Reasons Underlying Racial Differences in Stroke Incidence and Mortality
2013; Lippincott Williams & Wilkins; Volume: 44; Issue: 6_suppl_1 Linguagem: Inglês
10.1161/strokeaha.111.000691
ISSN1524-4628
Autores Tópico(s)Cerebrovascular and Carotid Artery Diseases
ResumoHomeStrokeVol. 44, No. 6_suppl_1Reasons Underlying Racial Differences in Stroke Incidence and Mortality Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBReasons Underlying Racial Differences in Stroke Incidence and Mortality Virginia J. Howard, PhD Virginia J. HowardVirginia J. Howard From the Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL. Originally published1 Jun 2013https://doi.org/10.1161/STROKEAHA.111.000691Stroke. 2013;44:S126–S128Although there has been a significant decline in overall stroke mortality rates since the 1950s, age-adjusted stroke death rates have remained higher in blacks than in whites through 2008.1 The Table shows the 2009 stroke death rates per 100000 according to age and sex for blacks and whites. The relative excess in deaths from stroke among blacks compared with whites is most marked in the population aged 64 years were smaller or nonexistent. Some limitations of this report include the use of administrative data (medical records, death certificates) codes rather than physician adjudication of stroke events, lack of smoking status, and less complete follow-up for blacks.9Incidence data for comparing rates for blacks and whites from the studies that included physician review of stroke cases have been recently summarized.17 Data from the Greater Cincinnati/Northern Kentucky Stroke Study (GCNKSS), one of the largest population-based surveillance studies of black–white differences in clinically reviewed stroke incidence cases, used the community socioeconomic status (SES) measure of percentage below poverty to examine the contribution of SES to the black–nonblack differences in incident stroke.13 Lower (poorer) community SES was found to be significantly associated with higher stroke incidence, and this effect was similar for blacks and nonblacks (largely whites). The contribution of community SES to excess black stroke incidence was estimated to be 39%, leaving 61% unaccounted for, but they were unable to adjust for individual-level risk factors, including diabetes mellitus and hypertension, that may overlap with SES.13 The Atherosclerosis Risk in Communities (ARIC) study that included 4 geographical areas of the United States (only 2 had sufficient numbers of blacks) showed that the addition of educational status (a surrogate measure of SES) to the model adjusting for age, sex, hypertension, and diabetes mellitus decreased the black/white ischemic stroke incidence rate ratio from 1.57 (95% confidence interval, 1.18–2.09) to 1.38 (95% confidence interval, 1.01–1.89), a reduction of one-third, although the potential for differential effects by age was not examined.10The Reasons for Geographic and Racial Differences in Stroke (REGARDS) study is a population-based national cohort study of 30239 community-dwelling individuals aged ≥45 years at enrollment in 2003–2007 that was designed to investigate factors associated with the excess stroke mortality of residents of the stroke belt region and that of blacks compared with whites.16 Follow-up is ongoing with physician adjudication of suspected stroke events. On the basis of follow-up through May 2010, data from REGARDS have shown that black–white patterns in stroke incidence are similar to national patterns of stroke mortality, suggesting that black–white disparities in stroke incidence play a role in black–white stroke mortality disparities.17 However, the magnitude of the disparities in stroke incidence is only approximately half of the mortality disparity, suggesting that stroke incidence only partially explains the black–white mortality disparities and that racial disparities in case fatality also may be contributing to disparities in mortality. However, data from the GCNKSS show a higher stroke incidence in blacks than in whites but a similar case fatality.11,19Using an approach similar to the work by Giles et al9 reporting the National Health and Nutrition Examination Survey follow-up data, further analyses of REGARDS data were conducted to determine whether blacks were still at higher risk for stroke than whites after adjusting for the traditional stroke risk factors (ie, variables in the Framingham Stroke Risk Score: age, sex, systolic blood pressure, use of antihypertensive medications, current smoking status, history of heart disease, diabetes mellitus, left ventricular hypertrophy, and atrial fibrillation)20,21 and SES, defined by annual household income and education. Of the analytic sample of 25714 participants, 40% were black. Blacks were younger and had higher prevalence of antihypertensive medication use, diabetes mellitus, left ventricular hypertrophy, smoking, and lower SES than whites. Similar to findings from National Health and Nutrition Examination Survey follow-up, after adjustment for the Framingham risk factors, there was substantial attenuation of the black excess risk and it was further attenuated after adjustment for SES factors. The hazard ratio for incident stroke in blacks compared