Stroke, Epidemiologyq

Virginia J Howard, University of Alabama at Birmingham, Birmingham, AL, United States

© 2018 Elsevier Inc. All rights reserved.

Deaths 1
Age and Sex 1
Race 1
Trends 2
Geographic Variation 2
International Comparisons 2
Illness and Disability 4
Prevalence 4
Incidence 4
Hospitalization 4
Ambulatory Care 4
Disability 5
Nursing Home Care, Home Health Care, and Discharged Hospice Care 5
Health Care Expenditures 5
International Burden of Stroke 5
Risk Factors and Prevention 5
Risk Factors 5
Prevention 5
US Goals for Health Promotion and Disease Prevention for 2020 6
Conclusions 6
Further Reading 7
Relevant Website 7

Deaths

Stroke had been the third leading cause of death in the United States (US) after heart disease and cancer for over five decades but
recent statistics show that stroke has now declined to be the fifth leading cause of death after heart disease, cancer, chronic lower
respiratory diseases and unintentional injuries/accidents. Of 2,626,418 total US deaths in 2014, 133,103 were attributed to stroke as
the underlying cause; 113,308 (85%) of these stroke deaths occurred in people age 65 or older. Stroke is also a major cause of death
worldwide.

Age and Sex

Stroke death rates rise steeply with agedfor example, in 2014, from 11.9 per 100,000 population at ages 45–54 to 265.3 per
100,000 at ages 75–84 and 841.4 per 100,000 at age 85þ for white males (Table 1). To eliminate the effects of different age distri-
butions of population groups, rates are commonly age-adjusted. For both blacks and whites, age-adjusted stroke death rates per
100,000 were higher in men than women in 2014 except for the oldest age group (85þ) (Table 1).

Race
US stroke death rates were higher in blacks than in whites in each age–sex group except for 85þ (Table 1). The relative excess in
deaths from stroke among blacks was most marked below age 65 (e.g., a black-to-white ratio of 2.68 among men aged 55–64,
and for women, a black-to-white ratio of 2.55 in ages 45–54; Table 1). The black-to-white ratio decreased with age in both sexes
until at age 85 þ rates in blacks were lower than in whites (Table 1). While there has been a significant decline in stroke death rates
overall since the 1950’s, age-adjusted death rates have remained higher in blacks than whites through 2014 (Fig. 1). A greater prev-
alence of uncontrolled high blood pressure and diabetes, which are powerful risk factors for stroke, may explain some of the excess
mortality in blacks. Differences between whites and other racial and ethnic groups in the United States are important but less
marked (Fig. 2). Stroke death rates were lowest in American Indians/Alaska natives (25.0–25.3 per 100,000 in 2014). Stroke death
rates were similar in Hispanic and Asian/Pacific Islanders and lower than in whites. Note that the race groups of whites, blacks, Asian
or Pacific Islander, and American Indian or Alaska Native include persons of Hispanic and non-Hispanic origin and the Hispanic
category includes persons across all race groups. Also, death rates are known to be underestimates for Asian/Pacific islanders, and
American Indians/Alaska natives for whom data may be inadequate.

1
2 Stroke, Epidemiology

Table 1 Death rates per 100,000 population for stroke according to age and sex, for blacks and whites: United States,
2014

Death rate
Male Female

Age (years) White Black White Black

All ages, age-adjusted 35.2 55.1 34.7 45.2

45–54 11.9 29.6 8.8 22.4
55–64 29.6 79.4 20.4 48.4
65–74 77.3 169.8 60.2 112.6
75–84 265.3 393.2 257.1 322.6
85þ 841.4 827.6 995.7 934.0

300

250
Deaths per 1000,00

200

150

100

50

0
1940 1950 1960 1970 1980 1990 2000 2010 2020
Year

White Males Black Males White Females Black Females

Figure 1 Age-adjusted stroke death rates, for blacks and whites, by sex. US (1950–2014).

