The End of the Long-term Decline in Stroke Mortality in the United States?
1997; Lippincott Williams & Wilkins; Volume: 28; Issue: 8 Linguagem: Inglês
10.1161/01.str.28.8.1527
ISSN1524-4628
AutoresRichard F. Gillum, Christopher T. Sempos,
Tópico(s)Blood Pressure and Hypertension Studies
ResumoHomeStrokeVol. 28, No. 8The End of the Long-term Decline in Stroke Mortality in the United States? Free AccessResearch ArticleDownload EPUBAboutView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticleDownload EPUBThe End of the Long-term Decline in Stroke Mortality in the United States? Richard F. Gillum and Christopher T. Sempos Richard F. GillumRichard F. Gillum From the Centers for Disease Control and Prevention, Hyattsville (R.F.G.), and the National Heart, Lung, and Blood Institute, Bethesda (C.T.S.), Md. and Christopher T. SemposChristopher T. Sempos From the Centers for Disease Control and Prevention, Hyattsville (R.F.G.), and the National Heart, Lung, and Blood Institute, Bethesda (C.T.S.), Md. Originally published1 Aug 1997https://doi.org/10.1161/01.STR.28.8.1527Stroke. 1997;28:1527–1529Stroke is the third leading cause of death in the United States.1234 A decline in the age-adjusted death rate for nonwhite women began in 1924, for nonwhite men in 1930, and for whites by 1918.5 The rate of decline accelerated in the 1970s, probably because of improved hypertension control, but slowed in the 1980s for reasons that remain unclear.6 Recently published statistics suggest that the long-term decline in stroke mortality rates in the United States may have ceased.There is unmistakable evidence for a marked slowdown in the decline in stroke mortality.6 The age-adjusted US stroke mortality rate increased between 1992 and 1993; a recent report documented another rise in the preliminary rate for 1995 (percent change from 1994 to 1995, +0.8).7 Age-adjusted rates per 100 000 for 1991 to 1995 were 26.8, 26.2, 26.5, 26.5, and 26.7, respectively (Table 1). It is important to view these increases in proper perspective while in no way diminishing the serious impact of the slowdown in the decline of stroke mortality in the United States since 1978.6 To this end, we tested the hypotheses (1) that the rate of decline of age-adjusted mortality rates in 1987 to 1994, the period since the previous report,6 has returned to that seen in the 1960s before the widespread availability of antihypertensive therapy, and (2) that this occurred in each sex/race group.In 1987 to 1994, the mean annual absolute and percent decline in age-adjusted death rates for stroke was less than observed in 1979 to 1986 for each sex/race group (Table 2).6 It was comparable to that observed in the 1960s, before the rapid decline of the 1970s that was commonly attributed to marked improvements in hypertension detection and treatment.2 This further deceleration in the decline affected all four sex/race groups. Although not included in calculations in Table 2, preliminary age-adjusted rates per 100 000 by sex and race for 1995 based on 80% of deaths were as follows: white men, 26.5; white women, 23.2; black men, 51.1; and black women, 39.3. A continuing deceleration of the decline in mortality rates has also been noted for ischemic heart disease, especially in blacks.89It might be hypothesized that declining levels of hypertension detection and control or increases in prevalence of other risk factors have led to the slowdown in the mortality decline and a possible upturn in stroke incidence. However, data from the most recent national examination survey offer no evidence of a deterioration in hypertension detection and control.10 Rather, modest further improvements were seen through 1991. Data collected through 1994 will soon be available to indicate whether improvements continued. Furthermore, data from Rochester, Minn, suggest that despite proven efficacy in lowering stroke incidence and mortality in clinical trials, improved hypertension control at the community level does not explain some recent trends in stroke incidence.1112 For example, between 1975 to 1979 and 1980 to 1984, stroke incidence declined among persons without hypertension but increased among persons with hypertension.12Rates of smoking and hypercholesterolemia have continued to decline in adults.1 However, the prevalence of diabetes and obesity has been increasing, especially in blacks.11314 In 1976 to 1980, 26% of blacks and 18% of whites were diabetic at age 65 to 74 years.14Although there is no evidence for increased prevalence of hypertension, the prevalence of congestive heart failure has risen to 10% in those aged 70 years and older, perhaps indicating an expanding pool of stroke-prone patients with severe heart disease.15 The prevalence of atrial fibrillation, an important risk factor for stroke,11 might also be increasing.1617 These trends may be related to improved long-term survival in persons with ischemic heart disease.18 Increases in stroke incidence in Rochester occurred mainly among survivors of ischemic heart disease.19 In persons aged 65 years or older, the national prevalence of self-reported ischemic heart disease increased from 114/1000 in 1979 to 1981 to 148/1000 in 1990.16Current efforts to control stroke risk factors must clearly continue, particularly in high-risk and underserved subpopulations. In the nation as a whole, trends in hypertension and smoking do not seem related to the slowdown in the decline of stroke mortality. However, adverse trends in the prevalence of diabetes, obesity, ischemic heart disease, and heart failure should be evaluated as possible causes of the slowdown.Could wider application of any medical or surgical interventions available for patients with symptomatic or asymptomatic cerebrovascular disease effect a nationwide acceleration in the decline in stroke mortality? In recent decades, survival after stroke has improved even in studies reporting increases in incidence.20 Currently available antiplatelet agents might affect mortality trends if they were used more widely in secondary prevention of ischemic heart disease and stroke.21222324 In persons aged 45 to 64 years in 1987 to 1989, the percentage of persons