NCHS Data Brief ■ No. 207 ■ July 2015

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics

Differences in Stroke Mortality Among Adults Aged 45 and 

Over: United States, 2010–2013

Deborah D. Ingram, Ph.D.; and Jessica A. Montresor-Lopez, M.P.H.

Key findings 

Data from the National 

Vital Statistics System, 

Mortality

● During 2010–2013, the

age-adjusted stroke death rate 

for non-Hispanic black men 

aged 45 and over (154.8 deaths 

per 100,000 population) was 

54% to 68% higher than the 

rates for men of the same age 

in other race-ethnicity groups. 

The rate for non-Hispanic black 

women aged 45 and over was 

30% to 61% higher than the 

rates for women of the same 

age in other race-ethnicity 

groups.

● The age distribution of 

stroke deaths differed by race 

and ethnicity.

● Stroke death rates were 32% 

higher in counties in the lowest 

median household income 

quartile than in counties in the 

highest income quartile.

● Nonmetropolitan counties 

had higher stroke death 

rates than counties at other 

urbanization levels.

● Stroke mortality inside and 

outside the Stroke Belt differed 

by race and ethnicity.

Despite steady decreases in U.S. stroke mortality over the past several 

decades, stroke remained the fourth leading cause of death during 2010–2012 

and the fifth leading cause in 2013 (1–3). Most studies have focused on the 

excess mortality experienced by black persons compared with white persons 

and by residents of the southeastern states, referred to as the Stroke Belt 

(2–7). Few stroke mortality studies have focused on Asian or Pacific Islander 

and Hispanic persons or have explored urban–rural differences. This report 

provides updated information about stroke mortality among U.S. residents 

aged 45 and over during 2010–2013 by age, race and ethnicity, income,

urban–rural residence, and residence inside or outside the Stroke Belt.

Keywords: health disparities • Stroke Belt • urban–rural • cerebrovascular 

diseases

Stroke mortality among adults aged 45 and over varied by 

race and Hispanic origin and sex during 2010–2013. Deaths per 100,000 population

Figure 1. Age-adjusted stroke death rates among men and women aged 45 and over, by race

and Hispanic origin: average annual, 2010–2013 

Men Women

1

Significantly higher than the rates for other race and ethnicity groups. 2

Significantly higher than the rate for women of the same race and ethnicity. 3

Significantly lower than the rates for non-Hispanic white and black persons.

NOTE: Death rates for Hispanic and non-Hispanic Asian or Pacific Islander persons should be interpreted with caution 

because of inconsistencies in reporting

Hispanic origin or race on the death certificate compared with population figures.

SOURCE: CDC/NCHS, Compressed Mortality File, 1999–2013 (reference 9).

100.7 101.1

1,2

154.8

2,3

92.8 2,3

91.9 3

81.6 3

83.0

1

131.4

0

30

60

90

120

150

180

Non-Hispanic

white

Non-Hispanic

black

Non-Hispanic

Asian or

Pacific Islander

Hispanic
NCHS Data Brief ■ No. 207 ■ July 2015

■  2  ■

● The age-adjusted stroke death rate for non-Hispanic black men aged 45 and over (154.8 

deaths per 100,000 population) was 54% higher than the rate for non-Hispanic white men, 

67% higher than the rate for non-Hispanic Asian or Pacific Islander men, and 68% higher 

than the rate for Hispanic men of the same age (Figure 1). 

● The rate for non-Hispanic black women (131.4 per 100,000 population) was 30% higher 

than the rate for non-Hispanic white women, 58% higher than the rate for non-Hispanic 

Asian or Pacific Islander women, and 61% higher than the rate for Hispanic women of the 

same age.

● Non-Hispanic Asian or Pacific Islander and Hispanic men and women had the lowest

age-adjusted stroke death rates (men: 92.8 and 91.9 per 100,000 population; women: 83.0 

and 81.6). 

● Non-Hispanic white men and women aged 45 and over had similar age-adjusted stroke 

death rates (100.7 and 101.1 deaths per 100,000 population). Men in the other race-ethnicity 

groups had higher age-adjusted stroke death rates than women of the same race and 

ethnicity (12% to 18% higher). 

The age distribution of stroke deaths varied by race and Hispanic origin 

during 2010–2013.

● More than one-fourth of the stroke deaths among non-Hispanic black persons aged 45 and 

over (28.6%) occurred to those in the youngest age group (45–64) (Figure 2). By contrast, 

the portion of stroke deaths in this age group among the other race˗ethnicity groups ranged 

Percent

Figure 2. Stroke deaths, by age group and race and Hispanic origin: average annual, 2010–2013

65–74 45–64

NOTE: N is the number of stroke deaths for the race-ethnicity group. 