Trends
For most of the past century, age-adjusted stroke death rates declined in the US (Fig. 1). Except for 1950 to 1960 when rates
increased for black males, the decline has been shared by blacks. With the rapid improvements in hypertension, detection and
control during the 1970s, the decline accelerated. Compared to the 1970’s, in the 1980s and 1990s, a marked slowdown occurred
in the rate of the decline (Fig. 1). The reasons for this slowdown remain unclear. Population increases in obesity and diabetes or
failure to continue to expand improvements in the control of high blood pressure may have contributed. Since 1970, black-to-white
mortality ratios have increased slightly in men but showed no consistent change in women.

Geographic Variation
Death from stroke is more common in some regions of the United States than in others. The stroke belt, first identified in 1965 as
a region of higher stroke mortality than the rest of the US, is commonly defined as comprising eight southern states: North Carolina,
South Carolina, Georgia, Tennessee, Mississippi, Alabama, Louisiana, and Arkansas. This region of excess stroke mortality has been
shown to exist since at least 1940 and despite relatively minor geographic shifts it still persists according to the latest data available
(Fig. 3). The Centers for Disease Control’s (CDC) Atlas of Stroke Mortality (2003), presents an extensive review of geographic vari-
ations in stroke mortality rates for 1991–98 by race-ethnic group. The atlas demonstrates a similar pattern of mortality for whites
and blacks (i.e., higher stroke mortality rates in the Southeastern and Northwestern United States). It also reveals substantial vari-
ations for Hispanics (with particularly high rates in west Texas and New Mexico), Asian/Pacific Islanders (with particularly high rates
in the Northwest, the Memphis area, and southern Nevada), and American Indians/Alaska Natives (with particularly high rates in
the Carolinas, the Northwest, and the Northern Great Plains). Comparisons of the total United States pattern of these racial-ethnic
groups with whites and blacks are difficult, however, because large areas of the United States lack sufficient representation of these
race-ethnic groups for reliable estimates of stroke mortality. The reasons for these geographic variations are not well understood.
Additional maps are available on the CDC website.

International Comparisons
Stroke is the second leading cause of death worldwide. In 2013, there were 6.5 million stroke deaths worldwide, and stroke deaths
accounted for 11.8% of total deaths. Age-adjusted death rates for stroke in selected WHO countries for the most recent years
 Stroke, Epidemiology 3

60
55.1

50
45.2

Death Rate per 100,000

40
35.2 34.7
32.1
28.3 29.4
30 27.2
25.3 25

20

10

0
White Black Hispanic Asian/ American Indian/
Pacific Islander Alaska Nave

Males Females
Figure 2 Age-adjusted stroke death rates by sex and race/ethnicity, 2014.

Figure 3 Stroke death rate per 100,000, all Race, all Sex, ages 35þ, 2012–14.

available (ranging from 1977 to 2014) reveal substantial variation with higher rates in low-income countries. Rates were highest in
north Asia, Eastern Europe, central Africa, and the south Pacific and lowest in North America, western and northern Europe, and
Australia. The country with the highest crude stroke mortality is Khazakstan, in northern central Asia and Eastern Europe but
data are only available for 2003. Other countries with very high stroke mortality include the Russian Federation, Bulgaria, Greece
and Romania. The lowest stroke morality was in Austria and Switzerland.
4 Stroke, Epidemiology

Illness and Disability

Prevalence
Stroke is an important cause of illness in the United States. Based on self-report from the 2014 National Health Interview Survey, it
was estimated that 6.3 million persons in the US civilian non-institutionalized population aged 18 and older had been diagnosed as
having a stroke. The percent of the population with prevalent stroke increases dramatically from 0.5% at ages 18%–44% to 9.7% for
those aged 75 and older (Fig. 4). Prevalence of stroke in 2014 was higher in blacks than in whites: 4.0% compared to 2.3%. The self-
reported prevalence of stroke was lowest in the northeast region (1.9%) and highest in the southern region (2.8%) of the US. The
prevalence was higher in nonmetropolitan areas than in central cities or suburbs. An inverse relationship to income was apparent,
with higher prevalence in those with family income less than $35,000 compared to $35,000 or more.

