Stroke Declines From Third to Fourth Leading Cause of
Death in the United States
Historical Perspective and Challenges Ahead
Amytis Towfighi, MD; Jeffrey L. Saver, MD
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Background and Purpose—Stroke recently declined from the third to the fourth leading cause of death in the United
States, its first rank transition among sources of American mortality in nearly 75 years.
Methods—This is a narrative review supplemented by new analyses of Centers for Disease Control and Prevention
National Vital Statistics Reports from 1931 to 2008.
Results—Historically, stroke transitioned from the second to the third leading cause of death in the United States in 1937,
but stroke death rates were essentially stable from 1930 to 1960. Then a long, great decline began, moderate in the
1960s, precipitous in the 1970s and 1980s, and moderate again in the 1990s and 2000s. By 2008, age-adjusted annual
death rates from stroke were three fourths less than the historic 1931 to 1960 norm (40.6 versus 175.0 per 100 000).
Total actual stroke deaths in the United States declined from a high of 214 000 in 1973 to 134 000 in 2008. Improved
stroke prevention, through control of hypertension, hyperlipidemia, and tobacco, contributed most greatly to the
mortality decline with a lesser but still substantial contribution of improved acute stroke care. Persisting challenges
include race– ethnicity, sex, and geographic disparities in stroke mortality; the burden of stroke disability; the expanding
obesity epidemic and aging of the US population; and the epidemic of cerebrovascular disease in low- and
middle-income countries worldwide.
Conclusions—The recent rank decline of stroke among leading causes of American death is testament to a half century
of societal progress in cerebrovascular disease prevention and acute care. Renewed commitments are needed to preserve
and broaden this historic achievement. (Stroke. 2011;42:2351-2355.)
Key Words: age-adjusted 䡲 cause of death 䡲 death rates 䡲 mortality 䡲 stroke 䡲 total deaths 䡲 trends
䡲 United States
T
Trends in Causes of Death in the United States,
1931 to 2008
he Centers for Disease Control and Prevention recently
released mortality data indicating that in 2008, stroke
declined from the third to the fourth leading cause of death
in the United States after heart disease, cancer, and chronic
lower respiratory diseases (CLRD).1 For stroke health
professionals, this demotion is a welcome indignity, and an
important occasion to reflect on historical trends in strokespecific mortality and the drivers of mortality reduction
and also to highlight persisting challenges, including
race– ethnicity, sex, and geographic disparities in stroke
mortality; the ongoing burden of stroke disability; the
expanding obesity epidemic and aging of the US population; and the epidemic of cerebrovascular disease worldwide, where stroke remains the second leading cause of
death after heart disease.
For historical perspective, it is useful to consider the long arc
of changing stroke mortality rates going back to the last time
stroke transitioned among the ranks of the leading causes of
death. Figure 1 shows age-adjusted death rates in the United
States from 1931 to 2008 for the current top 10 causes of
death using data from the Centers for Disease Control and
Prevention’s National Vital Statistics Reports.2 In 1931,
stroke was the second leading cause of death, after heart
disease, with an overall mortality rate of 195.0 per 100 000.
Over the next 20 years, stroke death rates declined slightly,
whereas cancer death rates climbed a little, with crossover in
1937, but these 2 remained a close and essentially stable
number 2 and number 3 through the early 1960s. Then a long,
Received March 29, 2011; final revision received April 30, 2011; accepted May 3, 2011.
From the Division of Stroke and Critical Care (A.T.), Department of Neurology, University of Southern California, Los Angeles, CA; the Department
of Neurology (A.T.), Rancho Los Amigos National Rehabilitation Center, Downey, CA; and the Department of Neurology and Stroke Center (J.L.S.),
University of California at Los Angeles, Los Angeles, CA.
Correspondence to Amytis Towfighi, MD, 7601 E Imperial Highway, HB145, Downey, CA 90242. E-mail [email protected]
© 2011 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org
DOI: 10.1161/STROKEAHA.111.621904
2351
2352
Stroke
August 2011
Figure 1. Temporal trends in age-adjusted death rates for the top 10 causes of death in the United States from 1931 to 2008.
