Twenty Years of Progress Toward Understanding the Stroke Belt

George Howard, DrPH; Virginia J. Howard, PhD


Stroke. 2020;51(3):742-750. 

In This Article

Abstract and Introduction


The Stroke Belt is a region of higher stroke mortality in the Southeastern United States that has persisted since at least 1940. Two decades ago (1999), potential contributors to this disparity were reviewed. This report serves to describe the subsequent progress in understanding the magnitude and contributors to the Stroke Belt. The Stroke Belt is defined based on higher stroke mortality from all strokes in the Southeastern United States compared with other regions. In 1968, the age-adjusted stroke mortality rate in the Stroke Belt was 582/100 000 compared with 433/100 000 for the rest of the United States. National declines in stroke mortality reduced these rates, and by 2016, the stroke mortality rates were 126/100 000 and 99/100 000, respectively. These changes reduced the absolute magnitude of the Stroke Belt disparity from 149/100 000 to 26/100 000 but the relative excess by only 34% to 27%. Higher mortality can be the product of higher incidence, higher case-fatality, or both. Higher stroke mortality in the Stroke Belt appears to be primarily related to a higher stroke incidence, with higher stroke case-fatality playing a smaller role. The Stroke Belt also includes a higher proportion of rural residents relative to other regions, and nationally, residents of rural regions have higher stroke incidence compared with residents living in more urban areas. The data suggest that contributors to the Stroke Belt may include larger proportion of blacks and residents with higher prevalence of traditional stroke risk factors, higher prevalence of inflammation and infection, and lower socioeconomic status. Environmental exposures and lifestyle choices perhaps play a lesser role. While substantial progress has been made to advance the understanding of the contributors to the Stroke Belt, much work remains to better understand this disparity.