A triethnic comparison of intracerebral hemorrhage mortality in Texas

Intracerebral hemorrhage mortality in individuals with atrial fibrillation: a nationwide analysis of mortality trends in the United States

BACKGROUND

Atrial fibrillation (AF) is a risk factor for intracerebral hemorrhage (ICH), both with and without use of anticoagulation. Limited data exists on mortality trends and disparities related to this phenomenon. We aimed to assess ICH mortality trends and disparities based on demographic factors in individuals with atrial fibrillation in the United States (US).

METHODS

Our cross-sectional analysis utilized mortality data from the CDC database through death certificate queries from the years 1999 to 2020 in the US. We queried for all deaths with ICH as the underlying cause of death and atrial fibrillation as the multiple causes of death. Mortality data was obtained for overall population and demographic subpopulations based on sex, race and ethnicity, and geographic region. Trend analysis and average annual-mortality percentage change (AAPC) were completed using log-linear regression models.

RESULTS

ICH age-adjusted mortality rate (AAMR) in patients with AF increased from 0.27 (95% CI 0.25-0.29) in 1999 to 0.30 (95% CI 0.29-0.32) in 2020. A higher mortality rate was observed in males (AAMR 0.33) than in females (AAMR 0.26). The highest mortality was found in Asian/Pacific Islander (AAMR: 0.32) populations, followed by White (AAMR: 0.30), Black (AAMR: 0.15), and American Indian/Alaska Native (AAMR: 0.11) populations. Southern (AAPC: 1.3%) and non-metropolitan US regions (AAPC: + 1.9%) had the highest increase in annual mortality change.

CONCLUSION

Our findings highlight the disparities in ICH mortality in patients with AF. Further investigation is warranted to confirm these findings and evaluate for contributors to the observed disparities.

Racial-ethnic disparities in acute blood pressure after intracerebral hemorrhage

OBJECTIVE

To assess race-ethnic differences in acute blood pressure (BP) following intracerebral hemorrhage (ICH) and the contribution to disparities in ICH outcome.

METHODS

BPs in the field (emergency medical services [EMS]), emergency department (ED), and at 24 hours were compared and adjusted for group differences between non-Hispanic black (black), non-Hispanic white (white), and Hispanic participants in the Ethnic Racial Variations of Intracerebral Hemorrhage case-control study. Outcome was obtained by modified Rankin Scale (mRS) score at 3 months. We analyzed race-ethnic differences in good outcome (mRS ≤ 2) and mortality after adjusting for baseline differences and included BP recordings in this model.

RESULTS

Of 2,069 ICH cases enrolled, 30% were white, 37% black, and 33% Hispanic. Black and Hispanic patients had higher EMS and ED systolic and diastolic BPs compared with white patients (p = 0.0001). Although attenuated, at 24 hours after admission, black patients had higher systolic and diastolic BPs. After adjusting for baseline differences, significant race/ethnic differences persisted for EMS systolic, ED systolic and diastolic, and 24-hours diastolic BP. Only ED systolic and diastolic BP was associated with poor functional outcome, and no BP predicted mortality. We found no race-ethnic differences in 3-month functional outcome or mortality after adjusting for group differences, including acute BPs.

CONCLUSIONS

Although black and Hispanic patients had higher BPs than white patients at presentation, we did not find race-ethnic disparities in 3-month functional outcome or mortality. ED systolic and diastolic BP was associated with poor functional outcome, but not mortality, in this race-ethnically diverse population.

Functioning of long-term survivors of first-ever intracerebral hemorrhage

OBJECTIVES

There are few data on long-term functional outcome after intracerebral hemorrhage (ICH). We aimed to assess functional dependency and cognitive impairment in long-term survivors of first-ever intracerebral hemorrhage.

MATERIALS AND METHODS

Between August and November 2011, we contacted all survivors from a cohort of 134 consecutive patients hospitalized with a first-ever ICH in the period 2005-2009 in a well-defined catchment area. We did an extensive face-to-face follow-up including the National Institute of Health Stroke Scale (NIHSS), the modified Rankin Scale (mRS), the Barthel Index (BI), and the Montreal Cognitive Assessment (MoCA).

