Burden of Ischemic and Hemorrhagic Stroke Across the US From 1990 to 2019

Author:

Renedo Daniela12,Acosta Julian N.1,Leasure Audrey C.1,Sharma Richa3,Krumholz Harlan M.456,de Havenon Adam1,Alahdab Fares7,Aravkin Aleksandr Y.8910,Aryan Zahra1112,Bärnighausen Till Winfried1314,Basu Sanjay1516,Burkart Katrin910,Coberly Kaleb9,Criqui Michael H.17,Dai Xiaochen910,Desai Rupak18,Dharmaratne Samath Dhamminda91019,Doshi Rajkumar20,Elgendy Islam Y.2122,Feigin Valery L.92223,Filip Irina24,Gad Mohamed M.2526,Ghozy Sherief27,Hafezi-Nejad Nima28,Kalani Rizwan29,Karaye Ibraheem M.3031,Kisa Adnan3233,Krishnamoorthy Vijay3435,Lo Warren3637,Mestrovic Tomislav938,Miller Ted R.3940,Misganaw Awoke1041,Mokdad Ali H.910,Murray Christopher J. L.910,Natto Zuhair S.4243,Radfar Amir44,Ram Pradhum45,Roth Gregory A.91046,Seylani Allen47,Shah Nilay S.48,Sharma Purva49,Sheikh Aziz50,Singh Jasvinder A.5152,Song Suhang53,Sotoudeh Houman54,Vervoort Dominique55,Wang Cong56,Xiao Hong57,Xu Suowen5859,Zand Ramin60,Falcone Guido J.13,Sheth Kevin N.123

Affiliation:

