Editorial Comment—Trends in Stroke Mortality
Stroke is a serious public health problem leading to long-term disabilities, recurrence, and death. Therefore, the prognosis of outcome is investigated in several epidemiological studies in recent years. Stroke mortality varies from country to country; an increase in mortality was observed in Eastern European countries, except in Poland, whereas mortality declined in other European population.1 Biological, clinical, environmental, and social factors may interact to facilitate or interfere with recovery from stroke.2 Barker and Lackland3 have demonstrated that within Britain and the United States there are geographic variations in poststroke mortality that are not correlated with differences in adult lifestyle. In particular, these authors found a higher stroke mortality in areas of England and Wales characterized in the past by poor living standards. Hardie and coworkers,4 in a population-based study in Australia, have found that the direct effects of initial stroke and cardiovascular diseases are the major causes of death after first-ever stroke.
The present study examines the 10-year prognosis, causes, and risk factors of death after first stroke in a Japanese cohort. A total of 1261 subjects, aged >40 years and living in Hisayama on Kyushu Island in southern Japan, were enrolled and followed from 1961 to 1987. When neurological symptoms were suspected, the patient underwent clinical and diagnostic examinations including lumbar puncture, cerebral angiography, and brain imaging. The 82.6% of patients who died underwent autopsy. To elucidate the risk factors for death, the authors have collected several clinical data: alcohol consumption, smoking habits, glucose intolerance, serum total cholesterol, body mass index, hypertension, and abnormal ECG findings. Multivariate statistical analysis indicated that age, lower body mass index, and hemorrhagic stroke were significant risk factors for death. The article describes differences between the presented findings and those obtained in previous studies from other authors. As concerns potential limitations of the study, the severity of the index stroke was not taken into account in the evaluation of risk factors for fatality.
Prospective studies on defined populations allow examination of patients representative of a broad range of cases including severe as well as very mild stroke. Therefore, these studies may better individuate and analyze parameters that may influence functional recovery, degree of disability, and stroke mortality. However, future studies have to consider in the employed statistical models also other variables related to the standards of medical care and rehabilitation, psychiatric complications, type of discharge, quality of life, and socioeconomic status.
Depression has been found to be a frequent psychiatric complication of stroke also in long-term survivors. The relationship between depression and location of brain damage is disputed, but several studies suggest that depression may impair long-term recovery in activities of daily living after stroke and can adversely affect resumption of social activities.5 Can mood disorders influence long-term mortality after stroke?
The role of comorbidity for recovery is debatable, however; for example, the Framingham study has demonstrated that ischemic stroke associated with atrial fibrillation leads to recurrence, higher disability, and more frequent death. Therefore, the medical care standard, including the possibility of having adequate pharmaceutical treatments for concomitant diseases, can explain some differences in mortality trends in different countries and in different geographic areas in the same country.
According to several trials,2,6 home care appears to be a fruitful intervention. The familiar settings and the resumption of previous activities are probably to prompt motivation; task- and context-oriented rehabilitation approaches may improve activities of daily living, social relationships, motor dexterity, and walking. Can the benefits from a long-term personalized assistance at home reduce mortality after stroke?
To have a good understanding of the factors affecting epidemiological trends in stroke mortality as well as in long-term functional recovery, population-based studies can play a fundamental role if they are well planned considering the above-mentioned parameters, also taking into account the subtypes and the severity of cerebral vascular damages and the level of disability after the acute phase.
Sarti C, Stegmayr B, Tolonen H, Mähönen M, Tuomilehto J, Asplund K. Are changes in mortality from stroke caused by changes in stroke event rates or case fatality? Results from the WHO Monica Project. Stroke. 2003; 34: 1833–1840.
Barker D, Lackland D. Prenatal influences on stroke mortality in England and Wales. Stroke. 2003; 34: 1598–1602.
Hardie K, Hankey G, Jamrozik K, Broadhurst R, Anderson C. Ten-years survival after first-ever stroke in the Perth Community Stroke Study. Stroke. 2003; 34: 1842–1846.
Widén Holmquist L, Vo Koch L, Kostulas V, Holm M, Widsell G, Tegler H, Johansson K, Alzamàn J, de Pedro Cuesta J. A randomized controlled trial of rehabilitation at home after stroke in southwest Stockholm. Stroke. 1998; 29: 591–597.