RESULTS

Fifty-one patients (38%) were alive. Fifty agreed to take part in the follow-up. The median follow-up time was 3.8 years. Thirty-four patients (68%) were independent (mRS 0-2) and 16 (32%) dependent (mRS 3-5). Factors independently associated with dependency were leukoaraiosis score (OR 2.3 per increasing point, P = 0.003) and female sex (OR 5.1, P = 0.038). Twenty-seven patients (61%) had cognitive impairment (MoCA ≤ 23). Factors independently associated with cognitive impairment were age (OR 2.4 per 10 years, P = 0.010) and lobar ICH location (OR 14.1, P = 0.016).

CONCLUSIONS

A large proportion of long-term survivors of ICH in Southern Norway live functionally independent lives in their private homes. Dependency is linked to leukoaraiosis and female sex. Cognitive impairment is common and linked to lobar location of ICH.

Intracerebral hemorrhage: new challenges and steps forward

Intracerebral hemorrhage (ICH) is a significant cause of morbidity and mortality. With the aging population, increased use of anticoagulants, and changing racial and ethnic landscape of the United States, the incidence of ICH will increase over the next decade. Improvements in preventative strategies to treat hypertension and atrial fibrillation are necessary to change the trajectory of this increase. Advances in the understanding of ICH at the vascular and molecular level may pave the way to new treatment options. This article discusses the epidemiology, pathophysiology, and current treatment options for patients with ICH. Differences in outcome and treatment between patients taking and not taking anticoagulant therapies are considered.

State of the art in managing nontraumatic intracerebral hemorrhage

Nontraumatic intracerebral hemorrhage constitutes a major public health problem worldwide. Intracerebral hemorrhage leads to a high rate of morbidity and mortality. To date, no medical or surgical trials have clearly attested to the benefit of a particular therapy. The aim of this review was to summarize the best evidence for management decision-making in intracerebral hemorrhage.

Intracerebral haemorrhage

Intracerebral haemorrhage is an important public health problem leading to high rates of death and disability in adults. Although the number of hospital admissions for intracerebral haemorrhage has increased worldwide in the past 10 years, mortality has not fallen. Results of clinical trials and observational studies suggest that coordinated primary and specialty care is associated with lower mortality than is typical community practice. Development of treatment goals for critical care, and new sequences of care and specialty practice can improve outcome after intracerebral haemorrhage. Specific treatment approaches include early diagnosis and haemostasis, aggressive management of blood pressure, open surgical and minimally invasive surgical techniques to remove clot, techniques to remove intraventricular blood, and management of intracranial pressure. These approaches improve clinical management of patients with intracerebral haemorrhage and promise to reduce mortality and increase functional survival.

Is there a sex or race difference in stroke mortality?

OBJECTIVES

We sought to confirm previous studies for the presence and direction of sex and race difference in stroke mortality.

METHODS

Administrative data for 40,450 Medicare beneficiaries who were hospitalized in 1994 to 1996 with acute stroke were used in regression analyses to study sex and race differences in 1-year all-cause mortality among patients with different types of stroke and cause-specific mortality in patients with all types of stroke combined. Hazard ratios were adjusted for age, sex or race, state, year of index stroke, past stroke, subsequent stroke, and fatal coexisting conditions excluding cerebrovascular diseases.

RESULTS

Men with ischemic cerebral infarction, nonspecific stroke, or all types of stroke combined were at 21% to 35% higher risk of all-cause mortality than women, but there was no sex difference among patients with subarachnoid or intracerebral hemorrhage. Nonwhite patients with ischemic cerebral infarction had 11% higher all-cause mortality than white patients, but there were no race differences after adjustments for fatal coexisting conditions. Compared with women, mortality was higher in men with all types of stroke regardless of the cause of death. There was higher risk of death caused by cerebrovascular diseases in white patients with all types of stroke combined, but the risk of death caused by cardiovascular diseases other than ischemic heart disease was higher in nonwhite patients.

CONCLUSIONS

There was no sex or race difference in all-cause mortality in patients with hemorrhagic stroke and higher risk in men with ischemic and nonspecific stroke. Relatively higher risk of mortality caused by cerebrovascular diseases was found in men and white patients.

