Further Good News on Stroke, but No Time for Rest

Abstract

P rogressive reduction in stroke deaths over the last few decades has resulted in the recent preliminary announcement that stroke has declined from the third to the fourthleading cause of death in the United States. 1 Moreover, the 2010 American Heart Association goal of reducing coronary heart disease and stroke mortality by 25% in the first decade of this century was achieved early, with a 30.7% reduction in CHD mortality and a 29.2% reduction in stroke mortality from 1999 to 2008. 2 Article see p 2111Stroke incidence also appears to be declining. Two population-based studies in the United States 3 and United Kingdom 4 have demonstrated an age-adjusted decrease in stroke incidence. The rise in the number of primary and comprehensive stroke centers in the United States, increasing use of acute stroke therapies, and greater availability of evidence-based approaches to prevent and treat stroke have undoubtedly had a favorable impact on these improving trends. 5 Less is known about temporal trends in recurrent stroke risks. Of the estimated 795 000 annual strokes in the United States, 23% are recurrent events. 6 In this issue of Circulation, Hong et al 7 have provided important data on trends in the risk of recurrent stroke over the last 50 years. They performed a study-level systematic review of the control arms of secondary stroke prevention randomized, controlled trials with broad inclusion criteria, excluding trials that tested interventions directed at specific stroke mechanisms, such as atrial fibrillation or carotid or intracranial stenoses. In total, 59 trials and 66 157 patients in control arms were analyzed. Significant absolute average declines of 1% per decade for annual rate of recurrent stroke, 0.3% for fatal recurrent stroke, and 1.3% for major vascular events were estimated.Other studies have also reported decreases in stroke recurrence in population-based samples. Among more than 2.5 million US Medicare beneficiaries, the 1-year recurrent ischemic stroke rate decreased by 4.5% from 13.2 per 100 000 in 1994 -1996 to 12.6 per 100 000 in 2000 -2002. 8 The Perth Community Stroke Study in Australia observed a reduction in the 5-year cumulative risk of recurrent stroke from 32% to 23% between the 1989 -1990 and 1995-1996 cohorts. 9 In Scotland, the adjusted risk of recurrent stroke hospitalization decreased by 27% over 15 years. 10 Another systematic review of more than 23 000 patients treated with aspirin in various studies observed a nonsignificant 0.9% annual relative risk reduction in stroke recurrence over time 11 ; however, that study did not include older studies without an aspirin arm, as did the present report. Lemmens et al 11 reported on only 35% of the patients in trials that averaged a 22% lower mean follow-up than the present study, which could easily explain the absence of statistical significance in their logistic model. These reports should thus not be viewed as discrepant.The meta-regression analyses in the present study by Hong et al 7 showed temporal decreases in blood pressure ...

Time-Dependent Changes in Atherosclerotic Plaque Composition in Patients Undergoing Carotid Surgery

“…One might hypothesize that patients experience stroke at an older age, as progression of atherosclerotic disease has been slowed down because of successful improvements in primary prevention. 23 On the other hand, overall prognosis and life expectancy of individuals is improving, thereby allowing selection criteria for carotid revascularization to be extended. Finally, elderly patients seem to have increased risks during carotid stenting as compared with younger patients.…”

The Incidence, Prevalence, and Mortality of Stroke in France, Germany, Italy, Spain, the UK, and the US: A Literature Review

“…Stroke mortality rates have been decreasing consistently over time, with recent reports indicating a 29.2% reduction in stroke mortality between 1999 and 2008 in the US [34]. Indeed, the data suggest that death by stroke has fallen from the third to the fourth leading cause of death in the US [35].…”

Differences in Lipid Profiles in Two Hispanic Ischemic Stroke Populations

“…In addition, there are almost 600 million individuals in Latin America and the Caribbean (12). In spite of recent trends suggesting decreasing stroke incidence and mortality, the higher incidence of diabetes, obesity, physical inactivity, and stroke in Hispanics in the United States and Mexico raises significant concerns for increased stroke burden in Hispanics (13).…”