Global, regional, and national burden of stroke and its risk factors, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019
Authors: Valery L Feigin, Benjamin A Stark, Catherine Owens Johnson, Gregory A Roth, Catherine Bisignano, Gdiom Gebreheat Abady, Mitra Abbasifard, Mohsen Abbasi-Kangevari, Foad Abd-Allah, Vida Abedi, Ahmed Abualhasan, Niveen ME Abu-Rmeileh, Abdelrahman I Abushouk, Oladimeji M Adebayo, Gina Agarwal, Pradyumna Agasthi, Bright Opoku Ahinkorah, Sohail Ahmad, Sepideh Ahmadi, Yusra Ahmed Salih, Budi Aji, Samaneh Akbarpour, Rufus Olusola Akinyemi, Hanadi Al Hamad, Fares Alahdab, Sheikh Mohammad Alif, Vahid Alipour, Syed Mohamed Aljunid, Sami Almustanyir, Rajaa M Al-Raddadi, Rustam Al-Shahi Salman, Nelson Alvis-Guzman, Robert Ancuceanu, Deanna Anderlini, Jason A Anderson, Adnan Ansar, Ippazio Cosimo Antonazzo, Jalal Arabloo, Johan Ärnlöv, Kurnia Dwi Artanti, Zahra Aryan, Samaneh Asgari, Tahira Ashraf, Mohammad Athar, Alok Atreya, Marcel Ausloos, Atif Amin Baig, Ovidiu Constantin Baltatu, Maciej Banach, Miguel A Barboza, Suzanne Lyn Barker-Collo, Till Winfried Bärnighausen, Mark Thomaz Ugliara Barone, Sanjay Basu, Gholamreza Bazmandegan, Ettore Beghi, Mahya Beheshti, Yannick Béjot, Arielle Wilder Bell, Derrick A Bennett, Isabela M Bensenor, Woldesellassie Mequanint Bezabhe, Yihienew Mequanint Bezabih, Akshaya Srikanth Bhagavathula, Pankaj Bhardwaj, Krittika Bhattacharyya, Ali Bijani, Boris Bikbov, Mulugeta M Birhanu, Archith Boloor, Aime Bonny, Michael Brauer, Hermann Brenner, Dana Bryazka, Zahid A Butt, Florentino Luciano Caetano dos Santos, Ismael R Campos-Nonato, Carlos Cantu-Brito, Juan J Carrero, Carlos A Castañeda-Orjuela, Alberico L Catapano, Promit Ananyo Chakraborty, Jaykaran Charan, Sonali Gajanan Choudhari, Enayet Karim Chowdhury, Dinh-Toi Chu, Sheng-Chia Chung, David Colozza, Vera Marisa Costa, Simona Costanzo, Michael H Criqui, Omid Dadras, Baye Dagnew, Xiaochen Dai, Koustuv Dalal, Albertino Antonio Moura Damasceno, Emanuele D'Amico, Lalit Dandona, Rakhi Dandona, Jiregna Darega Gela, Kairat Davletov, Vanessa De la Cruz-Góngora, Rupak Desai, Deepak Dhamnetiya, Samath Dhamminda Dharmaratne, Mandira Lamichhane Dhimal, Meghnath Dhimal, Daniel Diaz, Martin Dichgans, Klara Dokova, Rajkumar Doshi, Abdel Douiri, Bruce B Duncan, Sahar Eftekharzadeh, Michael Ekholuenetale, Nevine El Nahas, Islam Y Elgendy, Muhammed Elhadi, Shaimaa I El-Jaafary, Matthias Endres, Aman Yesuf Endries, Daniel Asfaw Erku, Emerito Jose A Faraon, Umar Farooque, Farshad Farzadfar, Abdullah Hamid Feroze, Irina Filip, Florian Fischer, David Flood, Mohamed M Gad, Shilpa Gaidhane, Reza Ghanei Gheshlagh, Ahmad Ghashghaee, Nermin Ghith, Ghozali Ghozali, Sherief Ghozy, Alessandro Gialluisi, Simona Giampaoli, Syed