Carotid stenosis in a multiethnic population

BACKGROUND

Carotid stenosis is an important, treatable cause of stroke. Several population-based studies have shown ethnic differences in the prevalence of carotid atherosclerosis. This study was performed at a large multiethnic hospital to clarify these differences.

METHODS

One thousand six carotid artery ultrasounds performed by the Department of Radiology at Los Angeles County General Hospital over a 4-year period were reviewed. Patients were classified as Caucasian (n=151), Hispanic (n=515), Black (n=173), or Asian (n=167) by self-declaration and birthplace. Carotid stenosis was defined as mild (1% to 39%), moderate (40% to 59%), severe (60% to 79%), critical (80% to 99%), or total (100%).

RESULTS

Twenty and one-half percent of Caucasian patients had greater than 59% stenosis compared with 10.1% of Hispanics, 8.7% of Blacks, and 10.7% of Asians (P<0.001). Nine and two-tenths percent of Caucasians had greater than 79% stenosis compared with 4.3% of Hispanics, 2.9% of Blacks, and 2.8% of Asians (P<0.001). There were no significant differences in age or gender representations between ethnic groups, and the indications for ordering carotid duplex sonography also did not vary by race. Caucasians and Blacks had a higher prevalence of cardiac disease, smoking, and heavy alcohol abuse. Hispanics had higher rates of diabetes.

CONCLUSIONS

These results indicate that significant differences in the degree of carotid stenosis exist among ethnic groups. Caucasian patients in our series showed a statistically higher likelihood of having a severe or critical level of stenosis. These findings may have implications for the allocation of health care resources as ethnic minorities compose a greater proportion of the population.

Risk factors for intracerebral hemorrhage in a pooled prospective study

BACKGROUND AND PURPOSE

Few prospective studies have reported risk factors for intracerebral hemorrhage (ICH), and results are inconsistent. We studied risk factors for ICH in a pooled cohort of the Atherosclerosis Risk in Communities Study (ARIC) and the Cardiovascular Health Study (CHS).

METHODS

The ARIC cohort was recruited in 1987 to 1989 and involves 15 792 men and women, aged 45 to 64 years at baseline, sampled from 4 US communities. The CHS cohort was recruited in 1989 to 1993 and involves 5888 men and women, aged 65 or over at baseline, sampled from 4 US communities. Baseline measurements included many potential vascular risk factors. The cohorts were followed for incident stroke events.

RESULTS

Over 263 489 person-years of follow-up, 135 incident ICH events occurred. In a multivariable model, age, African-American ethnicity (versus Whites), and hypertension were positively associated with incident ICH, whereas low-density lipoprotein cholesterol and triglycerides were inversely related to incident ICH. Participants with systolic blood pressure >or=160 mm Hg or diastolic blood pressure >/=110 mm Hg had 5.55 (95% CI 3.07 to 10.0) times the rate of ICH as nonhypertensives. Sex, smoking, alcohol intake, body mass index, waist-to-hip ratio, waist circumference, and diabetes were not related to ICH.

CONCLUSIONS

In this pooled cohort the risk factors for ICH were older age, African-American ethnicity, hypertension, lower LDL-C, and lower triglycerides.

The incidence of deep and lobar intracerebral hemorrhage in whites, blacks, and Hispanics

BACKGROUND

Black and Hispanic Americans have a greater risk of primary intracerebral hemorrhage (ICH) than whites. Deep ICH is most often associated with hypertension, while lobar ICH is associated with cerebral amyloid angiopathy. The authors conducted a population-based incidence study to directly compare the incidence of deep vs lobar ICH in all three race-ethnic groups.

METHODS

The authors used an active hospital and community surveillance program and autopsy reports to identify incident ICH cases among white, black, and Caribbean Hispanic adults in Northern Manhattan between July 1993 and June 1997. Incidence rates were adjusted for age and sex to the 1990 US Census. CIs for risk ratios (RR) were calculated with Byar's chi2 approximation of the Poisson distribution.

