Introduction for Focused Updates in Cerebrovascular Disease

HomeStrokeVol. 51, No. 3Introduction for Focused Updates in Cerebrovascular Disease Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBIntroduction for Focused Updates in Cerebrovascular Disease Larry B. Goldstein, MD Larry B. GoldsteinLarry B. Goldstein Correspondence to Larry B. Goldstein, MD, Department of Neurology, University of Kentucky, 740 S Limestone St, J401, Lexington, KY 40536. Email E-mail Address: [email protected] Originally published12 Feb 2020https://doi.org/10.1161/STROKEAHA.119.024159Stroke. 2020;51:708–710is accompanied byPopulation Impact of Potentially Modifiable Risk Factors for StrokeEffects of Genetic Variants on Stroke Riskis companion ofTwenty Years of Progress Toward Understanding the Stroke BeltInflammation, Autoimmunity, Infection, and StrokeRisk Factors for Ischemic Stroke in Younger AdultsOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: February 12, 2020: Ahead of Print See related articles, p 711, 719, 729, 736, 742In 2016, the GBD Study (Global Burden of Disease) investigators estimated the worldwide lifetime risk of stroke after 25 years of age was 25% (95% uncertainty interval [UI], 24%–26%)—a risk that was similar for men 25% (95% UI, 23%–26%) and women 25% (95% UI, 24%–27%).1 From 1990 to 2010, the global incidence of stroke was unchanged (251 [95% UI, 230–273] versus 258 [95% UI, 234–284] per 100 000; P=0.335), whereas mortality decreased by 25% (117 [95% UI, 112–130] versus 88 [95% UI, 80–94] per 100 000; P<0.001) contributing to a 15% increase in prevalence (435 [95% UI, 389–497] versus 502 [95% UI, 451–572] per 100 000; P=0.047). Disability-adjusted life-years decreased by 25% (2063 [95% UI, 1950–2280] versus 1554 [95% UI, 1374–1642]; P<0.001).2 Alarmingly, analyses based on data from the GBD now suggest that the reductions in stroke-related mortality and other worldwide epidemiological metrics have worsened between 2010 and 2017 (Figure; Table).3 During this period, stroke incidence increased by 5.3%, prevalence by 19.3%, mortality by 5.3%, and disability-adjusted life-years by 2.7%. Consistent with these global data, stroke-related mortality in the United States had dropped over a period of 4 decades but slowed over recent years with increases in the south (annual percentage change, 4.2%) and among Hispanics (annual percentage change, 5.8%) between 2013 and 2015.4 The prior declines in stroke mortality were not sustained in 38 states; it was estimated that 32 593 excess stroke deaths might have been avoided if the previous decline had continued.4 In some counties in the United States, life expectancy actually decreased between 1980 and 2014.5 These counties include those in the stroke belt region of eastern Kentucky, southwest West Virginia, and other counties in the South. Stroke deaths in the Appalachian region that includes eastern Kentucky and southwest West Virginia are 14% higher than the rest of the nation.6 Nearly 75% of the geographic variation in mortality is explained by a combination of socioeconomic, race/ethnicity, behavioral and metabolic, and healthcare factors.5Table. Worldwide Stroke Epidemiological Metrics, 2010 to 2017320102017Incidence148.4 (140.2–157.0)156.2 (145.5–167.9)Prevalence1142.91 (1098.9–1192.2)1363.5 (1288.6–1441.3)Mortality78.7 (77.7–80.2)80.7 (79.1–82.8)DALY1683.4 (1625.5–1739.5)1728.3 (1655.6–1797.7)Data for point estimates (95% uncertainty intervals). Incidence, prevalence, and mortality per 100 000 population. DALY indicates disability-adjusted life-year. Data from: Institute for Health Metrics Evaluation’s Global Health Data Exchange (ghdx.healthdata.org/gbd). The data are made available for download by IHME and can be used, shared, modified, or built upon by non-commercial users via the Open Data Commons Attribution License.Download figureDownload PowerPointFigure. Global trends for the indicated metrics between 1990 and 2017 (±95% uncertainty interval) per 100 000 population. The graphs show an increase in incidence (upper left) and prevalence (upper right) during the entire period with initial declines in mortality (lower left) and disability-adjusted life-year (DALYs; lower right) that leveled off between about 2005 and 2013 and subsequently