|ORIGINAL CONTRIBUTION: PREVENTIVE EPIDEMIOLOGY IN NEUROLOGY
|Year : 2014 | Volume
| Issue : 1 | Page : 9-16
Stroke burden and risk factors during 1997-2008: Examining the effect of ethnicity and gender
Baqar A Husaini1, Robert Levine2, Van Cain1, Meggan Novotny1, Jan Emerson1, Gail Orum3, Mohsen Bazargan3, Pamela Hull4, Muhib Khan5, Majaz Moonis5
1 Tennessee State University, Nashville, Tennessee, USA
2 Meharry Medical College, Nashville, Tennessee, USA
3 Charles Drew University, Los Angeles, California, USA
4 Vanderbilt University, Nashville, Tennessee, USA
5 University of Massachusetts, Massachusetts, USA
|Date of Web Publication||3-May-2014|
Prof. Baqar A Husaini
Box 9580 Tennessee State University, 3500 John Merritt Blvd. Nashville, TN 37209,
Source of Support: The analysis for this article was supported by a Grant from CDC Grant no. U58CCU422782 to Tennessee Department of Health (subcontract no. ED-07-20811-00 to Tennessee State University, B. Husaini, PI). Additional support for Levine, Husaini, and Cain was also provided by another NIH grant # P20-MD000516 (National Center on Minority Health and Health Disparity to Meharry Medical College)., Conflict of Interest: None
Objective: Examine the effect of race and gender variation on the burden of stroke and associated risk factors among hospital-discharged patients. Materials and Methods: We examined Tennessee Hospital Discharge Database from 1997 to 2008 for patients (older than 20 years) discharged with a diagnosis of stroke. The number of stroke patients was 17,149 in 1997; 19,020 in 2003; and 17,010 in 2008. We also extracted data on cardiovascular risk factors for each patient. Age-adjusted prevalence of hospitalization for stroke per 100K for non-Hispanic white and black patient groups was developed per Center of Disease Control (CDC) procedures of at-risk population. Race- and gender-specific prevalence of stroke and associated cardiovascular risk factors among hospitalized patients were examined using multivariate logistic models. To examine consistency, we compared the two groups at three different points: 1997, 2003, and 2008 regarding the prevalence of stroke and their associated risk factors. Results: Our analyses revealed three major trends: (1) Age-adjusted stroke rate declined by 13.8% over a 12-year period (from 466.8 per 100,000 in 1997 to 402.2 per 100,000 in 2008). This decline occurred for both black and white patients. However, the white stroke rate declined by 19.8% (from 401.9 in 1997 to 322.2 in 2008), compared with only 13.7% among blacks (from 599.2 in 1997 to 517.3 in 2008). Additionally, throughout the 12-year period, although no significant gender differences were observed, the stroke rates among blacks remained consistently higher compared with whites (black:white rate ratios of 1.60 in 1997, 1.40 in 2003, and 1.60 in 2008). Logistic regression analysis revealed the four risk factors that consistently predicted stroke for both black and white patients in 1997, 2003, and 2008, namely, hypertension (HTN), diabetes mellitus (DM), high cholesterol, and cardiac arrhythmia. Conclusion : Aggressive management of two cardiovascular risk factors (HTN and DM) may subsequently reduce stroke health disparity and the burden of stroke hospitalization among blacks.
