Abstract
Background
Lifetime stroke risk has been calculated in a limited number of selected populations. We determined lifetime risk of stroke globally and at the regional and country level.
Methods
Using Global Burden of Disease Study estimates of stroke incidence and the competing risks of non-stroke mortality, we estimated the cumulative lifetime risk of ischemic stroke, hemorrhagic stroke, and total stroke (with 95% uncertainty intervals [UI]) for 195 countries among adults over 25 years) for the years 1990 and 2016 and according to the GBD Study Socio-Demographic Index (SDI).
Results
The global estimated lifetime risk of stroke from age 25 onward was 24.9% (95% UI: 23.5–26.2): 24.7% (23.3–26.0) in men and 25.1% (23.7–26.5) in women. The lifetime risk of ischemic stroke was 18.3% and of hemorrhagic stroke was 8.2%. The risk of stroke was 23.5% in high SDI countries, 31.1% in high-middle SDI countries, and 13.2% in low SDI countries with UIs not overlapping for these categories. The greatest estimated risk of stroke was in East Asia (38.8%) and Central and Eastern Europe (31.7 and 31.6 %%), and lowest in Eastern Sub-Saharan Africa (11.8%). From 1990 to 2016, there was a relative increase of 8.9% in global lifetime risk.
Conclusions
The global lifetime risk of stroke is approximately 25% starting at age 25 in both men and women. There is geographical variation in the lifetime risk of stroke, with particularly high risk in East Asia, Central and Eastern Europe.
Keywords: stroke, lifetime risk, prevention
Introduction
Stroke accounts for almost 5% of all disability-adjusted life years (DALYs)1 and 10% of all deaths worldwide,2 with the bulk of this burden (over 75% of deaths from stroke and 81% of DALYs) falling on low- and middle-income countries.3 The total global burden of stroke is increasing1-3 and prevention of stroke may require an improved understanding of risk among younger individuals. Stroke prevention strategies in low and middle income countries may differ from those adopted for high-income countries due to differences in access to health care, health technologies and relative rates of stroke risk factors.4
Estimates of lifetime risk, the cumulative probability of someone of a given age and sex developing a disease during their remaining lifespan after accounting for competing mortality, provide a measure of disease risk.5 Lifetime stroke risk estimates may be useful for long-term health system planning.6 In addition, estimates of the lifetime risk of stroke across the age spectrum on a national level may serve as a useful summary metric for gauging the impact of stroke prevention strategies.
There are limited data on trends in the lifetime risk of stroke. Prior estimates of lifetime stroke risk have been reported in a limited number of selected populations6-12. Diverging trends in stroke incidence and mortality rates have been observed between developed (decreasing) and developing countries (increasing),13 against a background of increasing life expectancy for almost all countries.14
We used Global Burden of Disease (GBD) 2016 study estimates to provide global, regional, and country-specific lifetime risk of stroke in 1990 and 2016 by pathological subtype, age, sex and Socio-Demographic Index (SDI), accounting for competing risk of mortality due to all other non-stroke causes of death. The GBD is an ongoing global collaboration that uses all available epidemiological data to provide a comparative assessment of health loss across 328 causes for 195 countries and territories.
Methods
We used estimates from the GBD 2016 study1, 2, of first-ever-in-a-lifetime stroke, cause- specific mortality, and all-cause mortality at the global, regional (21 GBD regions nested within 7 GBD super-regions), and national (195 countries) levels by age and sex (see Supplement Table 1 and Supplement Table 2). Analysis was performed separately for ischemic stroke and hemorrhagic stroke (intracerebral hemorrhage and non-traumatic subarachnoid hemorrhage). The GBD 2016 study used all available representative population-based data on incidence, prevalence, case fatality and mortality to produce comparable estimates of disease burden for 195 countries, by sex and 5-year age categories. Mortality was estimated using the Cause of Death Ensemble Model, which produces cause- specific smoothed mortality cause fractions over time using vital registration and verbal autopsy data as well as country-specific covariates. Incidence was estimated using DisMod- MR, a Bayesian meta-regression disease modelling tool. Details of the methods used to estimate stroke incidence and mortality have been previously published and are summarized in the Supplement.
Countries were categorized by quintiles of the GBD SDI for the year 2016.15 SDI is a composite indicator of development similar to the Human Development Index.16 SDI uses as input country-level income per capita, average educational attainment among individuals over age 15, and total fertility rate.