increased.3 Data from: Institute for Health Metrics Evaluation’s Global Health Data Exchange (ghdx.healthdata.org/gbd). The data are made available for download by IHME and can be used, shared, modified, or built upon by non-commercial users via the Open Data Commons Attribution License.In addition to these overall trends, there is particular concern for increasing stroke risk in young adults. Prior work using death certificate data reflected a 38% reduction in stroke mortality among those aged 20 to 45 years between 1989 and 2009.7 Death rates for ischemic stroke, however, increased over the period by 11% to 36% among the young compared with a 53% decline among those over 45 years of age.8 Based on a subsequent analysis of data from the National Inpatient Sample, hospitalization rates for acute ischemic stroke for both men and women aged 18 to 54 years in the United States increased between 2003 to 2004 and 2011 to 2012, including a 41.5% increase among men aged 35 to 44 years.9 The rates nearly doubled for men aged 18 to 34 and 35 to 44 years after 1995 to 1996. With this, the prevalence of stroke risk factors among those hospitalized for acute ischemic stroke increased from 2003 to 2004 to 2011 to 2012 (absolute increases of 4%–11% for hypertension, 12%–21% for lipid disorders, 4%–7% for diabetes mellitus, 5%–16% for tobacco use, and 4%–9% for obesity).9 A German nation-wide case-control study also found that 4 modifiable risk factors (hypertension, low physical activity, smoking, and alcohol consumption) accounted for almost 78% of stroke risk in younger adults.10 Stroke incidence may also be rising in pregnancy. A Canadian study further reported that pregnancy-associated stroke rates increased from 10.8 per 100 000 in 2003 to 2004 to 16.6 per 100 000 in 2015 to 2016.11Globally, a group of 10 modifiable risk factors (hypertension, current smoking, physical inactivity, high apolipoprotein ApoB/ApoA1 ratio, poor diet, high waist-to-hip ratio, psychosocial factors, cardiac disease, excessive alcohol consumption, and diabetes mellitus) accounts for 90.7% of population-attributable stroke risk.12 The prior general decline in stroke mortality was thought to be related to improved and more widespread preventive interventions and programs, particularly those targeting hypertension control and efforts aimed at smoking cessation, diabetes mellitus, and dyslipidemia.13,14 The recent epidemiological trends suggest that risk profiles have changed and that current intervention programs may have become less effective.Several important topics related to stroke risk factors are discussed in the updates that follow. These include reviews of the population impact of stroke risk factors, contributors to the US stroke belt, risk factors for stroke in young adults, the role of inflammation, and the impact of genetic variants on stroke risk. Insights from these focused reviews may help direct efforts to address the increasing burden of stroke facing our communities and patients.DisclosuresNone.FootnotesPresented in part at the International Stroke Conference, Los Angeles, CA, February 19–21, 2020.Correspondence to Larry B. Goldstein, MD, Department of Neurology, University of Kentucky, 740 S Limestone St, J401, Lexington, KY 40536. Email larry.[email protected]eduReferences1. The GBD 2016 Lifetime Risk of Stroke Collaborators. Global, regional, and country-specific lifetime risks of stroke, 1990 and 2016.New Engl J Med. 2018; 379:2429–2437. doi: 10.1056/NEJMoa1804492Google Scholar2. Feigin VL, Forouzanfar MH, Krishnamurthi R, Mensah GA, Connor M, Bennett DA, et al; Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010) and the GBD Stroke Experts Group. Global and regional burden of stroke during 1990-2010: findings from the Global Burden of Disease Study 2010.Lancet. 