Keywords: Gender, race, risk factors, stroke rates, stroke
|How to cite this article:|
Husaini BA, Levine R, Cain V, Novotny M, Emerson J, Orum G, Bazargan M, Hull P, Khan M, Moonis M. Stroke burden and risk factors during 1997-2008: Examining the effect of ethnicity and gender. Astrocyte 2014;1:9-16
|How to cite this URL:|
Husaini BA, Levine R, Cain V, Novotny M, Emerson J, Orum G, Bazargan M, Hull P, Khan M, Moonis M. Stroke burden and risk factors during 1997-2008: Examining the effect of ethnicity and gender. Astrocyte [serial online] 2014 [cited 2023 May 28];1:9-16. Available from: http://www.astrocyte.in/text.asp?2014/1/1/9/131855
| Introduction|| |
Stroke is the fourth leading cause of mortality in Americans. Recent evidence suggests that every 40 seconds, someone in the United States experiences stroke and that approximately 800,000 Americans experience stroke each year. Moreover, nearly one-fourth of strokes are recurrent strokes. Additionally, stroke rates are increasing among younger adults (age < 45 years), whereas rates among older persons have somewhat stabilized. Finally, while more women than men are affected by stroke each year, reasons for the gender difference in incidence rates remain unclear. Recent reports indicate that stroke rates are declining but mortality remains higher in some minority groups. ,,,,,,,,,,,,,,,,,,,,,
Ethnic groups constitute a large portion of the American population. Among these groups, African Americans (blacks) account for nearly 13% of the nation's population. To provide quality care, there is an ever-growing need for providers to have an enhanced understanding of the complex impact of race and gender on stroke and chronic conditions (comorbidities) that contribute to lower life expectancy in the black population. , Since previous studies of stroke covered only shorter periods of time, this article examined a 12-year data (1997-2008) of hospitalized stroke patients with three focal points of comparison: (1) beginning period in 1997, (2) mid-period in 2003, and (3) ending period in 2008. Persistent trends that emerge across the three periods will add to the robustness of our findings. Thus, within this larger span of time, we evaluated consistency of our findings with regard to three questions: (1) Are there changes in the prevalence of stroke hospitalization over a 12-year period, (2) Are there persistent racial and gender differences in stroke morbidity, and (3) Are the stroke risk factors similar across three points of comparison, namely, 1997, 2003, and 2008?
| Materials and Methods|| |
We used Tennessee Hospital Discharge Data System (HDDS) to obtain relevant data on adult patients (older than 20 years) from 1997 to 2008. Patients from the Veteran Administration Hospitals, as well as, mental health hospitals are excluded from the HDDS data. Furthermore, the HDDS data are administrative files compiled by the Division of Health Statistics (Tennessee Department of Health). These administrative files provide patients' age, gender, race/ethnicity, county of residence, postal zipcode, date of admission/ discharge, admitting and discharge principal and secondary diagnoses (ICD-9 codes), principal procedure codes, and total ($) charges. These files do not provide data pertaining to patients' marital status, education, or annual income. All diagnoses are given by the attending physicians and the diagnoses appear only when the patients are treated for those diagnoses. No clinical data are provided either for tests performed or symptom indices used in arriving at clinical judgments/diagnoses.
This study used patients' primary discharge diagnosis of stroke (ICD-9 codes of 430-438). Although an individual may appear several times in a year, in our analysis the individual appears only once in any one year. Since 97% of Tennessee population constitutes non-Hispanic whites and blacks, our analysis is only confined to black and white comparisons. Data extracted from the HDDS files also included presence or absence of comorbidities such as hypertension (HTN), diabetes mellitus (DM), cardiac arrhythmia (CA), and other chronic conditions affecting the patient.
Prevalence for hospitalization of stroke (per 100,000) were directly age-adjusted and indexed to the year 2000 census per methodology provided by Center For Disease Control and Prevention (CDC) for the population at risk. Prevalence of comorbidities prevalence of comorbidities by race and gender were evaluated with Fisher's exact test. Percentages of stroke per discharge in each period were compared using a Pearson correlation and Chi-square tests with the Yates correction for continuity, and odd ratios were obtained through logistic regression analyses with age, HTN, DM, and other risk factors in the model.
| Results|| |
Changes in Stroke Morbidity over 12 years
Our analyses indicate that the prevalence of stroke among hospitalized patients in Tennessee has declined by 13.8% over the 12-year period (from 466.8 per 100,000 in 1997 to 402.2 per 100,000 in 2008). This decline occurred for both black and white patients [Figure 1]. The white stroke prevalence declined by 19.8% (from 401.9 in 1997 to 322.2 in 2008), whereas the decline among blacks was limited to only 13.7% over 12 years (from 599.2 in 1997 to 517.3 in 2008). Furthermore, stroke prevalence declined by 18.3% among males (from 498.9 in 1997 to 407.8 in 2008), whereas females had a smaller decline of 9.7% (from a rate of 442.2 in 1997 to a rate of 399.1 in 2008). The greater decline among males is largely reflective of a greater decline in stroke among whites. Finally, black males and black females show smaller declines (12.5% and 14.2%, respectively) compared with stroke declines among white females (20.7%) and white males (19.3%).