RESULTS

The authors identified 155 cases of ICH for an annual incidence of 30.9/100,000 (26.7 to 35.0). Men had a higher risk of ICH than women (RR 1.5, 95% CI 1.2 to 1.8), driven entirely by the incidence of deep ICH (RR 1.8) rather than lobar ICH (RR 1.0). Compared with whites, RR for blacks was all ICH 3.8 (2.2 to 8.9), deep 4.8 (2.3 to 21.1), lobar 2.8 (1.2 to 14.4); RR for Hispanics was all 2.6 (1.4 to 6.1), deep 3.7 (1.7 to 16.5), lobar 1.4 (0.4 to 7.4).

CONCLUSIONS

ICH is a heterogeneous disease with deep and lobar subtypes distinguishable on an epidemiologic basis. The different patterns of these two subtypes in our race-ethnically diverse population lend credence to the notion that ICH should no longer be treated as a single entity.

Priorities for clinical research in intracerebral hemorrhage: report from a National Institute of Neurological Disorders and Stroke workshop

BACKGROUND AND PURPOSE

Spontaneous intracerebral hemorrhage (ICH) is one of the most lethal stroke types. In December 2003, a National Institute of Neurological Disorders and Stroke (NINDS) workshop was convened to develop a consensus for ICH research priorities. The focus was clinical research aimed at acute ICH in patients.

METHODS

Workshop participants were divided into 6 groups: (1) current state of ICH research; (2) basic science; and (3) imaging, (4) medical, (5) surgical, and (6) clinical methodology. Each group formulated research priorities before the workshop. At the workshop, these were discussed and refined.

RESULTS

Recent progress in management of hemorrhage growth, intraventricular hemorrhage, and limitations in the benefit of open craniotomy were noted. The workshop identified the importance of developing animal models to reflect human ICH, as well as the phenomena of rebleeding. More human ICH pathology is needed. Real-time, high-field magnets and 3-dimensional imaging, as well as high-resolution tissue probes, are ICH imaging priorities. Trials of acute blood pressure-lowering in ICH and coagulopathy reversal are medical priorities. The exact role of edema in human ICH pathology and its treatment requires intensive study. Trials of minimally invasive surgical techniques including mechanical and chemical surgical adjuncts are critically important. The methodologic challenges include establishing research networks and a multi-specialty approach. Waiver of consent issues and standardizing care in trials are important issues. Encouragement of young investigators from varied backgrounds to enter the ICH research field is critical.

CONCLUSIONS

Increasing ICH research is crucial. A collaborative approach is likely to yield therapies for this devastating form of brain injury.

Stroke awareness among rural residents: the case of West Virginia

Stroke is the leading cause of disability and the third leading cause of death in the United States. There are modifiable and non-modifiable stroke risks and proper management of some of these risks could significantly reduce the risk of stroke incidence. However, proper management of stroke risks requires public awareness of these risks and awareness of appropriate approaches to managing them. In case of stroke incidence, it is also important for patients to be able to recognize stroke symptoms and get immediate emergency medical attention. In this article, stroke awareness is studied as awareness of stroke warning signs, proper management of stroke risks, and awareness of what to do in case of stroke. The article analyzes mail questionnaire responses from 1,114 West Virginia residents. Respondents were mostly not properly managing stroke risks such as diabetes and hypertension. There was also a lack of awareness of severe stroke symptoms such as loss of vision in one eye and sudden severe headache. While 83% of respondents reported that they would call 911 if they thought they were having a stroke, only 20% of respondents could correctly identify all stroke warning signs. The study has some limitations, but remains an important study of stroke awareness among rural residents in Appalachia.

Diabetes mellitus as a risk factor for stroke incidence and mortality in Mexican American older adults

BACKGROUND

Little is known regarding diabetes mellitus as a risk factor for stroke incidence and death in older Mexican Americans. The authors studied diabetes and other potential risk factors for stroke in a sample of community-dwelling older Mexican Americans.

METHODS

A prospective cohort design was used that involved the Hispanic Established Population for the Epidemiologic Study of the Elderly, a longitudinal study using a weighted probability sample of Mexican Americans (aged older than 65 years) living in the southwestern United States. 3050 older Mexican American persons were originally interviewed and tested at baseline and then followed with reassessment at 2, 5, and 7 years. The incidence of stroke and stroke death were studied for the participants during a 7-year follow-up period.