We estimated lifetime risk at a given age as the cumulative risk of stroke occurrence during the remaining lifetime, assuming the rates of stroke incidence, prevalence, and stroke mortality in each following 5 year age category. In this way, risk at each age represents the risk of stroke from that age onwards, conditional on survival to that age without having died or having had a nonfatal stroke. Further details of this method are provided in the Supplement. To account for the competing risks of stroke and mortality within a specific age group, we calculated the probability of stroke-deleted mortality and experiencing a stroke, then scaled the separate event probabilities to match the combined probability of having either a stroke or dying in an age group.
We calculated the lifetime risk only for people aged 25 years and older because stroke incidence rates in younger people are low and are less dependent on the modifiable risks and health systems that determine stroke burden in older populations.
Uncertainty intervals were the 2.5th and 97.5th percentile of the distribution for each estimate. Significance was reported when uncertainty intervals did not overlap.
Results
Global, regional, and national lifetime risk of stroke in 2016
In 2016, the lifetime risk of stroke globally was 24.9% (95% UI: 23.5–26.2), with large regional and between-country differences (Table 1, Supplement Table S3). The highest risk was estimated in China (39.3% [37.5–41.1]) with similarly high levels in Latvia, Bosnia and Herzegovina, Romania, Montenegro, Russia, Macedonia, and Bulgaria. Among the 21 GBD regions, East Asia (38.8% [37.0–40.6]), Central and Eastern Europe (31.7% [95% UI: 30.0– 33.3] and 31.6% [95% UI: 27.6–35.6], respectively) had the highest risk, and Eastern Sub- Saharan Africa (11.8% [95% UI: 10.9–12.8]) had the lowest risk. The risk was greatest in high-middle (31.1% [29.0–33.0]) and middle SDI countries (29.3% [27.8-30.8]), and lowest in low SDI countries (13.2% [12.3–14.2]).
Table 1. Lifetime risk of stroke (LTR in %) (with 95%UI) globally and regionally (21GBDregions and 7 super regions) in 2016 and its percentage change (with 95% UI) from 1990 to 2016 by pathological type of stroke and sex.
| GBD super regions | GBD regions | Men | Women | Both sexes | |||
|---|---|---|---|---|---|---|---|
| LTR (95% UI) | Percentage change(95%CI) 1990-2015 | LTR (95% UI) | Percentage change(95%CI) 1990-2015 | LTR (95% UI) | Percentage change(95%CI) 1990-2015 | ||
| Global | 24.7 (23.3,26.0) | 15.4 (12.5, 18.2) | 25.1 (23.7, 26.5) | 3.2 (0.2, 6.1) | 24.9 (23.5, 26.2) | 8.9 (6.2, 11.5) | |
| High-income | Southern Latin America | 17.8 (16.3, 19.3) | -14.2 (-20.4, -7.6) | 20.6 (18.9, 22.3) | -14.5 (-20.7, -8.4) | 19.2 (17.8, 20.5) | -14.1 (-19.0, -8.7) |
| Western Europe | 22.2 (20.9, 23.4) | 4.2 (0.3, 8.2) | 23.3 (21.9, 24.6) | -4.3 (-7.9, -0.4) | 22.7 (21.4, 23.9) | -0.4 (-3.6, 3.1) | |
| High-income North America | 22.4 (21.1, 23.7) | 4.9 (1.7, 8.7) | 25.1 (23.6, 26.4) | 0.5 (-2.8, 3.8) | 23.8 (22.4, 25.0) | 2.7 (-0.3, 5.9) | |
| Australasia | 20.9 (19.4, 22.4) | 8.1 (1.1, 14.8) | 23.0 (21.5, 24.7) | 1.4 (-4.6, 7.9) | 21.9 (20.6, 23.4) | 4.7 (-0.5, 10.1) | |
| High-income Asia Pacific | 22.2 (20.6, 23.8) | -11.4 (-16.3, -6.6) | 23.5 (21.8, 25.2) | -15.1 (-19.7, -10.6) | 22.8 (21.2, 24.3) | -13.5 (-17.4, -9.4) | |