|Figure 1 a-b: Age-adjusted Stroke Rates and Rate Ratio Per 100K by Race, Age 18+, 1997-2008.|
Click here to view
Stroke Morbidity by Race
[Figure 1] also indicates that for each year, the stroke prevalence (per hospitalized patients) was significantly higher among blacks compared with whites (and this is reflected by a higher black:white unadjusted rate ratios of 1.50 in 1997, 1.40 in 2003, and 1.60 in 2008). These higher rate ratios favoring blacks were confirmed by significant adjusted odd ratios in logistic models [significant odds ratio (OR) of 1.06, 95% confidence interval (CI) (1.01-1.11) in 1997; OR of 1.16, 95% CI (1.12-1.21) in 2003, and OR of 1.31, 95% CI (1.26-1.37) in 2008]. These adjusted ORs suggest that rates for blacks were consistently higher than whites despite controlling for comorbidities that jointly contributed to stroke rates at three points of comparisons. In sum, these adjusted ORs clearly indicate a higher burden of stroke among blacks despite the adjustments for the related comorbidities.
Stroke Morbidity by Gender
[Figure 2] shows that prior to year 2000, males had higher stroke rates than females. However, these gender differences disappeared after year 2000 for 8 years (2000-2008). This rate equalization suggests that females tended to have better outcomes starting in 2000 and this improvement (gender parity) continued through 2008. Recent evidence also provides support for the overall gender stroke parity. 
|Figure 2 a-b: Age-adjusted Stroke Rates and Rate Ratio per 100K by Sex, Age 18+, 1997-2008.|
Click here to view
However, when race was controlled in the analytical model for 2008 data, a within-gender stroke disparity was observed. Here, black females had worse outcomes compared with white females (rate of 505.7 per 100,000 among black females vs. 298.9 per 100K among white females (OR = 1.29, 95% CI = 1.22-1.36). The black-white differences among females were particularly noticeable among younger females (aged 20-54 years; see [Table 1], cols. 6, 12, 18) where the stroke prevalence for younger black females was at least two times higher (2:1) compared with same-age white females. These ratios spiral downward after the age of 65 years resulting in no racial differences (ratio of 0.94) at age 85 years. Similar results were obtained for black males (see [Table 1], cols. 5, 11, 17) where stroke prevalence was at least two times higher (2:1) for younger black males (age 18-54 years) compared with same-age whites peers in 2008 in [Table 1] (OR = 1.31, 95% CI = 1.23-1.39). Clearly, stroke burden among hospitalized patients is higher among blacks under the age of 54 years (both females and males) compared with their same-age white peers.
|Table 1: Stroke Rates and Rate Ratios by Ethnicity, Sex, and Age: 1997, 2003, 2008|
Click here to view
Stroke Morbidity and Age
[Table 2] shows that at three points of comparison (ie, 1997, 2003, 2008), the proportion of younger adults (age < 64 years) with stroke has steadily increased from 28% in 1997 to nearly 35% in 2008 [marking an increase of 25% among younger adults compared with a decline of 9.7% among the older adults (age >65 years)]. The proportion of younger adults (age < 64 years) experiencing stroke between 1997 and 2008 was significantly higher among blacks compared with whites (41% vs. 15%, P < 0.000), which also reflects increasing burden of stroke among younger blacks.
|Table 2: Stroke Percentages, Rates and Ratios by Age, Ethnicity, and Sex: 1997, 2003, 2008|
Click here to view
The racial disparity is further evident when black:white ratios are examined. [Table 2] (cols. 2, 6, 9) shows that the younger blacks (20-54 years of age) have more than twice (2.5:1) the prevalence of strokes compared with whites at each point of comparison (1997, 2003, 2008). Effects of race, however, are diminished when only male versus female comparisons are examined. Hence [Table 2] (cols. 12, 15, 18) shows a stroke gender parity for younger age. The black:white ratios ([Table 2], cols. 12, 15, 18) between males and females remained almost equal for younger age (<54 years) throughout each point of comparison.