RESULTS

690 participants were identified at baseline with diabetes. 238 participants experienced a first-time stroke during the follow-up period. 66 died as a result of a stroke. Cox proportional hazard regression analysis revealed an increased hazard ratio (HR) for stroke in persons with diabetes (HR, 1.80; 95% confidence interval [CI], 1.32 to 2.44; p <.0002) when adjusted for age, sex, body mass index, smoking, systolic blood pressure, previous heart attack, and lower extremity function. The stroke mortality rate was also higher (HR, 2.02; 95% CI, 1.04 to 3.93) for persons with diabetes when adjusted for covariates.

CONCLUSION

Diabetes was associated with an increased incidence of stroke and death in older Mexican Americans, particularly those taking insulin.

Access to Care, Acculturation, and Risk Factors for Stroke in Mexican Americans

Background and Purpose— Mexican Americans are the largest subgroup of Hispanic Americans, now the most numerous US minority population. We compared access to care, acculturation, and biological risk factors among Mexican American and non-Hispanic white stroke patients and the general population.

Methods— The Brain Attack Surveillance in Corpus Christi project is a population-based stroke surveillance study conducted in southeast Texas. All stroke cases were ascertained through active and passive surveillance from January 2000 through April 2002 and compared with population estimates from a random-digit telephone survey.

Results— Compared with non-Hispanic white stroke patients (n=405), Mexican American stroke patients (n=403) were less likely to have graduated from high school (odds ratio [OR], 15.4; 95% confidence interval [CI], 10.6 to 22.4) and more likely to earn less than $20 000 per year (OR, 6.5; 95% CI, 4.5 to 9.4). Mexican American stroke patients were more likely to have diabetes (OR, 2.7; 95% CI, 2.0 to 3.7) and less likely to have atrial fibrillation (OR, 0.5; 95% CI, 0.4 to 0.8). Compared with population estimates (n=719), stroke was associated with diabetes (Mexican Americans: OR, 3.6; 95% CI, 2.2 to 5.8; non-Hispanic whites: OR, 3.0; 95% CI, 1.7 to 5.5), hypertension (Mexican Americans: OR, 2.8; 95% CI, 1.8 to 4.3; non-Hispanic whites: OR, 3.3; 95% CI, 2.2 to 5.0), lower incomes (Mexican Americans: OR, 3.4; 95% CI, 2.1 to 5.4; non-Hispanic whites: OR, 3.0; 95% CI, 1.7 to 5.2), and lower educational attainment (Mexican Americans: OR, 5.1; 95% CI, 3.2 to 8.1; non-Hispanic whites: OR, 4.5; 95% CI, 2.2 to 9.3).

Conclusions— Biological and social variables are associated with stroke to a similar extent in both Mexican Americans and non-Hispanic whites. Health behavior interventions for both populations may follow from this work. Stroke disparities between these populations may be explained only partially by differences in the prevalence of currently identified biological and social factors.

Current intracerebral haemorrhage management

Primary intracerebral haemorrhage (ICH) refers to spontaneous bleeding from intraparenchymal vessels. It accounts for 10-20% of all strokes, with higher incidence rates amongst African and Asian populations. The major risk factors are hypertension and age. In addition to focal neurological findings, patients may present with symptoms of elevated intracranial pressure. The diagnosis of ICH can only be made through neuro-imaging. A CT scan is presently standard, although MRI is increasingly important in the evaluation of acute cerebrovascular disease. A significant proportion of intracerebral haematomas expand in the first hours post-ictus and this is often associated with clinical worsening. There is evidence that the peri-haematomal region is compromised in ICH. This tissue is oedematous, although the precise pathogenesis is controversial. An association between elevated arterial pressure and haematoma expansion has been reported. Although current guidelines recommend conservative management of arterial pressure in ICH, an acute blood pressure lowering trial is overdue. ICH is associated with a high early mortality rate, although a significant number of survivors make a functional recovery. Current medical management is primarily aimed at prevention of complications including pneumonia and peripheral venous thromboembolism. Elevated intracranial pressure may be treated medically or surgically. Although the latter definitively lowers elevated intracranial pressure, the optimal patient selection criteria are not clear. Aggressive treatment of hypertension is essential in the primary and secondary prevention of ICH.