Amir Gilani, Paramjit Singh Gill, Elena V Gnedovskaya, Mahaveer Golechha, Alessandra C Goulart, Yuming Guo, Rajeev Gupta, Veer Bala Gupta, Vivek Kumar Gupta, Pradip Gyanwali, Nima Hafezi-Nejad, Samer Hamidi, Asif Hanif, Graeme J Hankey, Arief Hargono, Abdiwahab Hashi, Treska S Hassan, Hamid Yimam Hassen, Rasmus J Havmoeller, Simon I Hay, Khezar Hayat, Mohamed I Hegazy, Claudiu Herteliu, Ramesh Holla, Sorin Hostiuc, Mowafa Househ, Junjie Huang, Ayesha Humayun, Bing-Fang Hwang, Licia Iacoviello, Ivo Iavicoli, Segun Emmanuel Ibitoye, Olayinka Stephen Ilesanmi, Irena M Ilic, Milena D Ilic, Usman Iqbal, Seyed Sina Naghibi Irvani, Sheikh Mohammed Shariful Islam, Nahlah Elkudssiah Ismail, Hiroyasu Iso, Gaetano Isola, Masao Iwagami, Louis Jacob, Vardhmaan Jain, Sung-In Jang, Sathish Kumar Jayapal, Shubha Jayaram, Ranil Jayawardena, Panniyammakal Jeemon, Ravi Prakash Jha, Walter D Johnson, Jost B Jonas, Nitin Joseph, Jacek Jerzy Jozwiak, Mikk Jürisson, Rizwan Kalani, Rohollah Kalhor, Yogeshwar Kalkonde, Ashwin Kamath, Zahra Kamiab, Tanuj Kanchan, Himal Kandel, André Karch, Patrick DMC Katoto, Gbenga A Kayode, Pedram Keshavarz, Yousef Saleh Khader, Ejaz Ahmad Khan, Imteyaz A Khan, Maseer Khan, Moien AB Khan, Mahalaqua Nazli Khatib, Jagdish Khubchandani, Gyu Ri Kim, Min Seo Kim, Yun Jin Kim, Adnan Kisa, Sezer Kisa, Mika Kivimäki, Dhaval Kolte, Ali Koolivand, Sindhura Lakshmi Koulmane Laxminarayana, Ai Koyanagi, Kewal Krishan, Vijay Krishnamoorthy, Rita V Krishnamurthi, G Anil Kumar, Dian Kusuma, Carlo La Vecchia, Ben Lacey, Hassan Mehmood Lak, Tea Lallukka, Savita Lasrado, Pablo M Lavados, Matilde Leonardi, Bingyu Li, Shanshan Li, Hualiang Lin, Ro-Ting Lin, Xuefeng Liu, Warren David Lo, Stefan Lorkowski, Giancarlo Lucchetti, Ricardo Lutzky Saute, Hassan Magdy Abd El Razek, Francesca Giulia Magnani, Preetam Bhalchandra Mahajan, Azeem Majeed, Alaa Makki, Reza Malekzadeh, Ahmad Azam Malik, Navid Manafi, Mohammad Ali Mansournia, Lorenzo Giovanni Mantovani, Santi Martini, Giampiero Mazzaglia, Man Mohan Mehndiratta, Ritesh G Menezes, Atte Meretoja, Amanual Getnet Mersha, Junmei Miao Jonasson, Bartosz Miazgowski, Tomasz Miazgowski, Irmina Maria Michalek, Erkin M Mirrakhimov, Yousef Mohammad, Abdollah Mohammadian-Hafshejani, Shafiu Mohammed, Ali H Mokdad, Yaser Mokhayeri, Mariam Molokhia, Mohammad Ali Moni, Ahmed Al Montasir, Rahmatollah Moradzadeh, Lidia Morawska, Jakub Morze, Walter Muruet, Kamarul Imran Musa, Ahamarshan Jayaraman Nagarajan, Mohsen Naghavi, Sreenivas Narasimha Swamy, Bruno Ramos Nascimento, Ruxandra Irina Negoi, Sandhya Neupane Kandel, Trang Huyen Nguyen, Bo Norrving, Jean Jacques Noubiap, Vincent Ebuka Nwatah, Bogdan Oancea, Oluwakemi Ololade Odukoya, Andrew T Olagunju, Hans Orru, Mayowa O