SOURCE: CDC/NCHS, Compressed Mortality File, 1999–2013 (reference 9).

85 and over 75–84

0

20

40

60

80

100

Hispanic

(N = 28,710)

Non-Hispanic Asian or

Pacific Islander

(N = 15,273)

Non-Hispanic black

(N = 60,373)

Non-Hispanic white

(N = 397,608)

47.4

24.9

34.7

30.5

29.6

26.1

29.5

30.0

13.0

10.0

20.4

28.6

17.2

18.6

17.2

22.4
NCHS Data Brief ■ No. 207 ■ July 2015

■  3  ■

from one-tenth among non-Hispanic white persons (10.0%) to less than one-fourth among 

Hispanic persons (22.4%). 

● The portion of stroke deaths in the oldest age group (85 and over) was largest among

non-Hispanic white persons (nearly one-half or 47.4%) and smallest among non-Hispanic 

black persons (one-fourth or 24.9%). 

● The percent distribution of stroke deaths by age was similar among non-Hispanic Asian or 

Pacific Islander and Hispanic persons. 

Stroke mortality among persons aged 45 and over decreased with 

increasing county median household income during 2010–2013.

● The age-adjusted stroke death rate for persons aged 45 and over decreased as county median 

household income increased (Figure 3). 

● The age-adjusted stroke death rate for persons residing in counties in the lowest median 

household income quartile was 32% higher than the rate for persons residing in counties in 

the highest quartile (126.9 compared with 96.1 deaths per 100,000 population). 

Deaths per 100,000 population

Figure 3. Age-adjusted stroke death rates among persons aged 45 and over, by county median household income

quartile: average annual, 2010–2013 

NOTES: Income categories are quartiles of county median household income. There is a significant linear trend across the categories (p < 0.05).

SOURCES: CDC/NCHS, Compressed Mortality File, 1999–2013 (reference 9) and 2012 U.S. Census Bureau Small Area Income and Poverty Estimates 

(reference 12).

County median household income (dollars)

0

30

60

90

120

150

180

At or above 50,084

96.1

43,019–50,083

107.3

37,142–43,018

117.1

At or below 37,141

126.9
NCHS Data Brief ■ No. 207 ■ July 2015

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During 2010–2013, stroke mortality among persons aged 45 and over 

increased as place of residence became more rural.

● Among persons aged 45 and over, age-adjusted stroke death rates were highest in 

nonmetropolitan counties (micropolitan and noncore: 120.5 and 121.0 deaths per 100,000 

population) and lowest in large central and large fringe metro counties (97.6 and 96.8) 

(Figure 4).

Deaths per 100,000 population

Figure 4. Age-adjusted stroke death rates among persons aged 45 and over, by urbanization level of county of residence: 

average annual, 2010–2013

1

Significantly lower than rates for medium metro, small metro, and nonmetropolitan counties.

2

Significantly higher than rates for metropolitan counties.

NOTE: Counties were classified into urbanization levels based on the 2013 NCHS Urban-Rural Classification Scheme for Counties.

SOURCE: CDC/NCHS, Compressed Mortality File, 1999–2013 (reference 9).

Metropolitan

Micropolitan Noncore

Nonmetropolitan

Large central

1

97.6

Large fringe

1

96.8

2

120.5 2

121.0

Medium

106.5

Small

111.9

0

30

60

90

120

150

180

Among persons aged 45 and over, stroke mortality inside and outside the 

Stroke Belt varied by race and Hispanic origin during 2010–2013. 

● Non-Hispanic black and non-Hispanic white persons aged 45 and over residing inside the 

Stroke Belt experienced excess stroke mortality compared with their counterparts residing 

outside the Stroke Belt (22% and 21% higher mortality) (Figure 5).

● The age-adjusted stroke death rate for non-Hispanic Asian or Pacific Islander persons 

residing inside the Stroke Belt did not differ from the rate for those residing outside the 

Stroke Belt (88.0 compared with 87.4 deaths per 100,000 population).