Incidence
Incidence is the number or rate of new cases of a disease during a given period in a specified population. Prospective cohort and
surveillance studies provide data on distribution of stroke as indexed by incidence. Based on extrapolations from several studies, it is
estimated that approximately 795,000 persons have a new or recurrent stroke each year. Because women live longer than men, more
women than men have a stroke; it is estimated that approximately 55,000 more women than men have a stroke each year. As with
stroke death, stroke incidence increases with increasing age. Surveillance data from the Greater Cincinnati/Northern Kentucky
Stroke Study showed a black-white age-sex-adjusted incidence rate ratio (IRR) for ischemic stroke of 1.6 (294/100,000 for blacks
vs. 179/100,000 for whites) for 2005; other studies have also confirmed a higher black-white stroke incidence similar to the pattern
of stroke mortality, with greatest disparity at the younger ages.

Hospitalization
Stroke is an important cause of hospitalization in the United States. In 2010, there were 1,015,000 hospital discharges from short-
stay nonfederal hospitals in the United States with cerebrovascular disease as the first-listed discharge diagnosis; 663,000 (65%) of
these were for persons 65 years of age or older. This includes new and recurrent cases. The average length of stay for all stroke admis-
sions was 6.1 (SE 0.77) days. More than 6.1 million days of care were utilized by patients with a first-listed diagnosis of cerebro-
vascular disease. The rate of hospitalization for stroke per 10,000 increased from 32.4 in 1989 to 34.9 in 1999, decreased to 31.8 in
2009 but increased to 33.0 in 2010. The hospital fatality rate (persons dying before discharge) declined from 9% in 1989 to 5% in
2009.

Ambulatory Care
There are a substantial number of office visits for stroke care in the United States. In the 2013 National Ambulatory Medical Care
Survey, 2.0% of the visits to office-based physicians were for patients with cerebrovascular disease; 28.1% were for patients with
hypertension.

12

10
% with History of Stroke

0
18-44 45-64 65-74 75+ Male Female
Figure 4 The 2014 stroke prevalence rate per 1000 population by age and sex. National Health Interview Survey.
 Stroke, Epidemiology 5

Disability
Stroke is a leading cause of disability in the United States. In a study among Medicare patients discharged following stroke, 45%
were discharged home, 24% were discharged to inpatient rehabilitation facilities, and 31% were discharged to skilled nursing facil-
ities. Stroke is among the top 18 diseases contributing to years lived with disability. Some studies report racial/ethnic disparities and
sex differences in stroke-related disabilities. To illustrate this for blacks and whites, data from two years (2000–01) of the National
Health Interview Survey were combined. Among non-institutionalized persons, 49.6% of blacks compared to 33.8% of whites with
self-reported stroke mentioned stroke as one of the health conditions that limited their activities. After adjustment for age and sex,
blacks were significantly more likely than whites to report limitations on all twelve of various activities queried, and more likely to
report using special equipment.

Nursing Home Care, Home Health Care, and Discharged Hospice Care
Stroke is an important cause of nursing home admission. In the National Nursing Home Survey of 2007, among residents 65 years
of age or older, stroke accounted for approximately 5.8% (N ¼ 86,400) of all primary admission diagnoses. Heart disease accounted
for 8.3%. All circulatory diseases accounted for 23.7%. Women comprised 69.25% of those admitted for stroke, and blacks 17.7%.
As the population ages, more persons receive community-based or home health care. Data from the 2007 National Home and
Hospice Care Survey show that stroke was among the most common primary admission diagnoses among the home health care
patients at 3.3% and 7.1% of the patients interviewed had cerebrovascular disease as one of their all-listed diagnoses. Cerebrovas-
cular disease was also one of the most common primary admission diagnoses among discharged hospice care patients at 4.5%, and
for 10.9% it was included in all-listed diagnoses at time of discharge.

Health Care Expenditures

The US national financial burden of stroke is substantial. Approximately $33.0 billion was spent in 2007 directly or indirectly
related to the consequences of stroke. It is estimated that medical care accounted for 52% of the total expenditure. Clearly, stroke
is a major contributor to the total expenditures for cardiovascular disease.