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great decline in age-adjusted stroke death rates began, dropping modestly but steadily through the 1960s (falling by 1.2
per 100 000 per year), rapidly in the 1970s (⫺5.6 per 100 000
per year) and 1980s (⫺3.3 per 100 000 per year), mildly in
the 1990s (⫺0.4 per 100 000 per year), and moderately in the
2000s (⫺2.5 per 100 000 per year). By 2008, the stroke
mortality rate was three fourths less than its historic 1931 to
1960 norm (40.6 versus 175.9 per 100 000). Cardiac mortality rates exhibited a similar pattern, suggesting parallel
sources of change in death rates for the 2 major vascular
diseases.
This historical view places in perspective a technical
aspect of the National Center for Health Statistics methodology. The crossover in 2008 between stroke and CLRD
mortality was artifactual in part, occurring in this particular year because the National Center for Health Statistics
changed the method for counting CLRD deaths. The
National Center for Health Statistics in 2008 departed from
past practices by including in the CLRD category deaths
due to pneumonia, influenza, and bronchitis. As a result,
from 2007 to 2008, CLRD death rates jumped sharply, a
contrast to the mild decline of the prior 5 years (7.8%
versus ⫺1.7% per year). At the same time, stroke death
rates from 2007 to 2008 fell a little less than usual
compared with the prior 5 years (⫺3.8% versus ⫺6.1% per
year). The rationale for including seemingly acute pulmo-
nary conditions, like pneumonia and influenza, in the
category of CLRD has been questioned. However, seen
from the long historic view, the change in CLRD death
definition is not the fundamental explanation for the rank
transition among causes of death. Even without the definition change, stroke mortality rates were trending to fall
below CLRD rates in the near future. The definition
alteration only moved up by a few years, a moment of
triumph that is the culmination of 40 years of progress in
control of stroke mortality.
Indeed, the historic perspective captured in Figure 1
affords hope that we will shortly be celebrating another
milestone. If recent trends in age-adjusted death rates
continue, stroke will soon decline even further, from fourth
to fifth, among the leading causes of death, below
accidents.
Age-adjusted death rates correct for variations over time
in the age distribution of Americans, permitting valid
comparisons to be made across eras. However, for health
policy planning and additional historical perspective, it is
also important to consider total actual deaths due to
different diseases. Total actual deaths reflect not only
disease control, but also the growth in the overall size of
the US population over time and changes in its age
distribution, including the recent demographic aging of
American society. Figure 2 shows total actual deaths for
Figure 2. Temporal trends in total number of actual deaths for the top 10 causes of death in the United States from 1931 to 2008.
Towfighi and Saver
the top 10 causes of death from 1931 to 2008. In 1931,
stroke was the fifth leading cause of actual deaths, after
heart disease, influenza and pneumonia, malignancy, and
nephritis (Figure 2). Total stroke deaths then increased
along with the size of the US population, modestly in the
1930s and 1940s and sharply in the 1950s. The rate of
growth moderated in the 1960s and early 1970s, because
decline in age-adjusted stroke death rates partially counterbalanced the continued overall population increase. Total
stroke deaths declined from 1976 to 1992, rose a bit through
2002, and declined again through 2008, reflecting the contending effects of further declines in stroke mortality rates
and overall population growth. In 2008, stroke fell from third
to fourth, below CLRD, among the leading causes of total
actual deaths in the United States. The 133 750 stroke deaths
in 2008 are 38% less than the historic high of 214 313 stroke
deaths experienced in 1973.