● In contrast to the other population groups, Hispanic persons residing inside the Stroke Belt 

had substantially lower stroke mortality than Hispanic persons residing outside the Stroke 

Belt (50.8 compared with 87.6 deaths per 100,000 population).
NCHS Data Brief ■ No. 207 ■ July 2015

■  5  ■

Deaths per 100,000 population

Figure 5. Age-adjusted stroke death rates among persons aged 45 and over, by residence inside or outside the Stroke 

Belt and race and Hispanic origin: average annual, 2010–2013

Non-Hispanic Asian Hispanic

or Pacific Islander

Non-Hispanic white Non-Hispanic black

Inside Stroke Belt Outside Stroke Belt

1

Significantly higher than the corresponding rate for persons residing outside the Stroke Belt.

2Significantly lower than the corresponding rate for Hispanic persons residing outside the Stroke Belt.

NOTES: The Stroke Belt includes eight states (Alabama, Arkansas, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, and Tennessee). Death rates 

for Hispanic and non-Hispanic Asian or Pacific Islander persons should be interpreted with caution because of inconsistencies in reporting Hispanic origin or race 

on the death certificate compared with population figures.

SOURCE: CDC/NCHS, Compressed Mortality File, 1999–2013 (reference 9).

0

20

40

60

80

100

120

140

160

180

1

119.9

1

162.8

2

50.8

99.1

133.8

88.0 87.4 87.6

Summary

An overarching goal of the Healthy People 2020 initiative is “to achieve health equity, eliminate 

disparities, and improve the health of all groups” in the United States (8). Despite significant 

declines in stroke mortality in recent decades, stroke continues to be one of the leading causes 

of death in the United States, and sociodemographic and geographic disparities persist (2–7). 

Consequently, there is an ongoing need to monitor the current magnitude and patterns of stroke 

mortality. This report describes current variations in stroke mortality by age, race and Hispanic 

origin, median household income, urbanization level of county of residence, and residence inside 

or outside the Stroke Belt.

During 2010–2013, stroke mortality among persons aged 45 and over varied by age and race and 

Hispanic origin. Non-Hispanic black persons had a markedly higher stroke death rate than any 

of the three other race-ethnicity groups, and a greater portion of their stroke deaths occurred at 

younger ages (45–64). Non-Hispanic Asian or Pacific Islander and Hispanic persons had lower 

rates than either non-Hispanic black or non-Hispanic white persons. For non-Hispanic white 

persons, a larger portion of stroke deaths occurred among those aged 85 and over, and a smaller 

portion occurred among those aged 45–64 compared with the other race-ethnicity groups. Except 

among non-Hispanic white persons, men had higher stroke death rates than women.

Disparities in stroke mortality also were observed by place of residence. Stroke mortality was 

higher for persons residing in counties with lower median household income than for persons 
NCHS Data Brief ■ No. 207 ■ July 2015

■  6  ■

residing in counties with higher median household income. Persons residing in nonmetropolitan 

counties (micropolitan and noncore) had the highest stroke mortality rates; those residing in the 

most urban counties (large central and large fringe metro) had the lowest rates. Excess stroke 

mortality was observed for non-Hispanic white and non-Hispanic black residents of the Stroke 

Belt but not for non-Hispanic Asian or Pacific Islander and Hispanic persons. Asian or Pacific 

Islander persons residing inside the Stroke Belt had a stroke death rate similar to those residing 

outside, while Hispanic persons residing inside the Stroke Belt had a much lower stroke death 

rate than those residing outside.

Definitions

Death rate, average annual: Computed by dividing the number of stroke deaths that occurred 

during 2010–2013 by the sum of the populations for 2010–2013. Age-adjusted rates were 

computed using the direct method and adjusted using the year 2000 U.S. standard population.

Metropolitan counties: Counties in metropolitan statistical areas (MSAs), as defined by the Office 

of Management and Budget (OMB). 

Large central metro: Counties in MSAs of 1 million or more population that contain the 

largest principal city of the MSA, are contained within the MSA’s largest principal city, or 

contain at least 250,000 residents of any principal city. 

Large fringe metro: Counties in MSAs of 1 million or more population that do not qualify 

as large central metro. They are considered to be “suburbs” of large cities.

Medium metro: Counties in MSAs of 250,000–999,999 population. 

Small metro: Counties in MSAs of less than 250,000 population. 

Nonmetropolitan counties: Counties not in MSAs. 

Micropolitan: Nonmetropolitan counties in OMB-defined micropolitan statistical areas. 

Noncore: Nonmetropolitan counties not in micropolitan statistical areas.

County median household income: Income of all members of a household aged 15 and over. The 

median divides the income distribution into two equal parts: one-half of the households falling 

below the median income and one-half above the median. 

