Stroke: A Tale of Two Worlds

Summary and Comment |
November 13, 2013

Stroke: A Tale of Two Worlds

  1. Hooman Kamel, MD

Stroke incidence is declining in high-income countries but increasing in the rest of the world, with most of the burden due to hemorrhagic stroke and much of it falling on the young.

  1. Hooman Kamel, MD

High-income countries have made major strides in combating cardiovascular disease over the past few decades, but the burden of noncommunicable diseases appears to be increasing globally ( Researchers with the Global Burden of Diseases 2010 initiative have combined published study results and World Health Organization databases to assess how these trends have affected worldwide patterns of stroke.

Feigin and colleagues report that between 1990 and 2010, high-income countries witnessed a significant 12% decrease in stroke incidence, whereas stroke incidence in middle- and low-income countries rose nonsignificantly by 12% (95% confidence interval, −3% to 22%). In contrast to these divergent trends in stroke incidence, global decreases occurred in the overall number of disability-adjusted life years (DALYs) lost (a measure that accounts for the years of life lost from premature death plus the number of years spent living with disability) and in stroke mortality.

In high-income countries in 2010, 50% of new strokes, 27% of stroke deaths, and 54% of DALYs lost were in patients younger than 75. In contrast, younger patients had 68% of new strokes, 53% of stroke deaths, and 77% of DALYs lost in middle- and low-income countries.

There were significantly more stroke survivors aged ≥75 in high-income countries than in the rest of the world, whereas there were significantly more stroke survivors <75 years of age in middle- and low-income countries than in high-income countries.

Krishnamurthi and colleagues report that in middle- and low-income countries, the increase in overall stroke incidence was primarily driven not by increases in ischemic stroke incidence, but by a 22% increase in the incidence of hemorrhagic stroke. Whereas 63% of ischemic strokes in 2010 occurred in middle- or low-income countries, these countries accounted for 80% of hemorrhagic strokes in that year. Similarly, ischemic rather than hemorrhagic stroke accounted for most DALYs lost to stroke in high-income countries, but the opposite was true at a global level and especially in middle- and low-income countries.


Several important conclusions can be drawn from these thorough surveillance studies. First, stroke imposes a substantial burden of death and disability on young people worldwide. Therefore, stroke should no longer be viewed as just a disease of the old. Second, we should pay much more attention to hemorrhagic stroke as a global health issue than we have historically. Third, better diagnosis and treatment of risk factors — of which hypertension is by far the most important — should be a top priority for worldwide efforts to reduce the burden of stroke.

  • Disclosures for Hooman Kamel, MD at time of publication Consultant / Advisory board Genentech Grant / research support American Heart Association


Reader Comments (2)

Dr. V Kantariya MD Physician, Family Medicine/General Practice

Stroke is a big problem in low-and middle-income countries. A 10-fold difference in the rates of stroke mortality and DALY loss between the most affected and least affected countries. By way of example, age-agested Stroke Mortality in RUSSIA 251 (per 100000) and in Switzeland 26, (ISC 2009) ".The time for action is now".

Vinod Nikhra M.D. Physician, Internal Medicine, Delhi, India

The decline trend in stroke incidence is welcome, appears most probably due to effective treatment of hypertension. The observed increase in the incidence of stroke in younger population is worrisome. A more in-depth analysis is needed.
Dr Vinod Nikhra

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