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Disparities in Stroke Mortality in the
United States
The welcome news of a general decline in stroke mortality
is tempered by evidence of substantial ongoing disparities
in the distribution of this success. A recent analysis of the
National Center for Health Statistics mortality data from
1996 to 2005 identified important racial and sex disparities
in stroke death rates. Stroke became the fifth leading cause
of death in men and fourth leading cause of death in whites
but remained the second leading cause of death in women
and blacks.3 Moreover, several studies have identified
important regional differences in stroke mortality rates
with disproportionately higher rates in the “stroke belt”
(North Carolina, South Carolina, Georgia, Alabama, Mississippi, Arkansas, Tennessee, and Louisiana). These
states have a stroke mortality rate approximately 40%
higher than the rest of the nation.4,5
Potential Reasons for the Decline in
Stroke Mortality
Better stroke prevention is almost certainly the larger
contributor to the dramatic decline of stroke deaths over
the past 40 years with a lesser, but not insubstantial,
contribution from improved acute treatment. The fall in
stroke mortality parallels a sharp decrease in stroke incidence during this time period. Numerous studies have
illustrated the declines in incidence of stroke, particularly
among white populations. An analysis of predominantly
white individuals aged ⱖ55 years followed in the Framingham Heart Study for up to 50 years over 3 consecutive
periods (1950 to 1977, 1978 to 1989, and 1990 to 2004)
revealed that the age-adjusted incidence of first stroke per
1000 person-years in each of the 3 periods was 7.6, 6.2,
and 5.3, respectively, in men (P⫽0.02 for trend) and 6.2,
5.8, and 5.1 in women (P⫽0.01 for trend). The lifetime
risk at age 65 years decreased from 19.5% to 14.5% in men
(P⫽0.11) and 18.0% to 16.1% in women (P⫽0.61).6 The
Greater Cincinnati Northern Kentucky Stroke Study demonstrated a racial disparity with stroke incidence declining
over the past decade in whites but stable among blacks.7
Hospitalizations for stroke have declined in tandem with
Stroke Now the Fourth Leading Cause of Death
2353
incidence. An assessment of primary and secondary stroke
hospitalizations in the United States between 1997 and
2006 using the Nationwide Inpatient Sample revealed that
age-adjusted stroke admission rates per 100 000 persons
decreased from 282.7 to 210.4 in men (26%; P⫽0.001) and
from 240.5 to 184.7 in women (23%; P⫽0.05), highlighting sex disparities in declines in stroke incidence.8
Declines in stroke incidence have coincided with improvements in vascular risk factor control. Consecutive National
Health and Nutrition Examination Surveys reveal that treatment and control rates of hypertension have improved,
particularly among non-Hispanic white and black men.9 In
addition, statin use has increased considerably in the United
States. In 1999/2000, 2001/2002, and 2003/2004, statins were
being used by 19.6%, 27.3%, and 35.9% of US adults with
high low-density lipoprotein cholesterol levels, respectively (P trend ⬍0.001). Age-standardized mean lowdensity lipoprotein cholesterol declined from 119.9 to
112.0 to 100.7 mg/dL among statin users between 1999 to
2000, 2001 to 2002, and 2003 to 2004. Low-density
lipoprotein cholesterol control to ATP-III-recommended
targets was achieved by 49.7%, 67.4%, and 77.6% of statin
users in 1999/2000, 2001/2002, and 2003/2004, respectively (P trend ⬍0.001).10 In addition, cross-sectional
population-based surveys over the past 20 years in Minnesota revealed that (1) blood pressure decreased and
awareness, treatment, and control of hypertension increased11; (2) total cholesterol levels decreased and awareness, treatment, and control of hypercholesterolemia increased12; and (3) smoking rates decreased.13 Among
stroke survivors in the Framingham Heart Study, mean
systolic blood pressure and cholesterol levels, prevalence
of hypertension, proportion of all participants receiving
treatment for hypertension, and prevalence of current
smoking decreased significantly over 3 consecutive periods (1950 to 1977, 1978 to 1989, and 1990 to 2004).6
However, the prevalence of diabetes in women and of
atrial fibrillation in men, and the mean body mass index in
both sexes, worsened significantly over time.6
Improved acute stroke management has likely also
contributed to the mortality decline, albeit to a lesser
degree. In controlled clinical trials, organized stroke care
reduces mortality modestly (OR, 0.86; 95% CI, 0.76 to
0.98; P⫽0.02).14 With the spread of organized stroke care
and Primary Stroke Centers in the United States, reductions in mortality among stroke admissions have been
noted in actual practice.6,15,16
Impact of the Obesity Epidemic and Population
Aging on Stroke Mortality
Unfortunately, the recent lows in stroke mortality may be
short-lived. The obesity epidemic and the aging of the
population in the United States threaten the improvements in
stroke mortality achieved by better control of blood pressure,
cholesterol, and tobacco use over the past 4 decades. In
2007/2008, the age-adjusted prevalence of obesity was 33.8%
(95% CI, 31.6% to 36.0%) overall, 32.2% (95% CI, 29.5% to
35.0%) among men, and 35.5% (95% CI, 33.2% to 37.7%)
among women. The corresponding prevalence of over-
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August 2011
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weight and obesity combined (body mass index ⱖ25
kg/m2) was 68.0% (95% CI, 66.3% to 69.8%), 72.3% (95%
CI, 70.4% to 74.1%), and 64.1% (95% CI, 61.3% to
66.9%).17 If the trajectory of the past 30 years continues,
86% of Americans will be overweight or obese by the year
2030.18 As a result of burgeoning obesity prevalence, rates
of diabetes and hypertension have increased. National
Health and Nutrition Examination Survey data reveal that
crude prevalence of diagnosed diabetes in adults rose from
5.1% in 1988 to 1994 to 7.7% in 2005 to 2006
(P⬍0.0001)19 and the age-standardized prevalence rate of
hypertension increased from 24.4% in 1988 to 1994 to
28.9% in 1999 to 2004 (P⬍0.001) with the largest increases among non-Hispanic women.9 Depending on sex
and race/ethnicity, from one fifth to four fifths of the
increase could be accounted for by increasing body mass
index.9
Obesity affects poststroke survival. Among adults with
prevalent stroke in the United States who participated in
National Health and Nutrition Examination Surveys 1988 to
1994 followed through 2000, risk for all-cause mortality
increased per kg/m2 of higher body mass index (P⫽0.030).
