Global and regional burden of stroke during 1990–2010: findings from the Global Burden of Disease Study 2010
Valery L. FeiginMohammad H. ForouzanfarRita KrishnamurthiGeorge A. MensahMyles ConnorDerrick BennettAndrew E. MoranRalph L. SaccoLaurie AndersonThomas TruelsenMartin O’DonnellNarayanaswamy VenketasubramanianSuzanne Barker‐ColloCarlene M.M. LawesWenzhi WangYukito ShinoharaEmma WittMajid EzzatiMohsen NaghaviChristopher J L Murray
Key result
Age-standardized stroke incidence dropped ~12% in high-income nations, yet global absolute burden rose.
- Decreased by 12%
- 95% CI 6-17
- P significant
Why the study?
No comprehensive and comparable assessment of stroke incidence, prevalence, mortality, disability, and epidemiological trends existed for most regions worldwide.
How has the global burden of stroke (incidence, prevalence, mortality, DALYs) changed between 1990 and 2010 across different income regions?
Key Points
- To estimate the global, regional, and country-specific burden of stroke across incidence, prevalence, mortality, and disability-adjusted life-years from 1990 to 2010.
- Systematic review of multiple databases identifying 119 studies (58 from high-income countries and 61 from low-income and middle-income countries) published between 1990 and 2010.
- GBD 2010 DisMod-MR Bayesian meta-regression modeling applied to calculate age-standardised stroke incidence, prevalence, mortality, and disability-adjusted life-years (DALYs) lost across age groups (<75, ≥75 years) and country income levels for 1990, 2005, and 2010.
- From 1990 to 2010, age-standardised stroke incidence decreased by 12% (95% CI 6–17) in high-income countries and increased non-significantly by 12% (–3 to 22) in low-income and middle-income countries, while mortality rates decreased by 37% (31–41) and 20% (15–30), respectively.
- In 2010, absolute global numbers reached 16·9 million first strokes, 33 million survivors, 5·9 million deaths, and 102 million DALYs lost, representing increases since 1990 of 68%, 84%, 26%, and 12%, respectively.
- Low-income and middle-income countries carried the vast majority of the 2010 burden, accounting for 68·6% of incident strokes, 52·2% of prevalent strokes, 70·9% of stroke deaths, and 77·7% of DALYs lost.
Study Design
Type
Systematic Review
Structured PICO
How has the global burden of stroke (incidence, prevalence, mortality, DALYs) changed between 1990 and 2010 across different income regions?
P
Population
Systematic review of 119 studies assessing the global incidence, prevalence, mortality, and disability-adjusted life-years of stroke across 21 world regions spanning from 1990 to 2010.
E
Exposure
Epidemiological observation of stroke trends over time from 1990 to 2010
C
Comparator
Baseline epidemiological stroke metrics in 1990
O
Outcome
Regional and country-specific estimates of stroke incidence, prevalence, mortality, and disability-adjusted life-years (DALYs) lost by age group and country income level for 1990, 2005, and 2010hard clinical
Main Result
Effect estimate: Decreased by 12% (95% CI 6-17)
p-value: p=significant
Limitations
- Scarcity of high-quality epidemiological stroke data from low-income and middle-income countries
- Substantial regional heterogeneity of stroke data
- Underestimation of stroke burden by excluding silent strokes and vascular dementia from the case definition
- Substantial regional heterogeneity of the stroke data
- Likely underestimation of stroke burden by not including silent strokes and vascular dementia
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
MGMaurice GiroudStroke researcher, University of Burgundy, France
“Despite some improvements in stroke prevention and management in high-income countries, the growth and ageing of the global population is leading to a rise in the number of young and old patients with stroke. Urgent preventive measures and acute stroke care should be promoted in low-income and middle-income countries, and the provision of chronic stroke care should be developed worldwide.”
