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Global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries (INTERSTROKE): a case-control study

Published on Aug 1, 2016in The Lancet 53.25
· DOI :10.1016/S0140-6736(16)30506-2
Martin O'Donnell50
Estimated H-index: 50
(National University of Ireland, Galway),
Siu Lim Chin3
Estimated H-index: 3
(Population Health Research Institute)
+ 43 AuthorsSalim Yusuf Mb Bs DPhil Frcpc209
Estimated H-index: 209
(Population Health Research Institute)
Summary Background Stroke is a leading cause of death and disability, especially in low-income and middle-income countries. We sought to quantify the importance of potentially modifiable risk factors for stroke in different regions of the world, and in key populations and primary pathological subtypes of stroke. Methods We completed a standardised international case-control study in 32 countries in Asia, America, Europe, Australia, the Middle East, and Africa. Cases were patients with acute first stroke (within 5 days of symptom onset and 72 h of hospital admission). Controls were hospital-based or community-based individuals with no history of stroke, and were matched with cases, recruited in a 1:1 ratio, for age and sex. All participants completed a clinical assessment and were requested to provide blood and urine samples. Odds ratios (OR) and their population attributable risks (PARs) were calculated, with 99% confidence intervals. Findings Between Jan 11, 2007, and Aug 8, 2015, 26 919 participants were recruited from 32 countries (13 447 cases [10 388 with ischaemic stroke and 3059 intracerebral haemorrhage] and 13 472 controls). Previous history of hypertension or blood pressure of 140/90 mm Hg or higher (OR 2·98, 99% CI 2·72–3·28; PAR 47·9%, 99% CI 45·1–50·6), regular physical activity (0·60, 0·52–0·70; 35·8%, 27·7–44·7), apolipoprotein (Apo)B/ApoA1 ratio (1·84, 1·65–2·06 for highest vs lowest tertile; 26·8%, 22·2–31·9 for top two tertiles vs lowest tertile), diet (0·60, 0·53–0·67 for highest vs lowest tertile of modified Alternative Healthy Eating Index [mAHEI]; 23·2%, 18·2–28·9 for lowest two tertiles vs highest tertile of mAHEI), waist-to-hip ratio (1·44, 1·27–1·64 for highest vs lowest tertile; 18·6%, 13·3–25·3 for top two tertiles vs lowest), psychosocial factors (2·20, 1·78–2·72; 17·4%, 13·1–22·6), current smoking (1·67, 1·49–1·87; 12·4%, 10·2–14·9), cardiac causes (3·17, 2·68–3·75; 9·1%, 8·0–10·2), alcohol consumption (2·09, 1·64–2·67 for high or heavy episodic intake vs never or former drinker; 5·8%, 3·4–9·7 for current alcohol drinker vs never or former drinker), and diabetes mellitus (1·16, 1·05–1·30; 3·9%, 1·9–7·6) were associated with all stroke. Collectively, these risk factors accounted for 90·7% of the PAR for all stroke worldwide (91·5% for ischaemic stroke, 87·1% for intracerebral haemorrhage), and were consistent across regions (ranging from 82·7% in Africa to 97·4% in southeast Asia), sex (90·6% in men and in women), and age groups (92·2% in patients aged ≤55 years, 90·0% in patients aged >55 years). We observed regional variations in the importance of individual risk factors, which were related to variations in the magnitude of ORs (rather than direction, which we observed for diet) and differences in prevalence of risk factors among regions. Hypertension was more associated with intracerebral haemorrhage than with ischaemic stroke, whereas current smoking, diabetes, apolipoproteins, and cardiac causes were more associated with ischaemic stroke (p Interpretation Ten potentially modifiable risk factors are collectively associated with about 90% of the PAR of stroke in each major region of the world, among ethnic groups, in men and women, and in all ages. However, we found important regional variations in the relative importance of most individual risk factors for stroke, which could contribute to worldwide variations in frequency and case-mix of stroke. Our findings support developing both global and region-specific programmes to prevent stroke. Funding Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Canadian Stroke Network, Health Research Board Ireland, Swedish Research Council, Swedish Heart and Lung Foundation, The Health & Medical Care Committee of the Regional Executive Board, Region Vastra Gotaland (Sweden), AstraZeneca, Boehringer Ingelheim (Canada), Pfizer (Canada), MSD, Chest, Heart and Stroke Scotland, and The Stroke Association, with support from The UK Stroke Research Network.
