Deaths from haemorrhagic stroke declined consistently through the 20th century, but deaths from ischaemic stroke showed a rise and fall, mirroring the coronary heart disease epidemic.1 Blood pressure has also declined,2 and if blood pressure is more strongly associated with haemorrhagic stroke than with ischaemic stroke, this might contribute to the divergent trends. Previous meta-analyses have shown contradictory findings; one showed similar associations for both stroke subtypes,3 and another, of Asian studies, showed a stronger association with haemorrhagic stroke than with ischaemic stroke.4 To resolve this uncertainty, we examined the association of blood pressure with subtype of stroke in a large cohort of Korean civil servants.
Participants, methods, and results
The Korean National Health System for public servants and teachers provides medical expenses and biennial multiphasic health examinations at which blood pressure is measured in the seated position by trained staff using a standard mercury sphygmomanometer (fifth Korotkoff sound used for diastolic pressure) or an electronic manometer.5 We grouped mean blood pressures for individuals between 1986 and 1996 according to the joint national committee on prevention, detection, and treatment of high blood pressure categories of normal, stages 1, 2, and 3 (table). We included deaths attributed to ICD-10 (international classification of diseases, 10th revision) codes of I60-I69 for all strokes, I61 for haemorrhagic stroke, and I63 and I67.8 for ischaemic strokes between 1991 and 2000 in these analyses. We categorised non-fatal strokes using data on the use of medical care and found an accuracy of 83.4% and 85.7% for ischaemic stroke and haemorrhagic stroke.
Table 1.
Mean blood pressure and stroke subtype from the Korean National Health System Study, 1986-2000. Data are adjusted relative risks (95% confidence intervals) unless otherwise indicated*
|
All strokes (ICD†codes 160-169)
|
Ischaemic stroke (ICD†codes 163 and 167.8)
|
Haemorrhagic stroke (ICD†code 161)
|
||
|---|---|---|---|---|
| Fatal | Non-fatal | |||
| Number of strokes | 2073 | 8643 | 5326 | 2695 |
| Blood pressure categories systolic/diastolic (mm Hg):
|
|
|
|
|
| Normal <140/<90 | 1 | 1 | 1 | 1 |
| Stage 1 140-159/90-99 | 3.61 (3.25 to 4.02) | 3.04 (2.89 to 3.20) | 2.76 (2.59 to 2.94) | 4.90 (4.46 to 5.40) |
| Stage 2 160-179/100-109 | 8.44 (7.41 to 9.62) | 5.29 (4.94 to 5.68) | 4.83 (4.43 to 5.26) | 11.55 (10.27 to 12.98) |
| Stage 3 ≥180/≥110 | 19.39 (16.41 to 22.90) | 11.21 (10.17 to 12.36) | 9.56 (8.46 to 10.80) | 28.83 (24.89 to 33.40) |
| Systolic blood pressure (20 mm Hg increase) | 2.78 (2.66 to 2.90) | 2.36 (2.30 to 2.42) | 2.23 (2.17 to 2.30) | 3.18 (3.06 to 3.30) |
Adjusted for age, sex, body mass index, height, blood glucose, blood cholesterol, haemoglobin concentration, ethanol consumption, smoking, monthly pay level, and area of residency.
International classification of diseases, 10th revision.
In 9.5 million person years of observation of 955 271 people; they had 14 057 strokes, giving crude and age standardised incidences of 1.48 and 2.24 for every 1000 person years. Of these, 10 716 (76%) strokes had complete information on major exposure variables and we included these in our analyses; we classified 2695 strokes as haemorrhagic, 5326 as ischaemic, 1731 as undetermined, and 964 as subarachnoid haemorrhage.
We calculated fully adjusted relative risks and 95% confidence intervals using logistic regression. The gradient of risk with blood pressure was steeper for fatal than non-fatal stroke, reflecting a relative excess of haemorrhagic strokes among fatal events. Both ischaemic stroke and haemorrhagic stroke had strong gradients with blood pressure, but these were much steeper for haemorrhagic stroke with a stage 3 category relative risks of 9.56 (95% confidence interval 8.46 to 10.80) and 28.83 (24.89 to 33.40) for ischaemic and haemorrhagic strokes. For each higher 20 mm Hg of systolic blood pressure, the relative risk of ischaemic and haemorrhagic stroke increased by 2.23 (2.17 to 2.30) and 3.18 (3.06 to 3.30), z test for difference between odds ratios 11.40, P < 0.00001. Those excluded because of incomplete data had similar distributions of stroke subtypes, and including them in analyses resulted in similar age-sex adjusted blood pressure gradients.
Comment
The gradient of the relationship between blood pressure and haemorrhagic stroke is steeper than that for ischaemic stroke. Falls in blood pressure observed over the 20th century may lead to bigger reductions in the incidence of haemorrhagic stroke compared with ischaemic stroke and thereby provide a partial explanation for the differential trends in stroke subtypes.1 Falls in blood pressure cannot be ascribed solely to antihypertensive drugs as they have been seen at young ages and during times when treatment was not widely used. Factors in early life, rather than treatment of hypertension, may have contributed to population declines in both blood pressure and risk of stroke, particularly haemorrhagic. Our findings also emphasise the importance of controlling blood pressure, particularly in countries with a high risk of haemorrhagic stroke.
Contributors: Y-MS contributed to design, analysis, interpretation and revision of the manuscript JS contributed to design, interpretation and revision of the manuscript YS contributed to interpretation and revision of the manuscript. DAL contributed to the design, interpretation, and revision of the manuscript. GDS contributed to the design, interpretation, and revision of the manuscript. SE wrote the first draft of the paper and contributed to design, interpretaton, and revision of the manuscript. Y-MS and SE are guarantors.
Funding: Korean Ministry of Health and Welfare (01-PJ1-PG1-01CH10-0007).
Competing interests: None declared.
Ethical approval: Korean Health iNsurance Corporation, who are legally able to use health insurance data for public health purposes.
References
- 1.Lawlor D, Davey Smith G, Leon D, Sterne J, Ebrahim S. Secular trends in mortality by stroke subtype in the 20th century: a retrospective analysis. Lancet 2002;360: 1818-23. [DOI] [PubMed] [Google Scholar]
- 2.McCarron P, Okasha M, McEwen J, Davey Smith G. Changes in blood pressure among students attending Glasgow University between 1948 and 1968: analyses of cross sectional surveys. BMJ 2001;322: 885-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Prospective studies collaboration. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002;360: 1903-13. [DOI] [PubMed] [Google Scholar]
- 4.Eastern stroke and coronary heart disease collaborative research group. Blood pressure, cholesterol and stroke in eastern Asia. Lancet 1998;352: 1801-7. [PubMed] [Google Scholar]
- 5.Song Y-M, Sung J, Kim JS. Which cholesterol level is related to the lowest mortality in a population with low mean cholesterol level: a 6.4 year follow-up study on 482,472 Korean men. Am J Epidemiol 2000;151: 739-47. [DOI] [PubMed] [Google Scholar]