The United States began recording national estimates for cause of death in the 1930s when stroke was the second leading cause of death. Stroke dropped to third by 1938, fourth by 2008, and fifth by 2013.1 The American Heart Association’s 2024 Stroke Statistics identify stroke as the fifth leading cause of death.2
We analyzed publicly available data from the CDC WONDER 1999–2023 underlying cause of deaths database (https://wonder.cdc.gov). The primary outcome is total deaths, which is highly relevant for population health, and secondary outcome is death rate per 100,000. These data are derived from death certificates filed in all 50 states and the District of Columbia, each documenting an underlying cause of death and up to 20 contributing conditions. Causes are coded using the International Classification of Diseases framework, with the underlying cause selected based on physician-reported sequences and classification algorithms. We report outcomes for ischemic (I63.x-I67.x, I69.3-I69.8) and hemorrhagic (I60.x-I62.x, 169.0–169.2) stroke, total stroke (I60-I69), and acute myocardial infarction (AMI) (I21.x) as a control given its inherent similarity to stroke.
From its lowest point in 2009, when there were 95,380 ischemic stroke deaths, the annual toll rose to 128,611 in 2023—an increase of 34.9%. In contrast, deaths from AMI declined by 53.2% over the same period, while hemorrhagic stroke deaths remained relatively stable (Figure 1A). However, by classifying all I64 stroke deaths as ischemic, we potentially underestimated hemorrhagic stroke deaths.
Figure 1.
A: total annual deaths for AMI, hemorrhagic and ischemic stroke, A: total annual deaths for the top six causes; C: age-adjusted ischemic stroke death rate stratified by Non-Hispanic White and Black race and Hispanic ethnicity; D: percentage change in total annual number of ischemic stroke deaths from 2009 (lowest observed point) to 2023 in US states.
By 2017 ischemic stroke was a more common cause of death than AMI. Between 2009 and 2023, the mortality rate for ischemic stroke also increased by 23.5%, from 31.1 to 38.4 deaths per 100,000. Total stroke deaths increased by 26.2%, from 128,842 in 2009 to 162,639 in 2023, making stroke the fourth-leading cause of death (Figure 1B). Stroke remained fourth when using rate per 100,000, which increased from 42.0 to 48.6 per 100,000 in 2009 and 2023, a 15.7% rise.
In 2009, of the 95,390 ischemic stroke deaths, 74,367 were in people aged ≥75. By 2023, that age group experienced 95,417 deaths. In 2009, non-Hispanic Whites suffered 76,941 ischemic stroke deaths and by 2023 it increased to 94,884. However, those data mask a persistent race/ethnicity-based disparity in ischemic stroke deaths (Figure 1C, in 2023 the age-adjusted ischemic stroke mortality rate for non-Hispanic Blacks was 44.3 per 100,000, 30.4 for non-Hispanic Whites, and 26.4 for Hispanics).
In 2023, the South recorded approximately 55,750 ischemic stroke deaths, outpacing the Midwest (28,311), West (27,623), and Northeast (16,927). Between 2009 and 2023 geographic variations emerged, with substantial increases in ischemic stroke deaths in Florida (+128%), Maryland (+157%), Arizona (+79%), and Nevada (+75%), while some Midwest and Mountain states reported decreases such as North Dakota (−27%) and Montana (−14%) (Figure 1D). Some state-level changes could reflect sampling variation in low-population states such as Montana or North Dakota.
Stroke has resurged as the fourth leading cause of death, reversing decades of progress. Although the rise to fourth is due in part to less death from respiratory illness including COVID, it also reflects a consistent increase in stroke deaths over the last decade. The increase of ischemic stroke deaths over AMI may reflect the relative increase in vascular risk factors in people with stroke and the greater mortality benefit of acute interventions for AMI.3,4 Clinicians, researchers, and policymakers should act immediately to curb this epidemic.
Funding:
Dr. de Havenon reports NIH/NINDS funding (UG3NS130228, R01NS130189, R21NS138995). Dr. Sheth by NIH/NINDS U01NS106513, R01NS11072, R01EB301114, R01MD016178, R03NS112859, U24NS107215, and U24NS107136.
Disclosures:
Dr. de Havenon has received research funding from the AAN, has received consultant fees from Novo Nordisk, royalty fees from UpToDate, and has equity in TitinKM and Certus.
Dr. Sheth reports compensation from Philips and Sense for data and safety monitoring services; compensation or equity from Astrocyte, Bexorg, BrainQ, Rhaeos, and contracts to Yale from Hyperfine and Genentech; a patent pending for Stroke wearables licensed to Alva Health.
Non-standard abbreviations:
- CDC WONDER
Centers for Disease Control and Prevention Wide-ranging ONline Data for Epidemiologic Research
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