International Burden of Stroke

The prevalence of stroke in 2013 was 25.7 million, with an estimated 10.3 million people having had a first stroke. Approximately
5.2 million (31%) of these first strokes were in persons < 65 years old. The majority of the global burden of stroke is in low- and
middle income countries. In 2010, in low- and middle – income countries, an estimated 11.6 million incident ischemic strokes
occurred and 5.3 million incident hemorrhagic strokes occurred. Between 1990 and 2013, the absolute number of stroke deaths
increased 40.2%, however the age-standardized death rate decreased 22.5%. Between 1990 and 2013, the incidence of ischemic
stroke declined significantly by 13% in high-income countries but there was no significant change in low- to middle-income coun-
tries. In 2010, in low- to middle-income countries, 39.4 million disability-adjusted life-years were lost due to ischemic stroke, and
62.8 million due to hemorrhagic stroke.

Risk Factors and Prevention

Risk Factors
A risk factor is a personal inborn, inherited, or developed characteristic, behavior, or lifestyle that is known to be associated with
a disease. Table 2 lists well-established and some putative variables that are associated with increased risk of stroke. Of these, hyper-
tension (Relative Risk (RR) 8), diabetes (RR 1.8–6.0), and smoking (RR 1.9) are perhaps the most important risk factors that can be
modified by health care or lifestyle change. Hypertension is the most well-established modifiable risk factor for stroke in terms of
strength and consistency of findings, meeting epidemiological criteria for a causal relationship. It is also the most important in terms
of percentage of strokes caused and potential for effective modification. The role of serum cholesterol and other lipids is unclear as
findings are not consistent across all studies, perhaps because of differences by stroke subtypes.

Prevention
Primary prevention refers to prevention of a disease in susceptible persons without the disease through promotion of health or
specific protective measures. The prevention, detection, and control of hypertension are the cornerstones of the primary prevention
of stroke. Clinical trials provide conclusive evidence that antihypertensive treatment is effective in preventing stroke. The efficacy of
cardiovascular lifestyle interventions, such as smoking cessation, physical activity, obesity control, diabetes control, lipid lowering,
and a diet rich in fruits and vegetables, weekly fish intake, etc., has been extrapolated from observational studies and clinical trial
evidence is beginning to accumulate. For example, ex-smokers have 30%–40% lower risk of stroke than current smokers 2–5 years
6 Stroke, Epidemiology

Table 2 Risk factors for stroke

Well-documented
Elevated blood pressure
Diabetes mellitus
Prior heart disease (coronary heart disease, other
heart disease)
Atrial fibrillation
Transient cerebral ischemia, carotid atherosclerosis
Smoking
Physical inactivity
Obesity
Advanced age
Male sex
Black race
Sickle cell disease
Low socioeconomic status
Less well-documented
Elevated serum cholesterol
Elevated lipoprotein(a)
Heavy alcohol intake
Inflammation
Residence in U.S. stroke belt (south Atlantic states)

after cessation of smoking. Evidence suggests that lipid lowering with statins may have value in prevention of stroke as well as coro-
nary heart disease. Clinical trials have demonstrated that treatment of atrial fibrillation with anticoagulation is highly efficacious in
stroke prevention. Clinical trials have also shown that carotid revascularization plus medical management in appropriately selected
asymptomatic patients with carotid atherosclerosis reduces risk of stroke.
Secondary prevention is the prevention of complications and aftereffects, including recurrent stroke and death, from existing
disease. In the setting of symptomatic cerebrovascular disease (e.g., transient cerebral ischemia, prior stroke, and carotid atheroscle-
rosis), clinical trial data support the use of aspirin or other antiplatelet agents and/or anticoagulation, Antiplatelet therapy may also
have a role in preventing stroke in persons with heart disease. Revascularization with carotid endarterectomy or carotid stenting,
performed in specialized centers, has been shown to be effective in preventing recurrent stroke in certain subgroups of patients
with severe carotid atherosclerosis (e.g., symptomatic with 70% stenosis).

US Goals for Health Promotion and Disease Prevention for 2020

It is important to continue to emphasize the large racial disparities in age-specific stroke mortality and incidence rates at younger
ages and to target programs accordingly. For example, despite the overall decline in stroke mortality, during 2010–3, the age-
adjusted stroke death rate for black men aged 45 and older was 54%–68% higher than the rates for men of the same age in other
race-ethnic groups. It is also important to reduce delay in receiving care by stroke victims by increasing population awareness of
stroke warning signals that should trigger emergency care. Related objectives include control of hypertension and reduction of
smoking, obesity, physical inactivity, and other risk factors.