Stroke Belt: A portion of the southeastern United States that has experienced excess stroke 

mortality. Definitions of the area have varied with the number of states included ranging from 

8 to 11, but 8 states are common to all definitions (5–7). In this report, the Stroke Belt includes 

Alabama, Arkansas, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, and 

Tennessee.

Data sources and methods

Mortality and population data are from the National Center for Health Statistics’ 1999–2013 

Compressed Mortality File (CMF) (9). CMF mortality data are from the National Vital Statistics 

System multiple cause-of-death files. Stroke deaths are those with International Statistical 
NCHS Data Brief ■ No. 207 ■ July 2015

■  7  ■

Classification of Diseases and Related Health Problems, 10th Revision underlying cause-of-death 

codes I60–I69 (10). Demographic information comes from death certificates. Population data for 

2010 are April 1 bridged-race census counts, and for 2011–2013 are July 1 bridged-race estimates 

from the Vintage 2013 postcensal series. These 4 years were combined to improve statistical 

reliability because of the smaller number of stroke deaths among the non-Hispanic Asian or 

Pacific Islander and Hispanic groups.

Age-adjusted death rates were calculated using the direct method and the projected 2000 standard 

population. Death rates for Hispanic and Asian or Pacific Islander persons should be interpreted 

with caution because of inconsistencies in reporting Hispanic origin or race on the death 

certificate (death rate numerators) compared with population figures (death rate denominators). 

The net effect of misclassification is an underestimation of death rates for Hispanic persons and 

for races other than white or black (11).

County median household income comes from 2012 state and county estimates from the U.S. 

Census Bureau’s Small Area Income and Poverty Estimates (12). Urbanization level is from the 

2013 NCHS Urban–Rural Classification Scheme for Counties (13).

The Bonferonni inequality was used to establish the critical value for statistically significant 

differences (overall level of significance of 0.05) based on the number of comparisons of interest 

for a given chart. Terms relating to differences, such as “higher than” or “lower than” indicate that 

the difference is statistically significant. Lack of comment regarding the difference does not mean 

that the difference was not significant.

About the authors

Deborah D. Ingram is with CDC’s National Center for Health Statistics, Office of Analysis 

and Epidemiology (OAE), and Jessica A. Montresor-Lopez is an OAE student intern from the 

University of Maryland School of Public Health.

References

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non-Hispanic population, and sex—United States, 2000–2013. MMWR 64(04):113. 2015.

4. Howard G. Ancel Keys lecture: Adventures (and misadventures) in understanding

(and reducing) disparities in stroke mortality. Stroke 44(11):3254–9. 2013.

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Dis 21(3):307–13. 2011.

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and geographic patterns in stroke mortality—United States. Ann Epidemiol 3(5):458–65. 1993. 
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7. Howard G, Labarthe DR, Hu J, Yoon S, Howard VJ. Regional differences 

in African Americans’ high risk for stroke: The remarkable burden of stroke 

for Southern African Americans. Ann Epidemiol 17(9):689–96. 2007. 

8. HHS. Healthy People 2020. Washington, DC. 

9. NCHS. Compressed Mortality File 1999–2013. CD-ROM Series 20 no 

2S as compiled from data provided by the 57 vital statistics jurisdictions 

through the Vital Statistics Cooperative Program. Hyattsville, MD. 2015. 

10. WHO. International statistical classification of diseases and related health 

problems, 10th revision (ICD–10). 2008 ed. Geneva, Switzerland. 2009.

11. Arias E, Schauman WS, Eschbach K, et al. The validity of race and 

Hispanic origin reporting on death certificates in the United States. National 

Center for Health Statistics. Vital Health Stat 2(148). 2008. 

12. U.S. Census Bureau. Small area income and poverty estimates: State and 

county estimates for 2012. Available from: http://www.census.gov/did/www/

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Suggested citation

Ingram DD, Montresor-Lopez JA. 

Differences in stroke mortality among adults 

aged 45 and over: United States, 2010–2013. 

NCHS data brief, no 207. Hyattsville, MD: 

National Center for Health Statistics. 2015. 

Copyright information

All material appearing in this report is in 

the public domain and may be reproduced 

or copied without permission; citation as to 

source, however, is appreciated.

National Center for Health 

Statistics

Charles J. Rothwell, M.S., M.B.A., Director

Nathaniel Schenker, Ph.D., Deputy Director

Jennifer H. Madans, Ph.D., Associate 

Director for Science

Office of Analysis and Epidemiology

Irma E. Arispe, Ph.D., Director

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