Sex differences in US mortality rates for stroke and stroke subtypes by race/ethnicity and age, 1995-1998

BACKGROUND AND PURPOSE

Ischemic stroke accounts for 70% to 80% of all strokes, but intracerebral and subarachnoid hemorrhagic strokes have greater fatality. Age-standardized death rates from overall stroke are higher among men than women, but little is known about sex differences in stroke subtype mortality by race/ethnicity.

METHODS

We analyzed 1995 to 1998 national death certificate data to compare sex-specific age-standardized death rates (per 100 000) for ischemic stroke (n=507 256), intracerebral hemorrhagic stroke (n=98 709), and subarachnoid hemorrhagic stroke (n=27 334) among whites, blacks, American Indians/Alaska Natives, Asians/Pacific Islanders, and Hispanics. We calculated rate ratios and 95% CIs comparing women with men within age and racial/ethnic groups.

RESULTS

Age-specific rates of ischemic and intracerebral hemorrhagic stroke deaths were lower for women than for men aged 25 to 44 and 45 to 64 years but were higher for ischemic stroke among older women, aged > or =65 years. Only among whites did women have higher age-standardized rates of ischemic stroke. Age-standardized death rates for intracerebral hemorrhagic stroke among women were lower than or similar to those among men in all racial/ethnic groups. Women had higher risk of death from subarachnoid hemorrhagic; this sex differential increased with age.

CONCLUSIONS

The female-to-male mortality ratio differs for stroke subtypes by race/ethnicity and age. A primary public health effort should focus on increasing the awareness of stroke symptoms, particularly among people at high risk, to decrease delay in early detection and effective stroke treatment.

Barriers to acute stroke therapy and stroke prevention in Mexican Americans

BACKGROUND AND PURPOSE

The purpose of this study was to identify specific targets to improve acute stroke treatment and stroke prevention in the Mexican American (MA) community.

METHODS

A professional, academic survey research team provided structured questions and elicited responses from 719 subjects identified by random-digit dialing in the biethnic community of Corpus Christi, TEXAS: This community of approximately 300 000 is approximately half MA and half non-Hispanic white (NHW). The cooperation rate for the survey was 58%.

RESULTS

MAs (n=357) were younger, less well educated, and had lower family income than NHWs (n=362, P=0.001). MAs had a higher prevalence of diabetes mellitus (P=0.001) but similar rates of hypertension, elevated cholesterol, and current tobacco use. MAs less commonly recognized that acute stroke therapy existed (P=0.029), were less likely to acknowledge a time window for acute stroke treatment (P=0.001), and were more reticent to say they would call 911 for stroke symptoms (P=0.01) than NHWS: MAs were significantly less able to recall stroke symptoms and risk factors than NHWS: Only approximately 20% of both groups identified stroke as the NO: 1 cause of disability. MAs expressed less confidence in their ability to prevent stroke (P<0.001), more distrust in the medical establishment (P=0.007), and more concern that money impedes their seeking medical care (P<0.001).

CONCLUSIONS

There are significant barriers to both acute stroke treatment and stroke prevention in MAS: This study identifies specific targets amenable for testing in an intervention project following confirmation by a methodology other than telephone survey.

Stroke in Hispanic Americans

The Hispanic American population is the fastest growing minority group with increasing representation among the older age strata. Current ethnic-specific cerebrovascular disease data regarding stroke outcomes and risk factor status reveal significant differences compared with other race/ethnic groups. The authors discuss the literature on stroke incidence and mortality among Hispanic populations. Traditional risk factors, access to care and stroke mechanism differences are also discussed. Advances in Hispanic American specific stroke prevention and treatment efforts demand further investigation to better define Hispanic American stroke prevention and acute treatment strategies.