  • References (47)
  • Citations (253)
Published on Apr 1, 2018in Statistical Methods in Medical Research 2.28
John Ferguson8
Estimated H-index: 8
(National University of Ireland, Galway),
Alberto Alvarez-Iglesias4
Estimated H-index: 4
(National University of Ireland, Galway)
+ 2 AuthorsMartin O'Donnell50
Estimated H-index: 50
(National University of Ireland, Galway)
Chronic diseases tend to depend on a large number of risk factors, both environmental and genetic. Average attributable fractions were introduced by Eide and Gefeller as a way of partitioning overall disease burden into contributions from individual risk factors; this may be useful in deciding which risk factors to target in disease interventions. Here, we introduce new estimation methods for average attributable fractions that are appropriate for both case–control designs and prospective studie...
5 Citations Source Cite
Published on Aug 1, 2016in Lancet Neurology 27.14
Valery L. Feigin69
Estimated H-index: 69
(AUT: Auckland University of Technology),
Gregory A. Roth48
Estimated H-index: 48
(UW: University of Washington)
+ 11 AuthorsMarie Ng27
Estimated H-index: 27
(UW: University of Washington)
Summary Background The contribution of modifiable risk factors to the increasing global and regional burden of stroke is unclear, but knowledge about this contribution is crucial for informing stroke prevention strategies. We used data from the Global Burden of Disease Study 2013 (GBD 2013) to estimate the population-attributable fraction (PAF) of stroke-related disability-adjusted life-years (DALYs) associated with potentially modifiable environmental, occupational, behavioural, physiological, ...
265 Citations Source Cite
Published on May 1, 2016in Atherosclerosis 4.47
Sanne A.E. Peters26
Estimated H-index: 26
(The George Institute for Global Health),
Yankuba Singhateh1
Estimated H-index: 1
(UQ: University of Queensland)
+ 2 AuthorsMark Woodward110
Estimated H-index: 110
(Johns Hopkins University)
Abstract Background Raised total cholesterol is a strong risk factor for cardiovascular disease (CVD). It remains unknown whether sex differences exist in the relationship between total cholesterol and CVD outcomes. Methods PubMed was searched in December 2014 for cohort studies reporting on the relationship between total cholesterol and coronary heart disease (CHD) and total stroke, separately in men and women. Random effects meta-analyses with inverse variance weighting were used to obtain adj...
47 Citations Source Cite
Published on Nov 1, 2015in The Lancet 53.25
Andrew Smyth17
Estimated H-index: 17
(National University of Ireland, Galway),
Koon Teo54
Estimated H-index: 54
(Population Health Research Institute)
+ 22 AuthorsAnders H. Rosengren84
Estimated H-index: 84
(Sahlgrenska University Hospital)
Summary Background Alcohol consumption is proposed to be the third most important modifiable risk factor for death and disability. However, alcohol consumption has been associated with both benefits and harms, and previous studies were mostly done in high-income countries. We investigated associations between alcohol consumption and outcomes in a prospective cohort of countries at different economic levels in five continents. Methods We included information from 12 countries participating in the...
54 Citations Source Cite
Published on Sep 1, 2015in BMJ Open 2.41
Renata Micha37
Estimated H-index: 37
(Tufts University),
Shahab Khatibzadeh18
Estimated H-index: 18
(Harvard University)
+ 3 AuthorsDariush Mozaffarian113
Estimated H-index: 113
(Tufts University)
To quantify global intakes of key foods related to non-communicable diseases in adults by region (n=21), country (n=187), age and sex, in 1990 and 2010.
88 Citations Source Cite
Published on Sep 1, 2015in Hypertension 6.82
Sophie V. Eastwood13
Estimated H-index: 13
(UCL: University College London),
Therese Tillin20
Estimated H-index: 20
(UCL: University College London)
+ 1 AuthorsAlun D. Hughes63
Estimated H-index: 63
(UCL: University College London)
It is unknown whether associations between blood pressure (BP) and stroke vary between Europeans and South Asians, despite higher stroke rates in the latter. We report findings from a UK cohort study of 1375 European and 1074 South Asian men, not receiving antihypertensive medication, aged 40 to 69 years at baseline (1988–1991). Assessment included BP, blood tests, anthropometry, and questionnaires. Incident stroke was established at 20 years from death certification, hospital and primary care r...