with a history of stroke taking aspirin ranged from only 17% of black women to 54% of white men.21 In persons aged 65 years and older in 1990, only 30.5% of women and 14.7% of men with coronary or cerebrovascular disease reported taking aspirin daily.22 The low rates of patient-reported aspirin use contrast sharply with much higher rates of physician-reported advice, suggesting difficulty with patient compliance and patient education.2325 Several studies indicate that neither aspirin nor warfarin is prescribed for many patients with atrial fibrillation, despite proven efficacy of antithrombotic therapy in prevention of stroke in this condition.2627 Newer trials of carotid endarterectomy have demonstrated benefits in certain patient groups but were unable to detect a significant difference in mortality from stroke or all causes because of limits of sample size.282930 Hence, the impact of increasing use of carotid endarterectomy on mortality at the population level remains unknown. Meta-analyses and statistical modeling approaches might provide estimates of potential effects.A stroke initiative similar to the National Heart Attack Alert Program will seek to ensure that most eligible patients with acute ischemic stroke are able to receive thrombolytic therapy within 3 hours after onset of stroke, as proposed at recent national conferences convened by the National Institute of Neurological Disorders and Stroke (NINDS), the American Academy of Neurology, the American Heart Association, and six other national medical organizations in coalition. Since the NINDS rt-PA Stroke Study did not show a significant difference in mortality at 3 months between the tissue plasminogen activator group and the placebo group, we must assess the effects of the emerging therapy acute thrombolysis on total stroke mortality rates in larger clinical trials and/or in a nationwide registry.3132 Since it is unlikely that more that 20% of stroke patients could receive recombinant tissue plasminogen activator therapy even with an effective stroke alert program according to presentations made at the aforementioned conferences, an impact on national stroke mortality trends cannot be assumed without empirical evidence.The currently available data suggest that the rate of decline in stroke mortality will continue at the low level seen in the 1960s until a new widely applicable and highly effective innovation in prevention or treatment is introduced. Among the lowest in the world, stroke mortality rates in US whites outside rural areas of the southeastern states may be nearing the best achievable with current technology.3334 However, rates in blacks remain higher than those in many countries and should be susceptible to further reduction.235 Further research is needed on the following: (1) the influence of increasing obesity, diabetes, ischemic heart disease, and heart failure prevalence on stroke mortality and morbidity; (2) trends in the prevalence of atrial fibrillation and use of aspirin and other antithrombotic agents; (3) statistical modeling approaches to provide estimates of the potential effect of trends in medical care on stroke mortality and morbidity trends; and (4) the potential costs and benefits for primary and secondary prevention programs to reduce diabetes and obesity prevalence, increase use of antiplatelet agents in high-risk patients, and promote more widespread use of early stroke care, including thrombolysis. Even though national surveys have not shown a deterioration in hypertension treatment and control in the early 1990s, the best chance to increase the rate of decline in stroke mortality rates may be to redouble efforts to achieve the goal for the year 2000 of increasing "to at least 50% the proportion of people with high blood pressure whose blood pressure is under control (less than 140 mm Hg systolic and 90 mm Hg diastolic)."3536 Increasing utilization of antithrombotic agents in high-risk patients may require increased patient as well as physician education efforts.Reprint requests to Richard F. Gillum, MD, Centers for Disease Control and Prevention, Office of Analysis, Epidemiology, and Health Promotion, National Center for Health Statistics, 6525 Belcrest Rd, Hyattsville, MD 20782.The opinions expressed in this editorial are not necessarily those of the editors or of the American Heart Association. Table 1. Age-Adjusted Stroke Mortality Rates per 100 000 by Sex and Race in the United States 1987-19951White MenWhite WomenBlack MenBlack Women198730.626.359.747.1198830.325.560.847.1198928.424.257.345.5199027.723.856.142.7199126.922.854.941.0199226.322.552.039.9199326.822.751.939.9199426.622.852.440.1199526.523.251.139.311995 preliminary data are based on 80% of deaths. Table 2. Trends in Age-Adjusted Stroke Mortality Rates per 100 000 by Sex and Race in the United States in Four PeriodsWhite MenWhite WomenBlack MenBlack Women1987-1994Mean annual absolute change−0.63−0.53−1.34−1.23Mean annual percent change−2.18−2.17−2.37−2.811979-1986Mean annual absolute change−1.72−1.33−2.99−2.02Mean annual percent change−4.57−4.18−4.29−3.631973-19781Mean annual absolute change−4.02−3.16−5.35−5.38Mean annual percent change−7.00−6.69−4.93−5.851960-19722Mean annual absolute change−0.97−1.16−1.00−3.13Mean annual percent change−1.31−1.89−0.74−2.43Data for 1960-1986 were adapted from Reference 6.11968-1978 for blacks.21960-1967 for blacks. References 1 National Center for Health Statistics. Health, United States, 1995. Hyattsville, Md: Public Health Service; 1996.Google Scholar2 Gillum RF. Stroke in blacks. Stroke.1988; 19:1-9.CrossrefMedlineGoogle Scholar3 Gillum RF. The epidemiology of stroke in Hispanics in the United States. 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August 1997Vol 28, Issue 8 Advertisement Article InformationMetrics Copyright © 1997 by American Heart Associationhttps://doi.org/10.1161/01.STR.28.8.1527 Manuscript receivedMarch 24, 1997Manuscript acceptedMay 20, 1997Originally publishedAugust 1, 1997Manuscript revisedMay 5, 1997 Keywordsstroke preventioncerebrovascular disordersracial differencesmortality Advertisement
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