Stroke Risk Factors
[Table 3] (cols. 1-9) shows that at each point of comparison (1997, 2003, 2008), blacks have both a higher stroke prevalence along with a higher prevalence of HTN, DM, and CA compared with whites. Furthermore, at each comparison point, HTN and DM were persistently higher among blacks than whites.
|Table 3: Comorbidities of Stroke Patients by Ethnicity and Sex: 1997, 2003, 2008|
Click here to view
We used multivariate logistic models to determine persistent risk factors for each racial group separately. [Table 4] shows that HTN, DM, high cholesterol, and CA significantly predicted stroke for both black and white patients consistently in 1997, 2003, and 2008. Both myocardial infarction and congestive heart failure (which existed among some of our patients) did not predict the onset of stroke. These findings support previously reported findings of risk factors, including atrial fibrillation. ,, Obviously, it is the higher prevalence and combined burden of these risk factors that contribute to higher stroke morbidity among blacks compared with whites. ,, No consistent patterns of risk factors emerged by gender since males and females included both black and white patients [[Table 3], cols. 10-18].
|Table 4: Odds Ratios and 95 % Confidence Interval of Risk Factors Predicting Stroke by Ethnicity: 1997, 2003, 2008|
Click here to view
| Discussion|| |
Our analyses indicate that stroke prevalence among patients discharged from Tennessee hospitals declined between 1997 and 2008. Although declines occurred among both blacks and whites, white declines exceeded those for blacks and declines for males exceeded those for females. Although stroke gender differences have been inconsistent, recent evidence shows a greater gender stroke parity.  Throughout this period, the largest stroke decline has been among white females followed by white males, black females, with the lowest decline occurring among black males.
Given the higher prevalence of stroke among blacks, it is clear that racial disparities in stroke morbidity has persisted over 12 years, which indicates that blacks have persistently experienced higher stroke burden compared with whites. These findings are from a single southern state, and to what extent they mirror the stroke disparities in other geographic areas of the country remains unclear. However, our findings appear to be consistent with those reported by Northern Manhattan (New York) , and greater Cincinnati (Ohio) investigators.  The Cincinnati area study provided similar results of higher Black: white stroke ratios particularly among blacks of various ages: A ratio of 2.05 in <34 years of age, 4.18 in those 35-44 years of age, 2.02 ratio among 45-54 years of age, 1.74 ratio among 55-64 years of age, and 1.66 in those 65-74 years of age.  In our study, similar black:white ratios of stroke emerged by age [Table 2]. Although our data did not specifically analyze the incidence of recurrent strokes, previous studies have reported a higher risk of recurrent stroke among blacks compared with whites (2.4:1).  Furthermore, having DM (which existed among more than one third of our study population) significantly increases the risk of stroke for all adults (age <65 years) regardless of race. These findings as well as CDC mortality data , further substantiate lower black life expectancy  and greater burden of stroke among blacks than whites.
Stroke disparity results from a number of factors, including number of comorbidities, access to healthcare providers, awareness of stroke symptoms, and age. Age plays a significant role in that younger individuals may perceive themselves to be in good health despite having latent chronic conditions, such as high blood pressure, which may produce an end-stage cardiac event. Our data provide some evidence for such a perspective in that, on average, the black stroke patients were younger compared with whites (68 years vs. 74 years, respectively) and that the higher stroke rates among younger blacks (age <54 years, both males and females) suggest that they might have been unaware of how their HTN combined with other comorbidities was impacting their lives.
In addition to comorbidities, other factors such as access to health care providers, adherence to medical regimen, and awareness of stroke symptoms may contribute to stroke disparity. Evidence suggests that only 40% of the population recognizes stroke symptoms and activates emergency response systems. However, awareness and recognition of stroke symptoms among blacks and use of emergency services is far less compared with whites. ,,, Results of a recent Baltimore study indicated that blacks who experienced and recognized stroke symptoms waited for a friend to take them to the emergency department (ED) instead of calling 911. 
