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Journal of Epidemiology and Community Health logoLink to Journal of Epidemiology and Community Health
. 2002 Feb;56(Suppl 1):i19–i24. doi: 10.1136/jech.56.suppl_1.i19

Total and HDL cholesterol and risk of stroke. EUROSTROKE: a collaborative study among research centres in Europe

M Bots, P Elwood, Y Nikitin, J Salonen, d Freire, D Inzitari, J Sivenius, V Benetou, J Tuomilehto, P Koudstaal, D Grobbee
PMCID: PMC1765509  PMID: 11815640

Abstract

Background: Controversy remains on the relation between serum lipids levels and stroke risk. This paper investigated the association of total and HDL cholesterol level to fatal and non-fatal, and haemorrhagic and ischaemic stroke in four European cohorts participating in EUROSTROKE.

Methods: EUROSTROKE is a collaborative project among ongoing European cohort studies on incidence and risk factors of stroke. EUROSTROKE is designed as a nested case-control study. For each stroke case, two controls were sampled. Strokes were classified according to MONICA criteria or reviewed by a panel of four neurologists. At present, data on stroke and risk factors were available from cohorts in Cardiff (84 cases), Kuopio (74 cases), Rotterdam (157 cases), and Novosibirsk (79 cases).

Results: Pooled analyses showed no significant association between total cholesterol and risk of stroke (odds ratio for increase of 1 mmol/l in cholesterol of 0.98 (95% CI 0.88 to 1.09)). Analyses for haemorrhagic stroke and cerebral infarction revealed odds ratios of 0.80 (95% CI 0.61 to 1.05) and 1.06 (95% CI 0.94 to 1.19), respectively. The association of HDL cholesterol to stroke was different in men compared with women. In men, there was a general trend towards a lower risk of stroke with an increase in HDL (odds ratio per 1 mmol/l increase in HDL cholesterol 0.68 (95% CI 0.40 to 1.16)). In women, however, an increase in HDL was associated with a significant increased risk of non-fatal stroke and of cerebral infarction (odds ratios of 2.46 (95% 0.1.20 to 5.04) and 2.52 (95% CI 1.15 to 5.50), respectively. The difference between men and women in the association of HDL with stroke seemed to differ mainly in smokers and never smokers, but not among ex smokers.

Conclusion: This analysis of the EUROSTROKE project could not disclose an association of total cholesterol with fatal, non-fatal, haemorrhagic or ischaemic stroke. HDL cholesterol however, seemed to be related to stroke differently in men than in women.

