Stroke Incidence and Mortality Trends in US Communities, 1987 to 2011
Stroke Incidence and Mortality Trends in US Communities, 1987 to 2011
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DOI：
10.1001/jama.2014.7692
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发表时间：
2014-07-16
影响因子：
120.7
通讯作者：
Coresh, Josef
中科院分区：
文献类型：
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作者：
Koton, Silvia;Schneider, Andrea L. C.;Coresh, Josef
先前的研究表明，随着时间的推移，中风死亡率会下降，但有关种族间卒中发病率和长期趋势的数据有限。目的研究1987年至2011年社区动脉粥样硬化风险（ARIC）队列中黑人和白人成人脑卒中发病率和随后死亡率的趋势。设计、环境和参与者在美国4个不同的社区进行了一项前瞻性队列研究，在基线时无卒中的14357名参与者（282897人年）。招募参与者的目的是研究1987-1989年间所有中风住院和死亡情况，并收集心血管危险因素的基线信息（通过访谈和体检）。对参与者进行随访（通过检查、年度电话访谈、对当地医院出院情况的积极监测以及与国家死亡指数的联系），直至2011年12月31日。该研究的内科评论家判定所有可能的中风，并将其分类为明确或可能的缺血性或出血性事件。使用泊松回归发病率比（IRRs）估计每10年日历时间内首次卒中发生率的趋势，并使用Cox比例风险回归模型和总体以及按种族、性别和65岁年龄划分的风险比（hr）分析随后的死亡率。结果在1051例（7%）卒中患者中，929例发生缺血性卒中，140例发生出血性卒中（18例在研究期间同时发生缺血性卒中和出血性卒中）。总卒中的粗发病率为3.73 (95% CI, 3.51-3.96) / 1000人年，缺血性卒中为3.29 (95% CI, 3.08-3.50) / 1000人年，出血性卒中为0.49 (95% CI, 0.41-0.57) / 1000人年。随着时间的推移，白人和黑人参与者的卒中发病率下降（每10年的年龄调整后的irs， 0.76 [95% CI, 0.66-0.87]；总体绝对下降0.93 / 1000人年）。年龄调整后的发病率在65岁及以上的参与者中下降明显（年龄调整后的IRR每10年为0.69 [95% CI, 0.59-0.81]；绝对下降1.35 / 1000人年），但在65岁以下的参与者中不明显（年龄调整后的IRR每10年为0.97 [95% CI, 0.76-1.25]；绝对下降0.09 / 1000人年）（相互作用的P = 0.02）。发病率的下降在性别上是相似的。在突发中风的参与者中，到2011年有614人（58%）死亡。出血性卒中的死亡率（68%）高于缺血性卒中的死亡率（57%）。总体而言，中风后死亡率随着时间的推移而下降（风险比[HR]， 0.80 [95% CI, 0.66-0.98]； 10年后每100次中风的绝对死亡率下降8.09[每10年]）。死亡率的下降主要是由于65岁以下患者死亡率的下降（相对危险度为0.65 [95% CI, 0.46-0.93]； 10年后每100次中风死亡率绝对下降14.19（每10年）），但不同种族和性别的死亡率相似。结论及相关性在美国社区黑人和白人成人的多中心队列研究中，1987年至2011年卒中发病率和死亡率下降。不同年龄组的下降幅度不同，但不同性别和种族的下降幅度相似，表明中风发病率和预后的改善一直持续到2011年。版权所有2014美国医学协会。版权所有。
IMPORTANCE Prior studies have shown decreases in stroke mortality over time, but data on validated stroke incidence and long-term trends by race are limited.OBJECTIVE To study trends in stroke incidence and subsequent mortality among black and white adults in the Atherosclerosis Risk in Communities (ARIC) cohort from 1987 to 2011.DESIGN, SETTING, AND PARTICIPANTS Prospective cohort study of 14 357 participants (282 097 person-years) free of stroke at baseline was facilitated in 4 different US communities. Participants were recruited for the purpose of studying all stroke hospitalizations and deaths and for collection of baseline information on cardiovascular risk factors (via interviews and physical examinations) in 1987-1989. Participants were followed up (via examinations, annual phone interviews, active surveillance of discharges from local hospitals, and linkage with the National Death Index) through December 31, 2011. The study physician reviewers adjudicated all possible strokes and classified them as definite or probable ischemic or hemorrhagic events.MAIN OUTCOMES AND MEASURES Trends in rates of first-ever stroke per 10 years of calendar time were estimated using Poisson regression incidence rate ratios (IRRs), with subsequent mortality analyzed using Cox proportional hazards regression models and hazard ratios (HRs) overall and by race, sex, and age divided at 65 years.RESULTS Among 1051 (7%) participants with incident stroke, there were 929 with incident ischemic stroke and 140 with incident hemorrhagic stroke (18 participants had both during the study period). Crude incidence rates were 3.73 (95% CI, 3.51-3.96) per 1000 person-years for total stroke, 3.29 (95% CI, 3.08-3.50) per 1000 person-years for ischemic stroke, and 0.49 (95% CI, 0.41-0.57) per 1000 person-years for hemorrhagic stroke. Stroke incidence decreased over time in white and black participants (age-adjusted IRRs per 10-year period, 0.76 [95% CI, 0.66-0.87]; absolute decrease of 0.93 per 1000 person-years overall). The decrease in age-adjusted incidence was evident in participants age 65 years and older (age-adjusted IRR per 10-year period, 0.69 [95% CI, 0.59-0.81]; absolute decrease of 1.35 per 1000 person-years) but not evident in participants younger than 65 years (age-adjusted IRR per 10-year period, 0.97 [95% CI, 0.76-1.25]; absolute decrease of 0.09 per 1000 person-years) (P =.02 for interaction). The decrease in incidence was similar by sex. Of participants with incident stroke, 614 (58%) died through 2011. The mortality rate was higher for hemorrhagic stroke (68%) than for ischemic stroke (57%). Overall, mortality after stroke decreased over time (hazard ratio [HR], 0.80 [95% CI, 0.66-0.98]; absolute decrease of 8.09 per 100 strokes after 10 years [per 10-year period]). The decrease in mortality was mostly accounted for by the decrease at younger than age 65 years (HR, 0.65 [95% CI, 0.46-0.93]; absolute decrease of 14.19 per 100 strokes after 10 years [per 10-year period]), but was similar across race and sex.CONCLUSIONS AND RELEVANCE In a multicenter cohort of black and white adults in US communities, stroke incidence and mortality rates decreased from 1987 to 2011. The decreases varied across age groups, but were similar across sex and race, showing that improvements in stroke incidence and outcome continued to 2011. Copyright 2014 American Medical Association. All rights reserved.