Stroke disparity can be improved through management of risk factors. Our study has revealed two major risk factors, HTN and DM, which are more prevalent among black than white patients. Blacks in other studies have also been found to have other risk factors such as left ventricular hypertrophy (LVH), smoking, and physical inactivity together with higher rates of DM and hypertension. ,, In some of these studies, DM and HTN have persistently emerged as independent risk factors for all ethnic groups, including the North Manhattan Study (NOMAS ),  as these risk factors have also affected a higher proportion of black than white patients in this study.
Previous studies have pointed to poor management of these risk factors in blacks. They have, for example, reported poor control of HTN despite adequate treatment. , Adherence to medical regimen is not only low for HTN and DM, but also for dyslipidemia as blacks are less likely to achieve lipid goals compared with whites. ,, Similarly, prophylactic use of aspirin and warfarin is low among blacks compared with whites. ,
It may be noted that low adherence to medication regimens could in part be related to low socioeconomic status (SES). According to the 2010 census figures, 25.8% of black families compared with 11.6% of white families, live below the poverty level.  The poor economic status of blacks may result in their inability to afford medications and hence discontinuation of treatment.  Low SES also contributes to low health literacy that translates into difficulties with following instructions, lack of self-empowerment, and distrust of new information. 
Access to health care is a major reason for higher morbidity and mortality in blacks. Blacks have longer wait times in the ED, , and lower specialty care, lower rates of referral from neurologists (10.6% among blacks vs. 20.3% among whites), and they (blacks) are 3.7 times less likely to receive intravenous thrombolysis in the EDs compared with those with referrals. ,,
Since our study examined data from a southern state, the findings require replication from other geographic areas to further substantiate the complex relationship between race and stroke, which permeates through gender, affecting black women negatively. To reduce these racial disparities, we need a better understanding of underlying factors such as genetic, biological, and SES that play a significant role in the onset and management of stroke. Because deficiencies in the health care system also contribute to stroke disparities, new population-based interventions targeting HTN and DM are needed to help reduce the racial divide in stroke outcomes. Such interventions aimed at reducing stroke may include educational programs that promote stroke symptom awareness, medication adherence, and lifestyle modifications including physical activity (simply walking more), which all together may contribute to lowering stroke morbidity and mortality in the underserved minority populations. ,,,,,
| Conclusion|| |
Stroke rates have declined over 12 years from 1997 to 2008. Despite the decline, rates have remained significantly higher for blacks compared with whites, particularly among younger blacks than < 54 years. No gender differences existed in stroke morbidity during the years of analysis. Risk factors associated with these rates are HTN, DM, CA, and cholesterol. Blacks have higher rates of HTN and DM, which contribute to significant stroke racial disparity. These comorbidities among blacks call for community-based primary prevention programs that may increase stroke symptom awareness and recognition, and improved management of comorbidities through lifestyle changes, increased physical activity, lower salt intake, and increased adherence to medical regimen. Such interventions may reduce stroke disparity that has persisted over 12 years.
| References|| |
Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Borden WB, et al
; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics-2013 update: A report from the American Heart Association. Circulation 2013;127:e6-245.
Roger VL, Go AS, Lloyd-Jones DM, Benjamin EJ, Berry JD, Borden WB, et al
. Heart disease and stroke statistics-2012 update: A report from the American Heart Association. Circulation 2012;125:e2-220.
Centers for Disease Control and Prevention. Prevalence of stroke: United States, 2006-2010. MMWR Morb Mortal Wkly Rep 2012;127:e132-52.
Vermeer SE, Longstreth WT Jr., Koudstaal PJ. Silent brain infarcts: A systematic review. Lancet Neurol 2007;6:611-9.
Prabhakaran S, Wright CB, Yoshita M, Delapaz R, Brown T, DeCarli C, et al
. Prevalence and determinants of subclinical brain infarction: The Northern Manhattan Study. Neurology 2008;70:425-30.