Racial variation in initial stroke severity

BACKGROUND AND PURPOSE

Blacks experience greater morbidity and mortality from stroke than do whites. The degree to which this is due to the severity of the initial stroke is not known. The objective of this study is to determine whether there is a racial difference in initial stroke severity.

METHODS

A secondary analysis of a prospective cohort of 984 veterans (29.7% black) admitted to any of 9 geographically diverse Veterans Administration Hospitals for acute stroke between April 1995 and March 1997 was performed. Initial stroke severity was ascertained by using the modified Canadian Neurological Scale (CNS) applied retrospectively to medical record data. Stroke severity, unadjusted and adjusted for covariates, was compared between black and white patients.

RESULTS

Blacks had greater initial stroke severity than did whites (mean CNS score 7.96 versus 8.32, respectively; P=0.039), with a 0.5-point difference on the scale corresponding to a single-level decrement in either speech or strength of half of an extremity. This difference persisted with adjustment for other important predictors of stroke severity (P=0. 035). However, there was no significant racial difference in severity when CNS scores were collapsed into a priori clinically relevant categories.

CONCLUSIONS

Compared with whites, blacks show greater severity of stroke at hospital admission. It remains uncertain whether the relatively small but significant difference at presentation fully explains the striking racial differences in morbidity and mortality from stroke.

Race/ethnicity and location of stroke mortality: implications for population-based studies

BACKGROUND AND PURPOSE

Stroke community surveillance projects often focus on hospital data rates. We hypothesized that not including strokes which occurred in nursing homes or at home would differentially affect race/ethnic stroke rates.

METHODS

Texas vital statistics data were studied to compare age-specific (45 to 59, 60 to 74, and >/=75 years) location of stroke death for African Americans (AAs), Hispanic Americans (HAs), and non-Hispanic whites (NHWs). Rate ratios are reported with 95% CIs; NHW is used as the referent group.

RESULTS

During 1991 to 1996, there were 52 996 stroke deaths in Texas for individuals aged 45 years and older. HAs in the oldest age group (>/=75 years) were 33% more likely than NHWs to die in the hospital, and HAs aged 45 to 59 and 60 to 74 years were 4% and 10%, respectively, more likely to die in the hospital. AAs aged >/=75 years were 19% more likely to die in the hospital. HAs aged 60 to 74 years were 35% less likely to die in a nursing home, whereas HAs aged >/=75 years were 43% less likely than NHWs to die in a nursing home. AAs aged >/=75 were 33% less likely to die in a nursing home. Death at home was 19% more likely in HAs aged 60 to 74 years. Significant gender differences are also reported.

CONCLUSIONS

Using hospital data alone would overestimate stroke mortality in the HA and AA groups. Stroke community surveillance projects should account for ethnic and gender differences in location of death to avoid bias in race/ethnic and gender comparisons.

Stroke mortality in blacks. Disturbing trends

BACKGROUND

Despite long-term declines in US stroke mortality rates, declines have slowed in the past decade and targets for blacks for the years 2000 and 2010 seem attainable only by extraordinary measures, if at all. This review focuses attention on key aspects of this problem. Data from the US National Center for Health Statistics and reports of population-based studies of stroke mortality published since 1987 retrieved by computerized literature searches were reviewed.

SUMMARY OF REVIEW

The third leading cause of death in black women and the sixth in black men in the United States in 1996, stroke accounted for 10 509 deaths in women and 7972 in men among blacks: 7.92% and 5.33%, respectively, of the total deaths. Age-adjusted death rates per 100 000 were black women, 39.2; white women, 22.9; black men, 50.9; and white men, 26.3. Available data indicate that compared with US whites, US blacks have greater mortality rates for every stroke subtype, with the likely exception of cerebral infarction due to extracranial carotid artery occlusion. These differences will persist into the 21st century. The number of stroke deaths in blacks increased by >8% between 1992 and 1996.

CONCLUSIONS

Increased research on stroke in blacks is needed to develop more effective strategies for primary and secondary prevention of stroke to reduce the high burden of premature mortality and morbidity. Renewed efforts to prevent and control stroke risk factors (in particular elevated blood pressure, diabetes, and smoking) are needed among US blacks.