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

Issued Date

2016-08-20

Resource Type

Article

ISSN

1474547X
01406736

DOI

10.1016/S0140-6736(16)30506-2

Other identifier(s)

2-s2.0-84991666872

Rights

Mahidol University

Rights Holder(s)

SCOPUS

Bibliographic Citation

The Lancet. Vol.388, No.10046 (2016), 761-775

Suggested Citation

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 Global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries (INTERSTROKE): a case-control study. The Lancet. Vol.388, No.10046 (2016), 761-775. doi:10.1016/S0140-6736(16)30506-2 Retrieved from: https://repository.li.mahidol.ac.th/handle/20.500.14594/41222

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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

Author(s)

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

Other Contributor(s)

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

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.

Keyword(s)

Medicine

Availability

URI

https://repository.li.mahidol.ac.th/handle/20.500.14594/41222

Collections

Scopus 2016-2017