular disease were lower in the US than in the countries of origin of most US Hispanic immigrants, with the exception of Puerto Rico. However, in 1968 through 1970, rates in the United States were similar to those in Cuba and higher than those in Mexico, indicating a much greater reduction in death rates in the United States, presumably in part due to improved hypertension control.11 13 14 15
The current pattern in the United States of lower stroke death rates for Hispanics compared with non-Hispanic whites aged 65 years and over resembles the international pattern of 1968 through 1970 (death rates lower in Mexico than in the United States). The current pattern of similar stroke death rates for middle-aged US Hispanics compared with non-Hispanic whites resembles the current international pattern of similar or somewhat higher death rates in Mexico compared with the United States. Perhaps, like persons in Mexico, middle-aged US Hispanics have benefited less than elderly Hispanics from improvements in US lifestyles and medical care because of more recent immigration or lower socioeconomic status.13 Among Hispanics in the 1990 US census, 6.4% were recent (<10-year) immigrants at ages 85+ compared with 11.9% at ages 45 to 54 years. Perhaps older US Hispanics have been able to share in improvements in US lifestyles and medical care because of longer US residence, enhanced socioeconomic status, and Medicare eligibility.
Another possible contributor to mortality patterns is the possibility that some elderly Mexican Americans and Puerto Ricans suffering from cerebrovascular disease might return to the communities in Mexico and Puerto Rico from which they emigrated decades earlier. This would tend to lower death rates among elderly US Mexican Americans. Further demographic and epidemiological research is needed to elucidate causes of mortality patterns.
Incidence, Hospitalization, and Case Fatality
Currently, studies of stroke incidence in US Hispanics are lacking. A study of a cohort of Puerto Rican men, the Puerto Rico Heart Health Program, did not have nonfatal stroke as an end point.10 Data by Hispanic origin or descent were not available for hospitalization data from the National Hospital Discharge Survey.14 However, New York State discharge data for 1983 through 1986 were used to compute acute stroke hospitalization rates among residents of an area of north Manhattan in New York City, defined by four zip codes.16 Age-adjusted rates at age 40 and over were 361 in Hispanics, 326 in white non-Hispanics, and 716 in black non-Hispanics among women and 306, 235, and 567, respectively, among men. Rates were higher in whites than Hispanics aged 80 and over but similar at ages 40 to 79 years. Fatality rates in the hospital for Hispanics (18.8% at ages 40 to 69, 16.1% at age 70 and over) were higher than for whites but lower than for blacks.16 Among survivors, 1- and 2-year readmission rates were similar among groups. Consistent with national proportional mortality data (Table 1⇑), the percentage of strokes coded intracranial hemorrhage was higher in Hispanics than whites, similar to observations in blacks and Native Americans.16 17 18
A subsequent study of a series of patients with cerebral infarction in north Manhattan indicated a greater proportion with intracranial atherosclerotic stroke and lacunar stroke in Hispanics and non-Hispanic blacks compared with whites.19 Few published case series reported findings for Hispanics.20 21 In New York City, Hispanic patients (n=82) hospitalized with cerebral infarct had significantly lower risk of death or recurrent stroke after 1 year than whites or blacks because of their lower prevalence of nonlacunar stroke and coexisting heart disease (abnormal first electrocardiogram).20 Cohort and surveillance studies of Hispanic populations are needed to determine rates of stroke incidence, hospitalization, case fatality, stroke subtypes, and long-term survival in Mexican Americans, Puerto Ricans, and Cuban Americans.