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Selected References

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  1. Asplund K., Tuomilehto J., Stegmayr B., Wester P. O., Tunstall-Pedoe H. Diagnostic criteria and quality control of the registration of stroke events in the MONICA project. Acta Med Scand Suppl. 1988;728:26–39. doi: 10.1111/j.0954-6820.1988.tb05550.x. [DOI] [PubMed] [Google Scholar]
  2. Bamford J., Sandercock P., Dennis M., Burn J., Warlow C. Classification and natural history of clinically identifiable subtypes of cerebral infarction. Lancet. 1991 Jun 22;337(8756):1521–1526. doi: 10.1016/0140-6736(91)93206-o. [DOI] [PubMed] [Google Scholar]
  3. Benfante R., Yano K., Hwang L. J., Curb J. D., Kagan A., Ross W. Elevated serum cholesterol is a risk factor for both coronary heart disease and thromboembolic stroke in Hawaiian Japanese men. Implications of shared risk. Stroke. 1994 Apr;25(4):814–820. doi: 10.1161/01.str.25.4.814. [DOI] [PubMed] [Google Scholar]
  4. Bots M. L., Hoes A. W., Koudstaal P. J., Hofman A., Grobbee D. E. Common carotid intima-media thickness and risk of stroke and myocardial infarction: the Rotterdam Study. Circulation. 1997 Sep 2;96(5):1432–1437. doi: 10.1161/01.cir.96.5.1432. [DOI] [PubMed] [Google Scholar]
  5. Byington R. P., Jukema J. W., Salonen J. T., Pitt B., Bruschke A. V., Hoen H., Furberg C. D., Mancini G. B. Reduction in cardiovascular events during pravastatin therapy. Pooled analysis of clinical events of the Pravastatin Atherosclerosis Intervention Program. Circulation. 1995 Nov 1;92(9):2419–2425. doi: 10.1161/01.cir.92.9.2419. [DOI] [PubMed] [Google Scholar]
  6. Feigin V. L., Wiebers D. O., Whisnant J. P., O'Fallon W. M. Stroke incidence and 30-day case-fatality rates in Novosibirsk, Russia, 1982 through 1992. Stroke. 1995 Jun;26(6):924–929. doi: 10.1161/01.str.26.6.924. [DOI] [PubMed] [Google Scholar]
  7. Gatchev O., Råstam L., Lindberg G., Gullberg B., Eklund G. A., Isacsson S. O. Subarachnoid hemorrhage, cerebral hemorrhage, and serum cholesterol concentration in men and women. Ann Epidemiol. 1993 Jul;3(4):403–409. doi: 10.1016/1047-2797(93)90068-f. [DOI] [PubMed] [Google Scholar]
  8. Gordon T., Kannel W. B., Castelli W. P., Dawber T. R. Lipoproteins, cardiovascular disease, and death. The Framingham study. Arch Intern Med. 1981 Aug;141(9):1128–1131. [PubMed] [Google Scholar]
  9. Grobbee D. E., Koudstaal P. J., Bots M. L., Amaducci L. A., Elwood P. C., Ferro J., Freire de Concalves A., Krüger O., Inzitari D., Nikitin Y. Incidence and risk factors of ischaemic and haemorrhagic stroke in Europe. EUROSTROKE: A collaborative study among research centres in Europe: rationale and design. Neuroepidemiology. 1996;15(6):291–300. doi: 10.1159/000109919. [DOI] [PubMed] [Google Scholar]
  10. Harmsen P., Rosengren A., Tsipogianni A., Wilhelmsen L. Risk factors for stroke in middle-aged men in Göteborg, Sweden. Stroke. 1990 Feb;21(2):223–229. doi: 10.1161/01.str.21.2.223. [DOI] [PubMed] [Google Scholar]
  11. Hebert P. R., Gaziano J. M., Hennekens C. H. An overview of trials of cholesterol lowering and risk of stroke. Arch Intern Med. 1995 Jan 9;155(1):50–55. [PubMed] [Google Scholar]
  12. Hofman A., Grobbee D. E., de Jong P. T., van den Ouweland F. A. Determinants of disease and disability in the elderly: the Rotterdam Elderly Study. Eur J Epidemiol. 1991 Jul;7(4):403–422. doi: 10.1007/BF00145007. [DOI] [PubMed] [Google Scholar]
  13. Håheim L. L., Holme I., Hjermann I., Leren P. Risk factors of stroke incidence and mortality. A 12-year follow-up of the Oslo Study. Stroke. 1993 Oct;24(10):1484–1489. doi: 10.1161/01.str.24.10.1484. [DOI] [PubMed] [Google Scholar]
  14. Iso H., Jacobs D. R., Jr, Wentworth D., Neaton J. D., Cohen J. D. Serum cholesterol levels and six-year mortality from stroke in 350,977 men screened for the multiple risk factor intervention trial. N Engl J Med. 1989 Apr 6;320(14):904–910. doi: 10.1056/NEJM198904063201405. [DOI] [PubMed] [Google Scholar]
  15. Kuller L., Reisler D. M. An explanation for variations in distribution of stroke and arteriosclerotic heart disease among populations and racial groups. Am J Epidemiol. 1971 Jan;93(1):1–9. doi: 10.1093/oxfordjournals.aje.a121223. [DOI] [PubMed] [Google Scholar]