The association of higher body mass index with mortality was
strongest in younger individuals and declined linearly with
increasing age.20
Moreover, for the next 2 decades, the demographic aging
of the US population appears destined to bring an increase in
the total actual deaths due to stroke, whatever the course of
age-adjusted stroke death rates. This year, 2011, the first of
the baby boomers turns 65 years of age and enters the most
stroke-prone years. Individuals aged ⬎65 years have a higher
prevalence of cardiovascular and cerebrovascular disease,
and this segment of the population is projected to increase
substantially over the next 2 decades. By 2030, it is estimated
that an additional 27 million people will have hypertension, 8
million will have heart disease, and 4 million will have had a
stroke.21
Stroke Remains a Leading Cause of Disability in
the United States
A tradeoff of mortality reduction through better acute stroke
care is an increase in survivors with poststroke morbidity.
Despite improvements in stroke death rates, stroke remains a
leading cause of serious, long-term disability in the United
States, costing an estimated $73.7 billion in economic costs in
2010 and a human cost to patients and families that is
incalculable. As more and more individuals survive their
strokes, the burden of poststroke disability will be an increasing public health priority. It will be of utmost importance to
rigorously assess and design interventions to improve functional outcomes and quality of life after stroke.
Stroke Mortality Worldwide
Despite improvements in stroke mortality in the United
States, stroke remains the second leading cause of death
worldwide. Over two thirds of stroke deaths worldwide occur
in developing countries.22 The World Health Organization
estimates for 2001 indicate that 4.61 million people died from
cerebrovascular disease, accounting for 9.5% of deaths.23
Although rates of stroke mortality and burden vary greatly
among countries, low-income countries are the most severely
affected. There has been a 42% decrease in stroke incidence
in high-income countries and ⬎100% increase in low- to
middle-income countries.24 The progress in prevention and
mortality achieved in developed world urgently need to be
translated to middle- and lower-income societies.
Conclusions
The decline in stroke from the third to fourth leading cause of
death in the United States marks an important milestone in
prevention and care of cerebrovascular disease. For stroke
health professionals, this accomplishment is an occasion for
celebration and rededication. Let us pause, for a moment, to
be justly proud of the achievement of generations of public
health, primary care and specialist physicians, and allied
health professionals in reducing stroke mortality. Then let us
take up our burden anew and focus on the challenges we, and
our patients, still face: (1) reducing racial/ethnic, sex, and
regional disparities in stroke incidence and outcomes; (2)
reducing the incidence of obesity; (3) achieving even greater
gains in blood pressure, cholesterol, and tobacco control; (4)
iteratively improving acute stroke care systems; (5) reducing
poststroke disability and improving quality of life after
stroke; and (6) improving stroke prevention and care efforts
in low- and middle-income countries.
Disclosures
None.
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Stroke Declines From Third to Fourth Leading Cause of Death in the United States:
Historical Perspective and Challenges Ahead
Amytis Towfighi and Jeffrey L. Saver
Downloaded from http://stroke.ahajournals.org/ by guest on June 16, 2017
Stroke. 2011;42:2351-2355; originally published online July 21, 2011;
doi: 10.1161/STROKEAHA.111.621904
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