| Latin America and Caribbean | Caribbean | 18.0 (16.6,19.3) | 1.3 (-4.5, 6.8) | 20.8 (19.3, 22.3) | -0.3 (-6.1, 5.9) | 19.4 (18.0,20.7) | 0.5 (-4.1, 5.4) |
| Central Latin America | 14.1 (13.1, 15.1) | 0.0 (-4.3, 4.3) | 16.4 (15.2, 17.6) | -2.4 (-6.4, 1.7) | 15.2 (14.2, 16.4) | -1.3 (-4.8, 2.6) | |
| Tropical Latin America | 18.9 (17.6, 20.2) | -10.4 (-13.9, -6.6) | 19.5 (18.1, 20.9) | -15.1 (-18.8, -11.0) | 19.1 (17.9,20.5) | -12.8 (-16.0, -9.2) | |
| Andean Latin America | 15.5 (14.0, 17.0) | -0.9 (-9.0, 8.1) | 17.9 (16.2, 19.6) | -0.1 (-7.8, 8.1) | 16.7 (15.2,18.2) | -0.3 (-6.7, 6.5) | |
| Sub-Saharan Africa | Central Sub-Saharan Africa | 11.6 (10.6, 12.7) | 12.4 (3.8, 20.8) | 13.8 (12.6, 15.1) | 1.4 (-6.9, 9.4) | 12.8 (11.7, 13.8) | 6.1 (-0.9, 12.9) |
| Eastern Sub-Saharan Africa | 11.2 (10.3, 12.3) | 13.8 (5.4, 22.5) | 12.5 (11.4, 13.6) | 6.7 (-0.1, 13.9) | 11.8 (10.9, 12.8) | 9.8 (3.8, 16.1) | |
| Southern Sub-Saharan Africa | 10.0 (9.2, 10.9) | -18.1 (-23.8, -12.3) | 14.9 (13.7, 16.1) | -14.0 (-18.9, -9.0) | 12.5 (11.6, 13.5) | -15.4 (-19.9, -11.1) | |
| Western Sub-Saharan Africa | 13.0 (11.9, 14.2) | 10.5 (2.3, 19.1) | 15.8 (14.5, 17.3) | 7.0 (-0.6, 15.8) | 14.4 (13.3, 15.7) | 7.9 (2.0, 14.4) | |
| North Africa andMiddle East | North Africa and Middle East | 19.4 (17.8, 20.9) | 10.2 (4.7, 15.7) | 23.1 (21.4, 24.8) | 3.7 (-0.8, 8.0) | 21.2 (19.6, 22.8) | 6.4 (2.5, 10.5) |
| South Asia | South Asia | 13.5 (12.5, 14.5) | 15.6 (11.0, 20.0) | 15.9 (14.7, 17.1) | 19.6 (14.5, 24.6) | 14.6 (13.6, 15.7) | 17.6 (13.6, 21.3) |
| Southeast Asia, East Asia, and Oceania | East Asia | 40.6 (38.7, 42.3) | 35.9 (31.9, 39.8) | 36.3 (34.5, 38.1) | 20.7 (16.6, 24.4) | 38.8 (37.0, 40.6) | 29.7 (26.1, 33.0) |
| SoutheastAsia | 19.6 (18.3, 20.9) | 6.9 (2.7, 11.5) | 20.0 (18.8, 21.4) | 14.2 (9.7, 18.9) | 19.8 (18.6, 21.1) | 10.4 (6.7, 14.2) | |
| Oceania | 15.5 (13.8,17.2) | 1.7 (-9.0, 13.0) | 16.5 (14.6, 18.3) | 1.6 (-9.2, 12.8) | 16.0 (14.2, 17.6) | 1.8 (-8.8, 12.7) | |
| Central Europe, Eastern Europe, and Central Asia | Central Asia | 22.7 (21.1, 24.4) | -2.4 (-8.1, 3.9) | 26.1 (24.4, 27.9) | -10.8 (-15.2, -6.2) | 24.4 (22.8, 25.9) | -7.7 (-11.7, -3.6) |
| Eastern Europe | 26.8 (22.0, 31.6) | -6.9 (-22.9, 11.0) | 36.5 (31.2, 41.9) | -8.7 (-21.5, 3.7) | 31.6 (27.6, 35.6) | -8.8 (-19.7, 2.7) | |
| Central Europe | 29.8 (28.0, 31.5) | 13.9 (9.2, 18.9) | 33.7 (31.8, 35.5) | 4.2 (-0.2, 8.7) | 31.7 (30.0, 33.3) | 8.7 (4.8, 12.8) | |
Contribution of Non-Stroke Mortality to Lifetime Risk of Stroke
Supplement Figure S1A-C and Supplement Table S5 show the hypothetical national lifetime stroke risk if all countries experienced the average non-stroke mortality rate of high SDI countries. In such a counterfactual scenario, the lifetime risk of stroke is no longer lowest in sub-Saharan Africa. The largest increases in lifetime risk of stroke due to decreased non- stroke mortality in this hypothetical scenario were in Oceania (from 16% to 30%), sub- Saharan Africa (from 12 to 22%), and South Asia (from 15 to 21%). Smaller increases were seen for other low and middle-income countries, reflecting geographic variation in competing non-stroke mortality as a major determinant of lifetime stroke risk (Supplement Figures S9A- R).
