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Title: Global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries (INTERSTROKE): a case-control study
Authors: Martin J. O'Donnell
Siu Lim Chin
Sumathy Rangarajan
Denis Xavier
Lisheng Liu
Hongye Zhang
Purnima Rao-Melacini
Xiaohe Zhang
Prem Pais
Steven Agapay
Patricio Lopez-Jaramillo
Albertino Damasceno
Peter Langhorne
Matthew J. McQueen
Annika Rosengren
Mahshid Dehghan
Graeme J. Hankey
Antonio L. Dans
Ahmed Elsayed
Alvaro Avezum
Charles Mondo
Hans Christoph Diener
Danuta Ryglewicz
Anna Czlonkowska
Nana Pogosova
Christian Weimar
Romaina Iqbal
Rafael Diaz
Khalid Yusoff
Afzalhussein Yusufali
Aytekin Oguz
Xingyu Wang
Ernesto Penaherrera
Fernando Lanas
Okechukwu S. Ogah
Adesola Ogunniyi
Helle K. Iversen
German Malaga
Zvonko Rumboldt
Shahram Oveisgharan
Fawaz Al Hussain
Daliwonga Magazi
Yongchai Nilanont
John Ferguson
Guillaume Pare
Salim Yusuf
Population Health Research Institute, Ontario
National University of Ireland Galway
St. John's Medical College
National Center for Cardiovascular Diseases
Beijing Hypertension League Institute
Universidad de Santander
Universidade Eduardo Mondlane
University of Glasgow
Sahlgrenska Universitetssjukhuset
University of Western Australia Faculty of Medicine and Dentistry
University of the Philippines Manila
Alzaeim Alazhari University
Instituto Dante Pazzanese de Cardiologia
Mulago Hospital
Universitats Klinikum Essen und Medizinische Fakultat
Institute of Psychiatry and Neurology, Warszawa
Ministry of Health of Russian Federation
The Aga Khan University Hospital
Estudios Clinicos Latinoamerica
Universiti Teknologi MARA
UCSI University
Dubai Medical College
Istanbul Medeniyet University
Luis Vernaza General Hospital
Universidad de la Frontera
University College Hospital, Ibadan
Københavns Universitet
Universidad Peruana Cayetano Heredia
University of Split
Rush University Medical Center
University of Limpopo
Mahidol University
King Saud University
Keywords: Medicine
Issue Date: 20-Aug-2016
Citation: The Lancet. Vol.388, No.10046 (2016), 761-775
Abstract: © 2016 Elsevier Ltd 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<0·0001). 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 Västra Götaland (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.
ISSN: 1474547X
Appears in Collections:Scopus 2016-2017

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