Das RR, Seshadri S, Beiser AS, Kelly-Hayes M, Au R, Himali JJ, et al
. Prevalence and correlates of silent cerebral infarcts in the Framingham offspring study. Stroke 2008;39:2929-35.
Howard G, Wagenknecht LE, Cai J, Cooper L, Kraut MA, Toole JF. Cigarette smoking and other risk factors for silent cerebral infarction in the general population. Stroke 1998;29:913-7.
Glasser SP, Judd S, Basile J, Lackland D, Halanych J, Cushman M, et al
. Prehypertension, racial prevalence and its association with risk factors: Analysis of the Reasons for Geographic And Racial Differences in Stroke (REGARDS) study. Am J Hypertens 2011;24:194-9.
Thomas AJ, Eberly LE, Davey Smith G, Neaton JD, Stamler J. Race/ethnicity, income, major risk factors, and cardiovascular disease mortality. Am J Public Health 2005;95:1417-23.
Howard VJ, McClure LA, Meschia JF, Pulley L, Orr SC, Friday GH. High prevalence of stroke symptoms among persons without a diagnosis of stroke or transient ischemic attack in a general population: The REasons for Geographic And Racial Differences in Stroke (REGARDS) study. Arch Intern Med 2006;166:1952-8.
Kleindorfer DO, Khoury J, Moomaw CJ, Alwell K, Woo D, Flaherty ML, et al
. Stroke incidence is decreasing in whites but not in blacks: A population-based estimate of temporal trends in stroke incidence from the Greater Cincinnati/Northern Kentucky Stroke Study. Stroke 2010;41:1326-31.
Reeves MJ, Bushnell CD, Howard G, Gargano JW, Duncan PW, Lynch G, et al
. Sex differences in stroke: Epidemiology, clinical presentation, medical care, and outcomes. Lancet Neurol 2008;7:915-26.
Petrea RE, Beiser AS, Seshadri S, Kelly-Hayes M, Kase CS, Wolf PA. Gender differences in stroke incidence and poststroke disability in the Framingham heart study. Stroke 2009;40:1032-7.
Sealy-Jefferson S, Wing JJ, Sánchez BN, Brown DL, Meurer WJ, Smith MA, et al
. Age- and ethnic-specific sex differences in stroke risk. Gend Med 2012;9:121-8.
Howard VJ, Kleindorfer DO, Judd SE, McClure LA, Safford MM, Rhodes JD, et al
. Disparities in stroke incidence contributing to disparities in stroke mortality. Ann Neurol 2011;69:619-27.
Kleindorfer D, Broderick J, Khoury J, Flaherty M, Woo D, Alwell K, et al
. The unchanging incidence and case-fatality of stroke in the 1990s: A population-based study. Stroke 2006;37:2473-8.
Carandang R, Seshadri S, Beiser A, Kelly-Hayes M, Kase CS, Kannel WB, et al
. Trends in incidence, lifetime risk, severity, and 30-day mortality of stroke over the past 50 years. JAMA 2006;296:2939-46.
White H, Boden-Albala B, Wang C, Elkind MS, Rundek T, Wright CB, et al
. Ischemic stroke subtype incidence among whites, blacks, and Hispanics: The Northern Manhattan Study. Circulation 2005;111:1327-31.
Cushman WC, Evans GW, Byington RP, Goff DC Jr, Grimm RH Jr, Cutler JA, et al
; ACCORD Study Group. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med 2010;362:1575-85.
Howard G, Prineas R, Moy C, Cushman M, Kellum M, Temple E, et al
. Racial and geographic differences in awareness, treatment, and control of hypertension: The reasons for geographic and racial differences in stroke study. Stroke 2006;37:1171-8.
Giles WH, Kittner SJ, Hebel JR, Losonczy KG, Sherwin RW. Determinants of black-white differences in the risk of cerebral infarction: The National Health and Nutrition Examination Survey Epidemiologic Follow-up Study. Arch Intern Med 1995;155:1319-24.