with whites at different ages is shown in the Figure. At ages <65 years, in which the black–white disparities in stroke risk are the greatest, the Framingham risk factors accounted for ≈40% of the excess risk in blacks; with the addition of SES factors, this was increased to ≈50%. Of the individual risk factors, systolic blood pressure had the most powerful effect on the black–white stroke risk, accounting for ≈50% of the combined Framingham risk factor effect. The next largest contributing factors were use of antihypertensive medications and diabetes mellitus, each accounting for ≈25% to 33% of the combined risk factor effect.22 Although the risk factor and SES adjustment accounted for approximately one-half of the disparity in the REGARDS cohort, the other half of the excess stroke incidence in the cohort must be attributable to other sources or factors. This same report suggested that the other potential contributors to the black–white disparity in stroke risk could potentially be arising from (1) a racial difference in the impact of risk factors, with the presence of risk factors having a larger impact on blacks than whites; (2) residual confounding from incomplete assessment of these traditional risk factors, in which, for example, characterizing hypertension with systolic blood pressure and medication use fails to capture other aspects such as the duration of the condition or diurnal variations in blood pressure; (3) novel risk factors such as inflammation, psychosocial factors, and others; and (4) measurement error in the predictive factors in the model.22 Very promising efforts are underway investigating these potential pathways, in which, for example, there seems to be a differential impact of elevated blood pressure on blacks, with a 3-times larger increase in stroke risk among blacks than whites for the same magnitude difference in systolic blood pressure.23Download figureDownload PowerPointFigure. Estimated black/white hazard ratio as a function of age and covariate adjustment. Black lines show hazard ratio and 95% confidence limits after adjustment for sex; dark gray lines show hazard ratio and 95% confidence limits after further adjustment for Framingham stroke risk factors; and light gray lines show hazard ratio and 95% confidence limits after further adjustment for socioeconomic status factors.Although the black–white disparities in stroke have been known for at least a half century, only recently has the pace of scientific investigations increased. Understanding the causes of these immense disparities is the first step to design and implement interventions to reduce the unequal distribution of the public health burden of stroke.Table. Death Rates Per 100 000 Population for Stroke According to Age and Sex for Blacks and Whites and Black/White Mortality Ratio, 2009MenWomenAge, yBlack Death RateWhite Death RateBlack/White Mortality RatioBlack Death RateWhite Death RateBlack/White Mortality Ratio45–5445.512.23.734.89.93.555–64106.932.33.366.724.72.765–74240.4110.12.2166.088.91.975–84544.0394.51.4471.3370.91.3≥851103.51142.31.01268.61325.41.0Rates provided for non-Hispanic whites and non-Hispanic blacks.Data taken from Centers for Disease Control and Prevention, National Center for Health Statistics. CDC WONDER Online Database, compiled from Compressed Mortality File 1999–2009 Series 20 No. 20, 2012. Accessed October 28, 2012 at http://wonder.cdc.gov/cmf-icd10.html.Sources of FundingThe REGARDS study was supported by cooperative agreement NS 041588 from the National Institute of Neurological Disorders and Stroke.DisclosuresNone.FootnotesCorrespondence to Virginia J. Howard, PhD, Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Ryals 210F, 1720 2nd Ave S, Birmingham, AL, 35294-0022. E-mail [email protected]References1. Roger VL, Go AS, Lloyd-Jones DM, Benjamin EJ, Berry JD, Borden WB, et al; on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart Disease and Stroke Statistics—2012 Update: A Report from the American Heart Association. Circulation.2012; 125:e2–e220.Google Scholar2. National Center for Health Statistics. Health, United States, 2011. With Special Features on Socioeconomic Status and Health. Hyattesville, MD:National Center for Health Statistics; 2012.Google Scholar3. Wylie CM. Death statistics for cerebrovascular disease: a review of recent findings.Stroke. 1970; 1:184–193.LinkGoogle Scholar4. Oh SJ. Cerebro-vascular diseases in Negroes.J Natl Med Assoc. 1971; 63:93–98.MedlineGoogle Scholar5. 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Lisabeth L and Howard G (2013) The Current State and Future of Stroke: Introduction, Stroke, 44:6_suppl_1, (S122-S122), Online publication date: 1-Jun-2013. June 2013Vol 44, Issue 6_suppl_1 Advertisement Article InformationMetrics © 2013 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.111.000691PMID: 23709708 Manuscript receivedJanuary 3, 2013Manuscript acceptedMarch 5, 2013Originally publishedJune 1, 2013 Keywordsrisk factorshealth status disparitiesAfrican Americans, statistics and numeric dataincidencestroke prevention and controlstroke, epidemiologystroke, mortalityPDF download Advertisement SubjectsPrimary Prevention
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