Table 2⇓ shows the estimated prevalence of self-reported stroke in the civilian noninstitutionalized population by age and ethnicity using data from the NHIS.22 In 1989 through 1991, an estimated annual average of 139 556 (95% CI, 111 880 to 167 232) Hispanics had a history of stroke. Of these, an estimated 82 982 were aged 65 years or over. At age 65 and over, the rate was 73 per 1000 (95% CI, 54 to 93). Unfortunately, despite pooling data from 3 years, the small number of Hispanics with stroke in the NHIS sample resulted in wide CIs, precluding meaningful comparison with the rates in non-Hispanics. Further analyses of aggregated years of NHIS data are needed for the years following 1992, in which Hispanics are being oversampled. Also needed are studies of the validity of self-reported stroke diagnoses in US Hispanics. If confirmed in subsequent studies of persons aged 65 years and over, a pattern of lower death rates, similar proportional mortality, similar hospitalization rates below age 80, and greater prevalence rate of stroke survivors in Hispanics compared with non-Hispanic whites might be explained by greater survivorship after stroke in Hispanics. Greater survivorship may be due to a lower occurrence of large nonlacunar strokes and coexisting ischemic heart disease.20
Stroke Risk Factors
Almost no published data are available from prospective cohort studies relating risk variables to stroke incidence or mortality in US Hispanics. Unpublished univariate and multivariate logistic regression analyses from the Puerto Rico Heart Health Program10 indicated that the following variables were directly related to 12-year occurrence of cerebrovascular death in both urban and rural men aged 35 to 79 years (Table 3⇓) (P. Sorlie, personal communication, 1994): systolic blood pressure, diastolic blood pressure, definite hypertension, electrocardiogram left ventricular hypertrophy (urban only). Levels of serum cholesterol, triglycerides, and blood glucose, diabetes mellitus, glucose intolerance, relative weight, cigarette smoking, hematocrit level, physical activity, and alcohol intake were not significantly associated with risk of cerebrovascular death. However, the small number of events limited statistical power to detect associations. Vital capacity and education were inversely associated with cerebrovascular death rates in urban and rural men. Further prospective cohort and case-control studies are needed of these and other risk factors in various Hispanic populations.
Are differences in stroke risk factor prevalence between Hispanics and non-Hispanic whites consistent with observed differences in stroke mortality and morbidity? Data from national surveys suggest that the ethnic differences in stroke may be due in part to lower blood pressure in Hispanics. However, patterns of smoking, diabetes, and obesity prevalence are not consistent with mortality patterns. A comprehensive review of all published studies of risk factors in Hispanics is beyond the scope of this article. NCHS data on stroke risk factors in Hispanics may be summarized briefly as follows.
Compared with whites or blacks in the second NHANES of 1976 through 1980, the prevalence of hypertension at ages 18 to 74 years was significantly lower in Mexican Americans (16.8% of men, 14.1% of women), Cuban Americans (22.8% of men, 15.5% of women), and Puerto Ricans (15.6% of men, 11.5% of women) in the HHANES of 1982 through 1984.23 The differences persisted after adjusting for age (Fig 3⇓). Mean blood pressure levels were also lower in Mexican Americans compared with non-Hispanic whites or with blacks, even after adjusting for age and body mass.24 Unfortunately, age-specific comparisons have not been presented because of limited sample size within Hispanic subgroups. For hypertension and other risk factors, estimates of levels and differences between Hispanics and non-Hispanics from NCHS surveys may vary from results of surveys of local populations.23 24 25 Data from the third NHANES of 1988 to 1994 will provide updated results for Mexican Americans.
In Mexican Americans in HHANES, age-adjusted prevalence of self-reported diabetes was 6.8% among men and 7.6% among women compared with US rates of 2.9% among men and 3.8% among women.26 At age 45 to 74 years, the prevalence of previously diagnosed diabetes was 2.4 times as great in Mexican Americans and Puerto Ricans and the same in Cubans as in non-Hispanic whites.27 When results of an oral glucose tolerance test were analyzed, the total prevalence of diabetes (World Health Organization criteria) at ages 45 to 74 years in Mexican Americans and Puerto Ricans was found to be more than two times as high as that for non-Hispanic whites in NHANES II (Mexican Americans, 23.9%; Puerto Ricans, 26.1%; Cubans, 15.8%; non-Hispanic whites, 12%).27
