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Hypertension constitutes the most important risk factor for
stroke5 and, according to our analysis, is highly correlated with
macroindicators of lower socioeconomic status at the population
level. Additionally, effective preventive drugs for cerebrovascular disease are underused worldwide with outstanding low use
rates in less economically developed countries.3 Consequently,
hypertension should be considered the primary low-cost target
for reducing stroke burden in lower income countries through
effective public health policies including community educational
programs, hypertension screening strategies, and improvement of
access to preventive care.
Letter by Sposato and Saposnik Regarding
Article, “Socioeconomic Status and Stroke:
An Updated Review”
Downloaded from http://stroke.ahajournals.org/ by guest on June 15, 2017
To the Editor:
We read with great interest the article “Socioeconomic Status
and Stroke: An Updated Review” by Addo et al.1 The authors
analyzed articles reporting the association between measures of
socioeconomic status and stroke between January 2006 and July
2011. They found a ⬎3-fold greater stroke impact (eg, disabilityadjusted life-years lost and mortality rates), a higher stroke
incidence, and a greater frequency of vascular risk factors in
low-income compared with high- and middle-income countries.
Similarly, in a systematic review of population-based studies
published between 2000 and 2010, reporting incident stroke risk
and/or 30-day case-fatality, we found that lower per-capita gross
domestic product adjusted for purchasing power parity and total
health expenditure per capita at purchasing power parity were
associated with higher incident risk of stroke, higher casefatality, a greater proportion of hemorrhagic strokes, and lower
age at stroke onset.2
Many factors may explain the high burden of stroke in
low-income countries, including higher rates of vascular risk
factors,1 lower access or underuse of healthcare services and
preventive treatments,3 and a deleterious preconditioning during
childhood (eg, poorer nutritional status).4 The common pathway
for this detrimental association between lower socioeconomic
status and poorer health is a greater and longer exposure to
vascular risk factors.
Hypertension is the strongest risk factor for ischemic and
hemorrhagic stroke with a population-attributable risk of 52%.5
Blood pressure is possibly the best target for stroke prevention in
low-income countries because it can be detected through lowcost screening programs with no need for expensive equipment
or highly specialized care. Likewise, nonpharmacological measures and inexpensive generic drugs can be used for significantly
reducing the burden of disease.
We also assessed the correlation (2-tailed Spearman test) of
hypertension, diabetes mellitus, smoking, and atrial fibrillation
with 3 macroindicators of socioeconomic status: gross domestic
product adjusted for purchasing power parity, total health expenditure per capita at purchasing power parity, and unemployment
in the same 30 population-based studies.2 We found a higher
frequency of hypertension in countries with lower gross domestic
product adjusted for purchasing power parity (␳⫽⫺0.622,
P⫽0.004) and lower total health expenditure per capita at
purchasing power parity (␳⫽⫺0.641, P⫽0.003). There was no
association between unemployment and hypertension. Diabetes
mellitus, smoking, and atrial fibrillation were not correlated with
any of the 3 macroindicators of socioeconomic status.
Disclosures
None.
Luciano A. Sposato, MD, MBA
Stroke Center at the Institute of Neurosciences
Favaloro University Hospital
Institute of Cognitive Neurology (INECO) and Vascular
Research Unit at INECO Foundation
Buenos Aires, Argentina; and
Universidad Diego Portales
Santiago, Chile
Gustavo Saposnik, MD, MSc, FAHA
Division of Neurology
Department of Medicine
Department of Health Policy, Management and Evaluation
St Michael’s Hospital
University of Toronto
Toronto, Ontario, Canada
1. Addo J, Ayerbe L, Mohan KM, Crichton S, Sheldenkar A, Chen R, et al.
Socioeconomic status and stroke: an updated review. Stroke. 2011;42:
1201–1206.
2. Sposato LA, Saposnik G. Gross domestic product and health expenditure
associated with incidence, 30-day fatality, and age at stroke onset: a
systematic review. Stroke. 2012;43:170 –177.
3. Yusuf S, Islam S, Chow CK, Rangarajan S, Dagenais G, Diaz R, et al.
Use of secondary prevention drugs for cardiovascular disease in the
community in high-income, middle-income, and low-income countries
(the PURE Study): a prospective epidemiological survey. Lancet. 2011;
378:1231–1243.
4. Hinkle LE Jr, Whitney LH, Lehman EW, Dunn J, Benjamin B, King R, et
al. Occupation, education, and coronary heart disease: risk is influenced
more by education and background than by occupational experiences in the
Bell System. Science. 1968;161:238 –246.
5. O’Donnell MJ, Xavier D, Liu L, Zhang H, Chin SL, Rao-Melacini P, et al;
INTERSTROKE investigators. Risk factors for ischaemic and intracerebral
haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case–
control study. Lancet. 2010;376:112–123.
(Stroke. 2012;43:e77.)
© 2012 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org
DOI: 10.1161/STROKEAHA.112.657957
e77
Letter by Sposato and Saposnik Regarding Article, ''Socioeconomic Status and Stroke: An
Updated Review''
Luciano A. Sposato and Gustavo Saposnik
Downloaded from http://stroke.ahajournals.org/ by guest on June 15, 2017
Stroke. 2012;43:e77; originally published online May 24, 2012;
doi: 10.1161/STROKEAHA.112.657957
Stroke is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright © 2012 American Heart Association, Inc. All rights reserved.
Print ISSN: 0039-2499. Online ISSN: 1524-4628
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