  16. Lindenstrøm E., Boysen G., Nyboe J. Influence of total cholesterol, high density lipoprotein cholesterol, and triglycerides on risk of cerebrovascular disease: the Copenhagen City Heart Study. BMJ. 1994 Jul 2;309(6946):11–15. doi: 10.1136/bmj.309.6946.11. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. MacMahon S., Peto R., Cutler J., Collins R., Sorlie P., Neaton J., Abbott R., Godwin J., Dyer A., Stamler J. Blood pressure, stroke, and coronary heart disease. Part 1, Prolonged differences in blood pressure: prospective observational studies corrected for the regression dilution bias. Lancet. 1990 Mar 31;335(8692):765–774. doi: 10.1016/0140-6736(90)90878-9. [DOI] [PubMed] [Google Scholar]
  18. Nissinen A., Kivela S. L., Pekkanen J., Tuomilehto J., Kostiainen E., Piippo H., Lammi U. K., Kaarsalo E., Romo M., Punsar S. Levels of some biological risk indicators among elderly men in Finland. Age Ageing. 1986 Jul;15(4):203–211. doi: 10.1093/ageing/15.4.203. [DOI] [PubMed] [Google Scholar]
  19. Reed D. M. The paradox of high risk of stroke in populations with low risk of coronary heart disease. Am J Epidemiol. 1990 Apr;131(4):579–588. doi: 10.1093/oxfordjournals.aje.a115542. [DOI] [PubMed] [Google Scholar]
  20. Salonen J. T., Puska P., Tuomilehto J., Homan K. Relation of blood pressure, serum lipids, and smoking to the risk of cerebral stroke. A longitudinal study in Eastern Finland. Stroke. 1982 May-Jun;13(3):327–333. doi: 10.1161/01.str.13.3.327. [DOI] [PubMed] [Google Scholar]
  21. Salonen J. T., Salonen R., Seppänen K., Rauramaa R., Tuomilehto J. HDL, HDL2, and HDL3 subfractions, and the risk of acute myocardial infarction. A prospective population study in eastern Finnish men. Circulation. 1991 Jul;84(1):129–139. doi: 10.1161/01.cir.84.1.129. [DOI] [PubMed] [Google Scholar]
  22. Shepherd J., Cobbe S. M., Ford I., Isles C. G., Lorimer A. R., MacFarlane P. W., McKillop J. H., Packard C. J. Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia. West of Scotland Coronary Prevention Study Group. N Engl J Med. 1995 Nov 16;333(20):1301–1307. doi: 10.1056/NEJM199511163332001. [DOI] [PubMed] [Google Scholar]
  23. Steele B. W., Koehler D. F., Kuba K., Azar M. M. An enzymatic approach to lipoprotein quantification. Am J Clin Pathol. 1980 Jan;73(1):75–78. doi: 10.1093/ajcp/73.1.75. [DOI] [PubMed] [Google Scholar]
  24. Tanne D., Yaari S., Goldbourt U. High-density lipoprotein cholesterol and risk of ischemic stroke mortality. A 21-year follow-up of 8586 men from the Israeli Ischemic Heart Disease Study. Stroke. 1997 Jan;28(1):83–87. doi: 10.1161/01.str.28.1.83. [DOI] [PubMed] [Google Scholar]
  25. The World Health Organization MONICA Project (monitoring trends and determinants in cardiovascular disease): a major international collaboration. WHO MONICA Project Principal Investigators. J Clin Epidemiol. 1988;41(2):105–114. doi: 10.1016/0895-4356(88)90084-4. [DOI] [PubMed] [Google Scholar]
  26. Thorvaldsen P., Asplund K., Kuulasmaa K., Rajakangas A. M., Schroll M. Stroke incidence, case fatality, and mortality in the WHO MONICA project. World Health Organization Monitoring Trends and Determinants in Cardiovascular Disease. Stroke. 1995 Mar;26(3):361–367. doi: 10.1161/01.str.26.3.361. [DOI] [PubMed] [Google Scholar]
  27. Tuomilehto J., Sarti C., Narva E. V., Salmi K., Sivenius J., Kaarsalo E., Salomaa V., Torppa J. The FINMONICA Stroke Register. Community-based stroke registration and analysis of stroke incidence in Finland, 1983-1985. Am J Epidemiol. 1992 Jun 1;135(11):1259–1270. doi: 10.1093/oxfordjournals.aje.a116232. [DOI] [PubMed] [Google Scholar]
  28. Willems J. L., Abreu-Lima C., Arnaud P., van Bemmel J. H., Brohet C., Degani R., Denis B., Gehring J., Graham I., van Herpen G. The diagnostic performance of computer programs for the interpretation of electrocardiograms. N Engl J Med. 1991 Dec 19;325(25):1767–1773. doi: 10.1056/NEJM199112193252503. [DOI] [PubMed] [Google Scholar]
  29. Wolf P. A., D'Agostino R. B., Belanger A. J., Kannel W. B. Probability of stroke: a risk profile from the Framingham Study. Stroke. 1991 Mar;22(3):312–318. doi: 10.1161/01.str.22.3.312. [DOI] [PubMed] [Google Scholar]
  30. van Bemmel J. H., Kors J. A., van Herpen G. Methodology of the modular ECG analysis system MEANS. Methods Inf Med. 1990 Sep;29(4):346–353. [PubMed] [Google Scholar]
  31. van der Bom J. G., Bots M. L., Haverkate F., Slagboom P. E., Meijer P., de Jong P. T., Hofman A., Grobbee D. E., Kluft C. Reduced response to activated protein C is associated with increased risk for cerebrovascular disease. Ann Intern Med. 1996 Aug 15;125(4):265–269. doi: 10.7326/0003-4819-125-4-199608150-00002. [DOI] [PubMed] [Google Scholar]

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