Rosamond WD, Folsom AR, Chambless LE, Wang CH, McGovern PG, Howard G, et al
. Stroke incidence and survival among middle-aged adults: 9-year follow-up of the Atherosclerosis Risk in Communities (ARIC) cohort. Stroke 1999;30:736-43.
Day JC. Population Projections of the United States by Age, Sex, Race and Hispanic Origin: 1995 to 2050. Washington, DC: US Government Printing Office; 1996. US Bureau of the Census, Current Population Reports, p. 25-1130.
Murray CJ, Kulkarni SC, Michaud C, Tomijima N, Bulzacchelli MT, Iandiorio TJ, et al
. Eight Americas: Investigating mortality disparities across races, counties, and race-counties in the United States. PLoS Med 2006;3:e260.
Lloyd-Jones D, Adams R, Carnethon M, De Simone G, Ferguson TB, Flegal K, et al
. Heart disease and stroke statistics: 2009 update: A report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2009;119:480-6.
Klein RJ, Schoenborn CA. Age adjustment using the 2000 projected US population. Healthy People 2010 Stat Notes. 2001:1-10.
Devries D, Zhang Y, Qu M, Ma J, Lin G. Gender difference in stroke case fatality: An integrated study of hospitalization and mortality. J Stroke Cerebrovasc Dis 2013;22:931-7.
Wang TJ, Massaro JM, Levy D, Vasan RS, Wolf PA, D'Agostino RV, et al
. A risk score for predicting strokeor death in individuals with new on-set atrial fibrillation in the community: The Framingham Heart Study. JAMA 2003;290:1049-56.
Healey JS, Connolly SJ, Gold MR, Israel CW, Van Gelder IC, Capucci A, et al
; ASSERT Investigators. Subclinical atrial fibrillation and the risk of stroke. N Engl J Med 2012;366:120-9.
Curb JD, Abbott RD, Rodriquez BL, Masaki KH, Chen R, Popper JS, et al
. High density lipoprotein cholesterol and the risk of elderly men; the Honolulu Heart Program. Am J Epidemiol 2004;160:150-7.
Sacco RL, Boden-Albala B, Abel G, Lin IF, Elkind M, Hauser WA, et al
. Race-ethnic disparities in the impact of stroke risk factors: The northern Manhattan stroke study. Stroke 2001;32:1725-31.
Sheinart KF, Tuhrim S, Horowitz DR, Weinberger J, Goldman M, Godbold JH. Stroke recurrence is more frequent in Blacks and Hispanics. Neuroepidemiology 1998;17:188-8.
Khoury JC, Kleindorfer D, Alwell K, Moomaw CJ, Woo D, Ad O, et al
. Diabetes Mellitus: A risk factor for ischemic stroke in a large biracial population. Stroke2013;44:1500-4.
Kochanek KD, Arias E, Anderson RM. How did cause of death contribute to racial differences in life expectancy in the United States in 2010?. NCHS Data Brief Number 125, (CDC) July, 2013.
Howard G, Howard VJ. Reasons for Geographic And Racial Differences in Stroke (REGARDS) Investigators. Ethnic disparities in stroke: The scope of the problem. Ethn Dis 2001;11:761-8.
Centers for Disease Control and Prevention. Awareness of stroke warning symptoms: 13 states and the District of Columbia, 2005. MMWR Morb Mortal Wkly Rep 2008;57:481-5.
Greenlund KJ, Neff LJ, Zheng ZJ, Keenan NL, Giles WH, Ayala CA, et al
. Low public recognition of major stroke symptoms. Am J Prev Med 2003;25:315-9.
Schneider AT, Pancioli AM, Khoury JC, Rademacher E, Tuchfarber A, Miller R, et al
. Trends in community knowledge of the warning signs and risk factors for stroke. JAMA 2003;289:343-6.
Hsia AW, Castle A, Wing JJ, Edwards DF, Brown NC, Higgins TM, et al
. Understanding reasons for delay in seeking acute stroke care in an underserved urban population. Stroke2011;42:1697-701.