1. Department of Neurology, Yale School of Medicine, New Haven, Connecticut

2. Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut

3. Yale Center for Brain & Mind Health, Yale School of Medicine, New Haven, Connecticut

4. Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut

5. Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut

6. Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut

7. Evidence-Based Practice Center, Mayo Clinic Foundation for Medical Education and Research, Rochester, Minnesota

8. Department of Applied Mathematics, University of Washington, Seattle

9. Institute for Health Metrics and Evaluation, University of Washington, Seattle

10. Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle

11. Brigham and Women’s Hospital, Harvard University, Boston, Massachusetts

12. Non-communicable Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran

13. Heidelberg Institute of Global Health (HIGH), Heidelberg University, Heidelberg, Germany

14. T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts

15. Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada

16. Department of General Internal Medicine, San Francisco General Hospital, San Francisco, California

17. Department of Family Medicine and Public Health, University of California San Diego, La Jolla

18. Division of Cardiology, Atlanta Veterans Affairs Medical Center, Decatur, Georgia

19. Department of Community Medicine, University of Peradeniya, Peradeniya, Sri Lanka

20. Department of Cardiology, St. Joseph’s University Medical Center, Paterson, New Jersey

21. Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington

22. National Institute for Stroke and Applied Neurosciences, Auckland University of Technology, Auckland, New Zealand

23. Research Center of Neurology, Moscow, Russia

24. Avicenna Medical and Clinical Research Institute, Oak Lawn, Illinois

25. Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio

26. Gillings School of Global Public Health, University of North Carolina Chapel Hill, Chapel Hill

27. Department of Radiology, Mayo Clinic, Rochester, Minnesota

28. Department of Radiology and Radiological Science, Johns Hopkins University, Baltimore, Maryland

29. Department of Neurology, University of Washington, Seattle

30. School of Health Professions and Human Services, Hofstra University, Hempstead, New York

31. Department of Anesthesiology, Montefiore Medical Center, Bronx, New York

32. School of Health Sciences, Kristiania University College, Oslo, Norway

33. Department of International Health and Sustainability, Tulane University, New Orleans, Louisiana

34. Department of Anesthesiology, Duke University, Durham, North Carolina

35. Department of Anesthesiology & Pain Medicine, University of Washington, Seattle

36. Department of Pediatrics, Ohio State University, Columbus

37. Department of Neurology, Nationwide Children’s Hospital, Columbus, Ohio

38. University Centre Varazdin, University North, Varazdin, Croatia

39. Pacific Institute for Research & Evaluation, Calverton, Maryland

40. School of Public Health, Curtin University, Perth, Western Australia, Australia

41. School of Public Health, College of Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia

42. Department of Dental Public Health, King Abdulaziz University, Jeddah, Saudi Arabia

43. Department of Health Policy and Oral Epidemiology, Harvard University, Boston, Massachusetts

44. College of Medicine, University of Central Florida, Orlando

45. Division of Cardiology, UPMC Western Maryland, University of Pittsburgh, Pittsburgh, Pennsylvania

46. Division of Cardiology, University of Washington, Seattle

47. National Heart, Lung, and Blood Institute, National Institute of Health, Rockville, Maryland

48. Department of Medicine (Cardiology), Northwestern University, Chicago, Illinois

49. Department of Medical Oncology, Kent Hospital, Warwick, Rhode Island

50. Usher Institute, University of Edinburgh, United Kingdom

51. School of Medicine, University of Alabama at Birmingham, Birmingham

52. Medicine Service, US Department of Veterans Affairs (VA), Birmingham, Alabama

53. Department of Health Policy and Management, University of Georgia College of Public Health, Athens

54. Department of Radiology, University of Alabama at Birmingham, Birmingham

55. Department of Health Policy and Management, Johns Hopkins University, Baltimore, Maryland

56. Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee

57. Department of Public Health Science, Fred Hutchinson Cancer Research Center, Seattle, Washington

58. Department of Endocrinology, University of Science and Technology of China, Hefei, China

59. Max-Planck-Institute for Heart and Lung Research, Bad Nauheim, Germany

60. Department of Neurology, Pennsylvania State University College of Medicine, Hershey

Abstract

ImportanceStroke is a leading cause of death and disability in the US. Accurate and updated measures of stroke burden are needed to guide public health policies.ObjectiveTo present burden estimates of ischemic and hemorrhagic stroke in the US in 2019 and describe trends from 1990 to 2019 by age, sex, and geographic location.Design, Setting, and ParticipantsAn in-depth cross-sectional analysis of the 2019 Global Burden of Disease study was conducted. The setting included the time period of 1990 to 2019 in the US. The study encompassed estimates for various types of strokes, including all strokes, ischemic strokes, intracerebral hemorrhages (ICHs), and subarachnoid hemorrhages (SAHs). The 2019 Global Burden of Disease results were released on October 20, 2020.ExposuresIn this study, no particular exposure was specifically targeted.Main Outcomes and MeasuresThe primary focus of this analysis centered on both overall and age-standardized estimates, stroke incidence, prevalence, mortality, and DALYs per 100 000 individuals.ResultsIn 2019, the US recorded 7.09 million prevalent strokes (4.07 million women [57.4%]; 3.02 million men [42.6%]), with 5.87 million being ischemic strokes (82.7%). Prevalence also included 0.66 million ICHs and 0.85 million SAHs. Although the absolute numbers of stroke cases, mortality, and DALYs surged from 1990 to 2019, the age-standardized rates either declined or remained steady. Notably, hemorrhagic strokes manifested a substantial increase, especially in mortality, compared with ischemic strokes (incidence of ischemic stroke increased by 13% [95% uncertainty interval (UI), 14.2%-11.9%]; incidence of ICH increased by 39.8% [95% UI, 38.9%-39.7%]; incidence of SAH increased by 50.9% [95% UI, 49.2%-52.6%]). The downturn in stroke mortality plateaued in the recent decade. There was a discernible heterogeneity in stroke burden trends, with older adults (50-74 years) experiencing a decrease in incidence in coastal areas (decreases up to 3.9% in Vermont), in contrast to an uptick observed in younger demographics (15-49 years) in the South and Midwest US (with increases up to 8.4% in Minnesota).Conclusions and RelevanceIn this cross-sectional study, the declining age-standardized stroke rates over the past 3 decades suggest progress in managing stroke-related outcomes. However, the increasing absolute burden of stroke, coupled with a notable rise in hemorrhagic stroke, suggests an evolving and substantial public health challenge in the US. Moreover, the significant disparities in stroke burden trends across different age groups and geographic locations underscore the necessity for region- and demography-specific interventions and policies to effectively mitigate the multifaceted and escalating burden of stroke in the country.

Publisher

American Medical Association (AMA)

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