Stalled Progress on Stroke a 'Wake Up' Call

Megan Brooks

September 07, 2017

The substantial decline in stroke death rates during the past four decades has slowed, stalled, or, in some cases, reversed in recent years, a new report from the Centers for Disease Control and Prevention (CDC) shows.

Progress in preventing stroke deaths has slowed in 38 states (3 of 4 states and District of Columbia) and most demographic groups, and stroke death rates have increased among Hispanics and people living in the South, according to the September 6 Vital Signs report.

This report is "an important wakeup call," CDC Director Brenda Fitzgerald, MD, said during a press briefing. "Every 40 seconds in the US someone has a stroke, and more than 140,000 people die from [stroke] each year. It also costs the nation $34 billion annually. The majority of strokes we see are avoidable and we know how to prevent them."

While the new report does not specifically address the reasons behind the slowdown in stroke death rates, other studies point to increased numbers of Americans with stroke risk factors, such as hypertension, obesity, and diabetes.

"Distressing" Trends

Quanhe Yang, PhD, from the CDC's Division for Heart Disease and Stroke Prevention, and colleagues analyzed trends from 2000 to 2015 in the rates of stroke as the underlying cause of death using data from the National Vital Statistics System.

Among adults aged 35 years and older, the overall age-standardized stroke death rate declined 38% from 2000 to 2015, but the annual percentage change (APC) changed unfavorably over the study period, particularly in recent years.

The APC decreased 3.4% decrease per year during 2000-2003, a 6.6% decrease during 2003-2006, a 3.1% decrease during 2006-2013, and a 2.5% (nonsignificant) increase during 2013-2015.

The data also show that trends in stroke death rates reversed in 2013 among Hispanics and in the South, where significant declines from year to year changed to significant increases during 2013-2015. Stroke death rates increased among Hispanics by 6% each year from 2013 to 2015. Blacks continue to have the highest stroke death rates among all races/ethnicities.

Dr Yang and colleagues say an estimated 32,593 excess stroke deaths might have occurred because of unfavorable changes in the rate of decline in stroke mortality during 2013-2015. Among the estimated excess stroke deaths, nearly one third occurred in adults aged 35 to 64 years.

"It's clear that we have work to do to reduce this burden," Dr Fitzgerald said. "There is no one answer. It will take all of us — public health, health systems, doctors, nurses, and healthcare professionals — to work together to make sure that this short-term trend of a decrease does not become a long-term one."

In a statement, American Heart Association (AHA)/American Stroke Association CEO Nancy Brown said, "Today's report is distressing, but unfortunately not unexpected based on our previous projections. After more than four decades of decline, progress in preventing stroke deaths has slowed across most states and demographic groups. We've especially lost ground in the battle to save lives among Hispanics and those living in the South, despite our ongoing efforts to reduce death and disability from stroke."

"The heartbreaking part is that while stroke is a leading cause of death in the US, it is largely preventable through lifestyle changes, increasingly treatable, and now, more than ever, should be beatable," said Brown.

"Back in 2010, the Association set an aggressive goal to reduce stroke deaths by 20% by 2020," she added. "This report gives us even more reason to aggressively continue our efforts, especially in multicultural communities and to reach people at younger ages, as we are seeing more strokes in people in their 30s and 40s." 

Lee H. Schwamm, MD, from Massachusetts General Hospital, Harvard Medical School, Boston, and AHA spokesperson, told Medscape Medical News, "The results are extremely concerning and are consistent with other reports related to cardiovascular disease in general."

"The results are believable," he added, "and represent a concerning finding in that the rates are changing differently for different demographics. This is probably the result of two simultaneous trends."

"Firstly, the major emphasis of stroke secondary prevention and mortality reduction over the past 1 to 2 decades has been focused on interventions in hospitalized patients. The substantial benefits of many of these hospital-based interventions have accrued, and incremental reductions from these interventions may be quite small in future years. Widespread increases in the use of statins in stroke have likely played a major role," Dr Schwamm said.

"Counteracting this beneficial trend is the rise of a tsunami of vascular risk factors, including obesity and unhealthy diets, sedentary lifestyle, hypertension, and smoking, that has been brewing in our society for several decades, and these individuals are now reaching an age where these risk factors are being expressed in the form of stroke," he said.

Dr Schwamm said the first step is increasing awareness and accurate epidemiologic surveillance of the rates of vascular events in the community.

"This should be accompanied by engagement of community stakeholders to create awareness locally and craft customized implementations of targeted national campaigns to reduce risk factors, such as AHA's Target BP, Target Cholesterol, and the AHA Million Hearts, for example," he said. "Public-private partnerships that engage key business leaders to contribute both expertise and financial support will be vital in deploying sustainable solutions to these vexing issues."

MMWR Morb Mortal Wkly Rep. Published online September 6, 2017. Full text

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