Hertz RP, Unger AN, Cornell JA, Saunders E. Racial disparities in hypertension prevalence, awareness, and management. Arch Intern Med 2005;165:2098-104.
Hajjar I, Kotchen TA. Trends in prevalence, awareness, treatment, and control of hypertension in the United States, 1988-2000. JAMA 2003;290:199-206.
Shaya FT, Du D, Gbarayor CM, Frech-Tamas F, Lau H, Weir MR. Predictors of compliance with antihypertensive therapy in a high-risk Medicaid population. J Natl Med Assoc 2009;101:34-9.
Trinacty CM, Adams AS, Soumerai SB, Zhang F, Meigs JB, Piette JD, et al
. Racial differences in long-term adherence to oral antidiabetic drug therapy: A longitudinal cohort study. BMC Health Serv Res 2009;9:24.
Yood MU, McCarthy BD, Kempf J, Kucera GP, Wells K, Oliveria S, et al
. Racial differences in reaching target low-density lipoprotein goal among individuals treated with prescription statin therapy. Am Heart J 2006;152:777-84.
Glasser SP, Cushman M, Prineas R, Kleindorfer D, Prince V, You Z, et al
. Does differential prophylactic aspirin use contribute to racial and geographic disparities in stroke and coronary heart disease (CHD)? Prev Med 2008;47:161-6.
Christian JB, Lapane KL, Toppa RS. Racial disparities in receipt of secondary stroke prevention agents among US nursing home residents. Stroke 2003;34:2693-7.
Macartney S, Bishaw A, Fontenot K. Poverty Rates for Selected Detailed Race and Hispanic Groups by State and Place: 2007-2011 (ACSBR/11--1, Feb., 2013.
Gellad WF, Haas JS, Safran DG. Race/ethnicity and nonadherence to prescription medications among seniors: Results of a national study. J Gen Intern Med 2007;22:1572-8.
Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical Association. Health literacy: Report of the Council on Scientific Affairs. JAMA1999;281:552-7.
Karve SJ, Balkrishnan R, Mohammad YM, Levine DA. Racial/ethnic disparities in emergency department waiting time for stroke patients in the United States. J Stroke Cerebrovasc Dis 2011;20:30-40.
Chiou-Tan FY, Keng MJ Jr, Graves DE, Chan KT, Rintala DH. Racial/ethnic differences in FIM scores and length of stay for under insured patients undergoing stroke inpatient rehabilitation. Am J Phys Med Rehabil 2006;85:415-23.
Artinian NT, Fletcher GF, Mozaffarian D, Kris-Etherton P, Van Horn L, Lichtenstein AH, et al
. Interventions to promote physical activity and dietary lifestyle changes for cardiovascular risk factor reduction in adults: A scientific statement from the American Heart Association. Circulation 2010;122:406-41.
Chin MH, Walters AE, Cook SC, Huang ES. Interventions to reduce racial and ethnic disparities in health care. Med Care Res Rev 2007;64(5Suppl):7-28S.
Davis AM, Vinci LM, Okwuosa TM, Chase AR, Huang ES. Cardiovascular health disparities: A systematic review of health care interventions. Med Care Res Rev 2007;64(5 Suppl):29-100S.
Cummings DM, Letter AJ, Howard G, Howard VJ, Safford MM, Prince V, et al
. Medication adherence and stroke/TIA risk in treated hypertensives: Results from the REGARDS study. J Am SocHypertens2013;7:363-9.
Dimeo F, Pagonas N, Seibert F, Arndt R, Zidek W, Westhoff TH. Aerobic exercise reduces blood pressure in resistant hypertension. Hypertension 2012;60:653-8.
Hoogwegt MT, Versteeg H, Hansen TB, Thygesen LC, Pedersen SS, Zwisler AD. Exercise mediates the association between positive affect and 5-year mortality in patients with ischemic heart disease. Circ Cardiovasc Qual Outcomes 2013;6:559-66.
Jefferis BJ, Whincup PH, Papacosta O, Wannamethee SG. Protective effect of time spent walking on risk of stroke in older men. Stroke 2014;45:194-9.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]