“People of this younger age group have been increasingly exposed to the risk factors of stroke. Specifically, people from low- to middle-income countries have been increasingly exposed to a Westernized lifestyle that includes fast food, an unbalanced diet and a diet with lots of salt and saturated fats. This leads to increased blood pressure and other cardiovascular complications, including diabetes and excess body weight, all of which increase likelihood of stroke. In young and middle aged adults, evidence from other research points to an epidemic of obesity and diabetes; this is clearly one of the main risk factors for stroke.”
GHGraeme HankeyNeurologist and clinical professor, University of Western Australia
“Population-based mass strategies to reduce consumption of salt, calories, alcohol, and tobacco by improving education and the environment will complement high-risk strategies of identifying those at risk of hemorrhagic (and ischemic) stroke, thus empowering these individuals to improve their lifestyle behaviors and, if necessary, lower their mean blood pressure and blood pressure variability with appropriate doses of antihypertensive drugs.”
Implication
Despite localized reductions in age-standardized stroke mortality, population growth and aging have driven massive increases in the absolute global burden of stroke, concentrated heavily in low- and middle-income nations.
Abstract
Background Although stroke is the second leading cause of death worldwide, no comprehensive and comparable assessment of incidence, prevalence, mortality, disability, and epidemiological trends has been estimated for most regions. We used data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010) to estimate the global and regional burden of stroke during 1990–2010. Methods We searched Medline, Embase, LILACS, Scopus, PubMed, Science Direct, Global Health Database, the WHO library, and WHO regional databases from 1990 to 2012 to identify relevant studies published between 1990 and 2010. We applied the GBD 2010 analytical technique (DisMod-MR), based on disease-specific, pre-specified associations between incidence, prevalence, and mortality, to calculate regional and country-specific estimates of stroke incidence, prevalence, mortality, and disability-adjusted life-years (DALYs) lost by age group (<75 years, ≥75 years, and in total) and country income level (high-income, and low-income and middle-income) for 1990, 2005, and 2010. Findings We included 119 studies (58 from high-income countries and 61 from low-income and middle-income countries). From 1990 to 2010, the age-standardised incidence of stroke significantly decreased by 12% (95% CI 6–17) in high-income countries, and increased by 12% (–3 to 22) in low-income and middle-income countries, albeit non-significantly. Mortality rates decreased significantly in both high income (37%, 31–41) and low-income and middle-income countries (20%, 15–30). In 2010, the absolute numbers of people with first stroke (16·9 million), stroke survivors (33 million), stroke-related deaths (5·9 million), and DALYs lost (102 million) were high and had significantly increased since 1990 (68%, 84%, 26%, and 12% increase, respectively), with most of the burden (68·6% incident strokes, 52·2% prevalent strokes, 70·9% stroke deaths, and 77·7% DALYs lost) in low-income and middle-income countries. In 2010, 5·2 million (31%) strokes were in children (aged <20 years old) and young and middle-aged adults (20–64 years), to which children and young and middle-aged adults from low-income and middle-income countries contributed almost 74 000 (89%) and 4·0 million (78%), respectively, of the burden. Additionally, we noted significant geographical differences of between three and ten times in stroke burden between GBD regions and countries. More than 62% of new strokes, 69·8% of prevalent strokes, 45·5% of deaths from stroke, and 71·7% of DALYs lost because of stroke were in people younger than 75 years. Interpretation Although age-standardised rates of stroke mortality have decreased worldwide in the past two decades, the absolute number of people who have a stroke every year, stroke survivors, related deaths, and the overall global burden of stroke (DALYs lost) are great and increasing. Further study is needed to improve understanding of stroke determinants and burden worldwide, and to establish causes of disparities and changes in trends in stroke burden between countries of different income levels. Funding Bill & Melinda Gates Foundation.
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Cite This Study
Feigin et al. (2013) conducted a systematic review in Stroke. Time period (1990 to 2010) vs. Baseline (1990) was evaluated on Change in age-standardised incidence of stroke in high-income countries (Decreased by 12%, 95% CI 6-17, p=significant). Between 1990 and 2010, age-standardized stroke incidence decreased in high-income countries, but the absolute numbers of incident strokes, deaths, and DALYs lost increased globally.