Owolabi, Jagadish Rao Padubidri, Adrian Pana, Tarang Parekh, Eun-Cheol Park, Fatemeh Pashazadeh Kan, Mona Pathak, Mario F P Peres, Arokiasamy Perianayagam, Truong-Minh Pham, Michael A Piradov, Vivek Podder, Suzanne Polinder, Maarten J Postma, Akram Pourshams, Amir Radfar, Alireza Rafiei, Alberto Raggi, Fakher Rahim, Vafa Rahimi-Movaghar, Mosiur Rahman, Muhammad Aziz Rahman, Amir Masoud Rahmani, Nazanin Rajai, Priyanga Ranasinghe, Chythra R Rao, Sowmya J Rao, Priya Rathi, David Laith Rawaf, Salman Rawaf, Marissa B Reitsma, Vishnu Renjith, Andre M N Renzaho, Aziz Rezapour, Jefferson Antonio Buendia Rodriguez, Leonardo Roever, Michele Romoli, Andrzej Rynkiewicz, Simona Sacco, Masoumeh Sadeghi, Sahar Saeedi Moghaddam, Amirhossein Sahebkar, KM Saif-Ur-Rahman, Rehab Salah, Mehrnoosh Samaei, Abdallah M Samy, Itamar S Santos, Milena M Santric-Milicevic, Nizal Sarrafzadegan, Brijesh Sathian, Davide Sattin, Silvia Schiavolin, Markus P Schlaich, Maria Inês Schmidt, Aletta Elisabeth Schutte, Sadaf G Sepanlou, Allen Seylani, Feng Sha, Saeed Shahabi, Masood Ali Shaikh, Mohammed Shannawaz, Md Shajedur Rahman Shawon, Aziz Sheikh, Sara Sheikhbahaei, Kenji Shibuya, Soraya Siabani, Diego Augusto Santos Silva, Jasvinder A Singh, Jitendra Kumar Singh, Valentin Yurievich Skryabin, Anna Aleksandrovna Skryabina, Badr Hasan Sobaih, Stefan Stortecky, Saverio Stranges, Eyayou Girma Tadesse, Ingan Ukur Tarigan, Mohamad-Hani Temsah, Yvonne Teuschl, Amanda G Thrift, Marcello Tonelli, Marcos Roberto Tovani-Palone, Bach Xuan Tran, Manjari Tripathi, Gebiyaw Wudie Tsegaye, Anayat Ullah, Brigid Unim, Bhaskaran Unnikrishnan, Alireza Vakilian, Sahel Valadan Tahbaz, Tommi Juhani Vasankari, Narayanaswamy Venketasubramanian, Dominique Vervoort, Bay Vo, Victor Volovici, Kia Vosoughi, Giang Thu Vu, Linh Gia Vu, Hatem A Wafa, Yasir Waheed, Yanzhong Wang, Tissa Wijeratne, Andrea Sylvia Winkler, Charles D A Wolfe, Mark Woodward, Jason H Wu, Sarah Wulf Hanson, Xiaoyue Xu, Lalit Yadav, Ali Yadollahpour, Seyed Hossein Yahyazadeh Jabbari, Kazumasa Yamagishi, Hiroshi Yatsuya, Naohiro Yonemoto, Chuanhua Yu, Ismaeel Yunusa, Muhammed Shahriar Zaman, Sojib Bin Zaman, Maryam Zamanian, Ramin Zand, Alireza Zandifar, Mikhail Sergeevich Zastrozhin, Anasthasia Zastrozhina, Yunquan Zhang, Zhi-Jiang Zhang, Chenwen Zhong, Yves Miel H Zuniga, Christopher J L Murray
Journal: The Lancet Neurology (2021)

<h2>Summary</h2><h3>Background</h3> 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. <h3>Methods</h3> 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. <h3>Findings</h3> 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]). <h3>Interpretation</h3> 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. <h3>Funding</h3> Bill & Melinda Gates Foundation.