Age-specific current smoking rates in the three Hispanic groups surveyed in HHANES were generally higher than the rates observed for non-Hispanic whites in the 1985 NHIS and were only slightly lower than the rates for blacks.28 The age-adjusted rates for men were Mexican American 42.5%, Cuban American 39.8%, and Puerto Rican 41.6%; those for women were 23.8%, 24.4%, and 30.3%, respectively. Puerto Rican and Cuban male smokers were more likely and Mexican American male smokers less likely to smoke more than 20 cigarettes per day compared with all white men (37%). Heavy smoking was also twice as prevalent in Puerto Rican and Cuban women compared with Mexican American and all white women. Data from the 1992 NHIS for persons aged 18 years and over indicate a prevalence of current smokers in Hispanics of 20.4% (95% CI, ±2.7%), which is slightly lower than the 26.2% for all whites (95% CI, ±0.8%).29 Prevalence was slightly higher in men (22.2%) than women (18.6%). Data from HHANES indicate that Hispanics may underreport cigarette smoking.30
Among Mexican-Americans aged 20 to 74 years in the southwest United States, 16.6% overall, 16.6% of men, and 16.5% of women had serum total cholesterol levels of 6.20 mmol/L (240 mg/dL) or more.31 Among Cubans in Dade County, Florida, the percentages were 18.3% overall, 17.5% of men, and 18.8% of women. Among Puerto Ricans in the New York metropolitan area, the percentages were 17.7% overall, 16.8% of men, and 18.2% of women. In 1976 through 1980, 27% of white adults had serum cholesterol levels of 6.20 mmol/L (240 mg/dL) or more. Age-adjusted mean serum cholesterol levels for the three Hispanic origin groups (Mexican Americans, Cubans, and Puerto Ricans) were 5.35, 5.30, and 5.25 mmol/L (207, 205, and 203 mg/dL) for men and 5.35, 5.15, and 5.40 mmol/L (207, 199, and 209 mg/dL) for women, respectively.
Among Mexican-Americans aged 20 to 74 years in the southwest United States, 38.4% overall, 46.3% of men, and 30.4% of women had ratios of total cholesterol to high-density lipoprotein cholesterol of 4.5 or more. Among Cubans in Dade County, Florida, the percentages were 40.6% overall, 56.6% of men, and 27.4% of women. Among Puerto Ricans in the New York metropolitan area, the percentages were 49.1% overall, 58.4% of men, and 43.2% of women. In 1976 through 1980, 47% of white adults had ratios of total to high-density lipoprotein cholesterol of 4.5 or more.
In HHANES and NHANES II, overweight was defined as a body mass index equal to or greater than that at the 85th percentile of men (27.8 kg/m2) or women (27.3 kg/m2) aged 20 to 29 years from NHANES II. In HHANES at ages 20 to 74, 29.6% of Mexican American men, 29.4% of Cuban men, and 25.2% of Puerto Rican men were overweight compared with 24.4% of US white men in NHANES II.32 33 In HHANES at ages 20 to 74 years, 39.1% of Mexican American women, 34.1% of Cuban women, and 37.3% of Puerto Rican women were overweight compared with 25.1% of US white women in NHANES II.32 33 Skinfold-thickness data indicated a strong tendency toward centralized distribution of body fat in Hispanics.34
Stroke is a leading cause of death in US Hispanics. However, little published information is available about the epidemiology of stroke in Hispanics. Vital statistics data indicate similar death rates for Hispanics and non-Hispanic whites under 65 years of age, with lower rates for Hispanics at age 65 and over. Stroke accounted for a somewhat lower percentage of deaths in Hispanics than in non-Hispanic whites; hemorrhagic stroke was slightly more frequent in Hispanics. US Hispanics had higher levels of diabetes, smoking, and overweight but lower levels of blood pressure and serum cholesterol compared with non-Hispanic whites. No prospective cohort studies have published data on stroke incidence or risk factors in US Hispanics. Cohort studies, well-designed case-control studies, continued improvements in vital statistics, analyses of administrative hospitalization data, and continued oversampling of Hispanics in national surveys are needed to further define the epidemiological patterns of stroke in US Hispanics overall and in Mexican Americans, Puerto Ricans, and Cuban Americans.
Selected Abbreviations and Acronyms
|HHANES||=||Hispanic Health and Nutrition Examination Survey|
|NCHS||=||National Center for Health Statistics|
|NHANES||=||National Health and Nutrition Examination Survey|
|NHIS||=||National Health Interview Survey|
Reprint requests to R. F. Gillum, MD, Centers for Disease Control and Prevention, National Center for Health Statistics, 6525 Belcrest Rd, Hyattsville, MD 20782.
- Received March 3, 1995.
- Revision received June 5, 1995.
- Accepted June 5, 1995.
- Copyright © 1995 by American Heart Association
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