21 Citations Source Cite
Published on Apr 16, 2015in Stroke 6.24
Valery L. Feigin69
Estimated H-index: 69
(AUT: Auckland University of Technology),
Rita Krishnamurthi25
Estimated H-index: 25
(AUT: Auckland University of Technology)
+ 76 AuthorsElaine Rush28
Estimated H-index: 28
(AUT: Auckland University of Technology)
The socioeconomic and health effect of stroke and other noncommunicable disorders (NCDs) that share many of the same risk factors with stroke, such as heart attack, dementia, and diabetes mellitus, is huge and increasing.1–4 Collectively, NCDs account for 34.5 million deaths (66% of deaths from all causes)3 and 1344 million disability-adjusted life years lost worldwide in 2010.2 The burden of NCDs is likely to burgeon given the aging of the world’s population and the epidemiological transition c...
32 Citations Source Cite
Published on Mar 31, 2015in PLOS Medicine 11.68
C. Sudlow45
Estimated H-index: 45
(Edin.: University of Edinburgh),
John Gallacher52
Estimated H-index: 52
(Cardiff University)
+ 16 AuthorsMartin J. Landray32
Estimated H-index: 32
(University of Oxford)
• UK Biobank is a very large and detailed prospective study with over 500,000 participants aged 40–69 years when recruited in 2006–2010. • The study has collected and continues to collect extensive phenotypic and genotypic detail about its participants, including data from questionnaires, physical measures, sample assays, accelerometry, multimodal imaging, genome-wide genotyping and longitudinal follow-up for a wide range of health-related outcomes. • Wide consultation; input from scientific, ma...
791 Citations Source Cite
Published on Feb 1, 2015in Annals of Epidemiology 2.80
Carlos J. Rodriguez32
Estimated H-index: 32
(Wake Forest University),
Elsayed Z. Soliman47
Estimated H-index: 47
(Wake Forest University)
+ 4 AuthorsSusan R. Heckbert93
Estimated H-index: 93
(UW: University of Washington)
Purpose We studied incident atrial fibrillation (AF) in the prospective community-based Multi-Ethnic Study of Atherosclerosis (MESA). Reportedly, non-Hispanic blacks (NHBs) have a lower AF burden compared with their non-Hispanic white (NHW) counterparts. Information on the epidemiology of AF in Hispanic and Asian populations is much more limited.
54 Citations Source Cite
Published on Jan 1, 2015in Circulation 18.88
Rachel R. Huxley59
Estimated H-index: 59
(UQ: University of Queensland),
Yoichiro Hirakawa26
Estimated H-index: 26
(The George Institute for Global Health)
+ 5 AuthorsMark Woodward110
Estimated H-index: 110
(The George Institute for Global Health)
Cardiovascular disease (CVD) is the leading cause of mortality worldwide, causing an estimated 18 million deaths annually. Much of the burden of CVD resides in lower- and middle-income countries, particularly those Asian countries comprising the Western Pacific Region. Epidemiological studies have convincingly shown that up to 90% of all CVD can be explained by a small number of modifiable risk factors, including blood pressure, smoking, diabetes, total cholesterol and excess body weight. Howeve...
15 Citations Source Cite
Cited By253
Published on Apr 12, 2019in Journal of Thrombosis and Thrombolysis 2.62
Jing Song5
Estimated H-index: 5
(PKU: Peking University),
Yiqun Wu5
Estimated H-index: 5
(PKU: Peking University)
+ 3 AuthorsYonghua Hu13
Estimated H-index: 13
(PKU: Peking University)
The rs7903146, an established genetic variant susceptible to type 2 diabetes (T2D), is also reported to be related to ischemic stroke (IS), though conflicting. Furthermore, it remained unknown whether the genetic association with stroke is independent of T2D. In the current study, 1603 individuals across 986 families were included. The genetic pleiotropic effect on each outcome diseases (T2D, overall IS, or each subtype) was assessed using multilevel logistic regression after adjustment for mult...
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Published on Apr 1, 2019in Lancet Neurology 27.14
Sheila C Ouriques Martins , Claudio Sacks5
Estimated H-index: 5
(Valpo: Valparaiso University)
+ 51 AuthorsDiana Vaca McGhie1
Estimated H-index: 1
(AHA: American Heart Association)
Summary The large and increasing burden of stroke in Latin American countries, and the need to meet the UN and WHO requirements for reducing the burden from non-communicable disorders (including stroke), brought together stroke experts and representatives of the Ministries of Health of 13 Latin American countries for the 1st Latin American Stroke Ministerial meeting in Gramado, Brazil, to discuss the problem and identify ways of cooperating to reduce the burden of stroke in the region. Discussio...
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