Conclusions

This entry summarized data on the epidemiology of stroke in the US population with particular attention to blacks and people 65
years of age or older. Despite recent downward trends, stroke remains one of the leading causes of death. Furthermore, stroke is the
cause of illness, utilization of health services, and disability in increasing numbers of persons older than 65. These increases are
likely to continue unless the incidence of stroke can be substantially reduced. This highlights the need for even more vigorous efforts
at prevention of stroke to reduce the burden of illness and the mortality rate from stroke.

q
Change History: December 2017. VJ Howard added new section on International Burden of Stroke with statistics on prevalence, incidence, disability-adjusted
life-years lost, and change in incidence and stroke deaths between 1990 and 2013. Recommendations for further reading were expanded on to include more
citations of international statistics.
Change History: December 2016. VJ Howard updated abstract, statistics of death, prevalence, hospitalization, ambulatory care (office visits), disability and
health care expenditures. Additional text of sections on Risk Factors and US Goals for Health Promotion and Disease Prevention for 2010 were also updated as
well as recommendations for further reading. Figs. 1–4 and Tables 1–2 were updated with most current statistics available.
 Stroke, Epidemiology 7

Further Reading

Benjamin, E.J., Blaha, M.J., Chiuve, S.E., et al., 2017 Mar 7. Heart disease and stroke statistics-2017 update: a report from the American Heart Association. Circulation 135 (10),
e146–e603.
Casper, M.L., Barnett, E., Williams Jr., G.I., et al., 2003. Atlas of Stroke Mortality: Racial, Ethnic, and Geographic Disparities in the United States. Atlanta (GA). Department of Health
and Human Services, Centers for Disease Control and Prevention.
Feigin, V.L., Krishnamurthi, R.V., Parmar, P., et al., 2015. GBD 2013 Writing Group; GBD 2013 Stroke Panel Experts Group. Update on the global burden of ischemic and
hemorrhagic stroke in 1990-2013: the GBD 2013 study. Neuroepidemiology 45, 161–176.
Kernan, W.N., Ovbiagele, B., Black, H.R., et al., 2014 Jul. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare
professionals from the American Heart Association/American Stroke Association. Stroke 45 (7), 2160–2236.
Kim, A.S., Johnston, S.C., 2013 Jun. Temporal and geographic trends in the global stroke epidemic. Stroke 44 (6 Suppl. 1), S123–S125.
Lackland, D.T., Roccella, E.J., Deutsch, A.F., et al., 2014 Jan. Factors influencing the decline in stroke mortality: a statement from the American Heart Association/American Stroke
Association. Stroke 45 (1), 315–353.
Meschia, J.F., Bushnell, C., Boden-Albala, B., et al., 2014 Dec. Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart
Association/American Stroke Association. Stroke 45 (12), 3754–3832.
National Center for Health Statistics, 2016. Health, United States, 2015: With Special Features on Racial and Ethnic Health Disparities. Hyattsville, MD.
Thrift, A.G., Thayabaranathan, T., Howard, G., et al., 2017 Jan. Global stroke statistics. Int. J. Stroke 12 (1), 13–32.
Thrift, A.G., Howard, G., Cadilhac, D.A., et al., 2017 Oct. Global stroke statistics: an update of mortality data from countries using a broad code of “cerebrovascular diseases”. Int.
J. Stroke 12 (8), 796–801.
Wolf, P.A., Kannel, W.B., 2011. Epidemiology of stroke. In: Mohr, J.P., Wolf, P.A., Grotta, J.C., Moskowitz, M.A., Mayberg, M.R., von Kummer, R. (Eds.), Stroke: Pathophysiology,
Diagnosis, and Management, fifth ed. Elsevier Saunders, Philadelphia, PA, pp. 198–218.

Relevant Website

https://www.cdc.gov – Centers for Disease Control and Prevention.