2014; 383:245–254. doi: 10.1016/s0140-6736(13)61953-4CrossrefMedlineGoogle Scholar3. Institute for Health Metrics and Evaluation (IHME). Global Health Data Exchange.2019. University of Washington. Avaliable at: http://ghdx.healthdata.org/gbd-results-tool. Accessed August 10, 2019.Google Scholar4. Yang Q, Tong X, Schieb L, Vaughan A, Gillespie C, Wiltz JL, et al. Vital signs: recent trends in stroke death rates - United States, 2000-2015.MMWR Morb Mortal Wkly Rep. 2017; 66:933–939. doi: 10.15585/mmwr.mm6635e1CrossrefMedlineGoogle Scholar5. Dwyer-Lindgren L, Bertozzi-Villa A, Stubbs RW, Morozoff C, Mackenbach JP, van Lenthe FJ, et al. Inequalities in life expectancy among us counties, 1980 to 2014: temporal trends and key drivers.JAMA Intern Med. 2017; 177:1003–1011. doi: 10.1001/jamainternmed.2017.0918CrossrefMedlineGoogle Scholar6. Marshall JL, Thomas L, Lane NM, Holmes GM, Arcury TA, Randolph R, et al. Health disparities in Appalachia. Creating a culture of health in Appalachia.2017. https://www.arc.gov/research/researchreportdetails.asp?REPORT_ID=138. Accessed August 29, 2019.Google Scholar7. Poisson SN, Glidden D, Johnston SC, Fullerton HJ. Deaths from stroke in US young adults, 1989-2009.Neurology. 2014; 83:2110–2115. doi: 10.1212/WNL.0000000000001042CrossrefMedlineGoogle Scholar8. Goldstein LB, Lynch J. Declining stroke mortality in young adults: hope and concern.Neurology. 2014; 83:2102–2103. doi: 10.1212/WNL.0000000000001059Google Scholar9. George MG, Tong X, Bowman BA. Prevalence of cardiovascular risk factors and strokes in younger adults.JAMA Neurol. 2017; 74:695–703. doi: 10.1001/jamaneurol.2017.0020CrossrefMedlineGoogle Scholar10. Aigner A, Grittner U, Rolfs A, Norrving B, Siegerink B, Busch MA. Contribution of established stroke risk factors to the burden of stroke in young adults.Stroke. 2017; 48:1744–1751. doi: 10.1161/STROKEAHA.117.016599LinkGoogle Scholar11. Liu S, Chan WS, Ray JG, Kramer MS, Joseph KS. Stroke and cerebrovascular disease in pregnancy.Stroke. 2019; 50:13–20.LinkGoogle Scholar12. O’Donnell MJ, Chin SL, Rangarajan S, Xavier D, Liu L, Zhang H, et al; INTERSTROKE Investigators. Global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries (INTERSTROKE): a case-control study.Lancet. 2016; 388:761–775. doi: 10.1016/S0140-6736(16)30506-2CrossrefMedlineGoogle Scholar13. Lackland DT, Roccella EJ, Deutsch AF, Fornage M, George MG, Howard G, et al; American Heart Association Stroke Council; Council on Cardiovascular and Stroke Nursing; Council on Quality of Care and Outcomes Research; Council on Functional Genomics and Translational Biology. Factors influencing the decline in stroke mortality: a statement from the American Heart Association/American Stroke Association.Stroke. 2014; 45:315–353. doi: 10.1161/01.str.0000437068.30550.cfLinkGoogle Scholar14. Mensah GA, Wei GS, Sorlie PD, Fine LJ, Rosenberg Y, Kaufmann PG, et al. Decline in cardiovascular mortality: possible causes and implications.Circ Res. 2017; 120:366–380. doi: 10.1161/CIRCRESAHA.116.309115LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Wang B, Yu P, Lin W, Zhai Z and Stankowska D (2021) MicroRNA-21-5p Reduces Hypoxia/Reoxygenation-Induced Neuronal Cell Damage through Negative Regulation of CPEB3, Analytical Cellular Pathology, 10.1155/2021/5543212, 2021, (1-11), Online publication date: 2-Dec-2021. Saini V, Guada L and Yavagal D (2021) Global Epidemiology of Stroke and Access to Acute Ischemic Stroke Interventions, Neurology, 10.1212/WNL.0000000000012781, 97:20 Supplement 2, (S6-S16), Online publication date: 16-Nov-2021. Grosse G, Schwedhelm E, Worthmann H and Choe C (2020) Arginine Derivatives in Cerebrovascular Diseases: Mechanisms and Clinical Implications, International Journal of Molecular Sciences, 10.3390/ijms21051798, 21:5, (1798) Related articlesPopulation Impact of Potentially Modifiable Risk Factors for StrokeGraeme J. Hankey,Stroke. 2020;51:719-728Effects of Genetic Variants on Stroke RiskJames F. Meschia,Stroke. 2020;51:736-741Twenty Years of Progress Toward Understanding the Stroke BeltGeorge Howard, et al. Stroke. 2020;51:742-750Inflammation, Autoimmunity, Infection, and StrokeNeal S. Parikh, et al. Stroke. 2020;51:711-718Risk Factors for Ischemic Stroke in Younger AdultsMary G. George,Stroke. 2020;51:729-735 March 2020Vol 51, Issue 3 Advertisement Article InformationMetrics © 2020 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.119.024159PMID: 32078448 Manuscript receivedAugust 21, 2019Manuscript acceptedAugust 29, 2019Originally publishedFebruary 12, 2020Manuscript revisedAugust 21, 2019 KeywordsepidemiologyincidencemortalityprevalencestrokePDF download Advertisement SubjectsEpidemiologyPrimary PreventionRisk Factors