A Systematic Review and Meta-analysis of Ethnic Inequalities in Stroke Incidence Patterns and Trends in High-Income Countries (2015-2025)

Background: Ethnic minority groups experience higher stroke risk than majority groups. While overall stroke incidence has declined, it is unclear whether recent prevention strategies have narrowed ethnic inequalities. We systematically reviewed last decade trends on ethnic inequalities in stroke incidence. Methods: We systematically reviewed observational studies (2015-2025) reporting first-ever stroke incidence by ethnicity in adults globally. We searched MEDLINE, Embase, and Scopus; assessed bias using ROBINS-E; reported narratively using PRISMA-2020 and conducted random-effects meta-analysis for Black versus White populations in North America. Results: Twenty-six publications from 22 studies across high-income countries were included. Five studies had low risk of bias; six had some concerns, twelve were high or very high risk of bias. Black populations in the US experienced higher stroke incidence versus White populations (pooled incidence rate ratio=1.62; 95% CI 1.18-2.22), with persistent and, in some repeated-wave registries, widening inequalities in the US and UK. Aboriginal and Torres Strait Islander peoples in Australia and Māori in New Zealand showed two- to threefold excess incidence with widening gaps observed across successive survey waves. Asian and Middle Eastern populations and Hispanic/Latino populations showed heterogeneous patterns. Adjustment for socioeconomic status and cardiovascular risk factors only partially reduced inequalities. Conclusions: Ethnic inequalities in stroke incidence persist and and show widening in some long-running registry populations, particularly among Black, Aboriginal and Torres Strait Islander, and Māori populations. Cardiovascular risk factors only partly explain these inequalities, indicating that additional unmeasured drivers are also at play. While improved detection and treatment of hypertension and diabetes remains necessary, it is insufficient on its own; reducing inequalities will also require investigation of these upstream determinants and population-based prevention strategies that address structural barriers to equitable care. Evidence from low- and middle-income countries is urgently needed.