6.5 million people die of Stroke every year (2019), the 2nd leading cause of death globally.


Global, regional, and national burden of stroke and its risk factors, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019

The Lancet Neurology
GBD 2019 Stroke Collaborators
Open AccessPublished: September 03, 2021

DOI:https://doi.org/10.1016/S1474-4422(21)00252-0


Key messages (copied from the end of the Summary)

The annual number of strokes and deaths due to stroke increased substantially from 1990 to 2019, despite substantial reductions in age-standardised rates, particularly among people older than 70 years.

The highest age-standardised stroke-related mortality and DALY rates were in the World Bank low-income group.

The fastest-growing risk factor for stroke between 1990 and 2019 was high body-mass index.

Without urgent implementation of effective primary prevention strategies, the stroke burden will probably continue to grow across the world, particularly in low-income countries.

Based on the available evidence, public health and research priorities should include:

  • expanding evidence-based prevention strategies that reduce exposure to stroke risk factors;

  • reducing the gaps in acute and chronic stroke prevention, screening, and treatment services between high-income and low-income to middle-income countries; and

  • further epidemiological research on stroke risk and outcomes across different countries and populations.

Summary

Background

Regularly updated data on stroke and its pathological types, including data on their incidence, prevalence, mortality, disability, risk factors, and epidemiological trends, are important for evidence-based stroke care planning and resource allocation. 

The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) aims to provide a standardised and comprehensive measurement of these metrics at global, regional, and national levels.

Methods

We applied GBD 2019 analytical tools to calculate stroke incidence, prevalence, mortality, disability-adjusted life-years (DALYs), and the population attributable fraction (PAF) of DALYs (with corresponding 95% uncertainty intervals [UIs]) associated with 19 risk factors, for 204 countries and territories from 1990 to 2019. 

These estimates were provided for ischaemic stroke, intracerebral haemorrhage, subarachnoid haemorrhage, and all strokes combined, and stratified by sex, age group, and World Bank country income level.

Findings

In 2019, there were 12·2 million (95% UI 11·0–13·6) incident cases of stroke, 101 million (93·2–111) prevalent cases of stroke, 143 million (133–153) DALYs due to stroke, and 6·55 million (6·00–7·02) deaths from stroke. 

Globally, stroke remained the second-leading cause of death (11·6% [10·8–12·2] of total deaths) and the third-leading cause of death and disability combined (5·7% [5·1–6·2] of total DALYs) in 2019. 

  • From 1990 to 2019, the absolute number of incident strokes increased by 70·0% (67·0–73·0), 
  • prevalent strokes increased by 85·0% (83·0–88·0), 
  • deaths from stroke increased by 43·0% (31·0–55·0), 
  • and DALYs due to stroke increased by 32·0% (22·0–42·0). 

During the same period, 

  • age-standardised rates of stroke incidence decreased by 17·0% (15·0–18·0), 
  • mortality decreased by 36·0% (31·0–42·0), 
  • prevalence decreased by 6·0% (5·0–7·0), and 
  • DALYs decreased by 36·0% (31·0–42·0). 

However, among people younger than 70 years, prevalence rates increased by 22·0% (21·0–24·0) and incidence rates increased by 15·0% (12·0–18·0). 

In 2019, the age-standardised stroke-related mortality rate was 3·6 (3·5–3·8) times higher in the World Bank low-income group than in the World Bank high-income group, and the age-standardised stroke-related DALY rate was 3·7 (3·5–3·9) times higher in the low-income group than the high-income group. 

  • Ischaemic stroke constituted 62·4% of all incident strokes in 2019 (7·63 million [6·57–8·96]), while 
  • intracerebral haemorrhage constituted 27·9% (3·41 million [2·97–3·91]) and 
  • subarachnoid haemorrhage constituted 9·7% (1·18 million [1·01–1·39]).

In 2019, the five leading risk factors for stroke were 

  • high systolic blood pressure (contributing to 79·6 million [67·7–90·8] DALYs or 55·5% [48·2–62·0] of total stroke DALYs), 
  • high body-mass index (34·9 million [22·3–48·6] DALYs or 24·3% [15·7–33·2]), 
  • high fasting plasma glucose (28·9 million [19·8–41·5] DALYs or 20·2% [13·8–29·1]), 
  • ambient particulate matter pollution (28·7 million [23·4–33·4] DALYs or 20·1% [16·6–23·0]), and 
  • smoking (25·3 million [22·6–28·2] DALYs or 17·6% [16·4–19·0]).

Interpretation

The annual number of strokes and deaths due to stroke increased substantially from 1990 to 2019, despite substantial reductions in age-standardised rates, particularly among people older than 70 years. 

The highest age-standardised stroke-related mortality and DALY rates were in the World Bank low-income group. 

The fastest-growing risk factor for stroke between 1990 and 2019 was high body-mass index. 

Without urgent implementation of effective primary prevention strategies, the stroke burden will probably continue to grow across the world, particularly in low-income countries.


Implications of all the available evidence

The findings from this study can help guide evidence-based health-care planning, prevention, and resource allocation for stroke and its pathological types, including country-specific prioritisation of these measures. 

By evaluating the risk-attributable burden of different stroke types in different geographical locations, this study can be used to develop location-specific strategies for reducing the burden of stroke. 

Based on the available evidence, public health and research priorities should include: 

  • expanding evidence-based prevention strategies that reduce exposure to stroke risk factors; 
  • reducing the gaps in acute and chronic stroke prevention, screening, and treatment services between high-income and low-income to middle-income countries; and 
  • further epidemiological research on stroke risk and outcomes across different countries and populations.

Appendix

Funding


Bill & Melinda Gates Foundation.


About the Authors

GBD 2019 Stroke Collaborators

Footnotes

† Collaborators are listed at the end of the Article

Authors List (top 5 names on the list. For the complete list, refer to the original publication)


ORIGINAL PUBLICATION (Full version)

Global, regional, and national burden of stroke and its risk factors, 1990-2019: a systematic…
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