Lifetime risk by sex, age, and stroke type
In 2016, the lifetime risk of stroke in men (24.7% [95% UI 23.3–26.0]) globally was not significantly different than in women (25.1% [23.7–26.5]) (Table 1), but there were regional (Table 1; Figure 1; Supplement Figures S10A and S10B) and between-country differences in sex-specific risk. The greatest risk in men was in China (41.1% [39.2–42.9]) where there was also the largest difference between men (41.1% [39.2-42.9]) and women (36.7% [35.0-38.6]). Latvia had the greatest risk in women (41.7% [37.7–45.4]) with similar levels in Russia, Montenegro, Romania, Bosnia and Herzegovina, Lithuania, Macedonia, Bulgaria, Ukraine, Slovakia, Albania, Serbia and Belarus. Among 21 GBD regions, the highest lifetime risk in men (Table 1; Supplement Figure S2B) was in East Asia (40.6% [38.7-42.3]), while in women (Supplement Figure S2C) the highest risk was in both Eastern Europe (36.5% [31.2-41.9]) and East Asia (36.3% [34.5-38.1]).
Figure 1. Global map showing lifetime risk of stroke occurrence (in %), both sexes combined, 2016.
The risk was significantly higher in women than men in Central Latin America, Southern and Western Sub-Saharan Africa, North Africa and Middle East, South Asia, and Central Europe. The lifetime risk of hemorrhagic stroke showed less variation by sex than ischemic stroke. The lifetime risk of ischemic stroke was about two times higher than the risk of hemorrhagic stroke in both men and women across different regions (Table 1) and SDI level quintiles (Supplement Table S6).
In 2016, the lifetime risk of total stroke was not significantly different between age 25 (24.7% [23.3-26.0]) and 70 years (22.6% [21.0-24.1]) in men, and women (25.1% [23.7-26.5] and 22.3% [20.6-23.9], respectively) (Supplement Figures S11A and S11B; Supplement Table S7). After age 70, the remaining lifetime risk decreased, reaching 13.4% (11.8–15.1) for adults aged 95 years (Figure 2).
Figure 2. Global remaining lifetime risk of stroke occurrence (in% with 95% UI) by pathological types, age, and sex, 2016.
Relationship between lifetime risk of stroke and age. Each colored line represents a trend of the relationship for the specified pathological type. The 95% confidence interval is within the shaded region surrounding each line. Modeled age starts at 25.
Similar age patterns in lifetime risk were apparent for both ischemic and hemorrhagic strokes across all SDI geographies, with less decline with ageing for hemorrhagic stroke in low-middle and low SDI countries. (Supplement Figures S4-S8). The lifetime risks for ischemic and hemorrhagic separately add up to more than the total risk for all stroke because total risk is inclusive of both subtypes and represents the risk of getting either an ischemic or hemorrhagic stroke.
Differences for lifetime risk in 1990 and 2016
Globally from 1990 to 2016, there was a significant increase in the average lifetime risk of stroke from 22% to 24%, a relative increase of 9% (Table 1; Supplement Table S4). The relative increase in the risk was greater for men (15.4% [12.5-18.2]) than women (3.2% [0.2- 6.1]), and for ischemic stroke (12.7% [8.9, 16.3]) than hemorrhagic stroke (4.0% [0.2, 7.6]). There was a significant increase in risk in Western and Eastern Sub-Saharan Africa, North Africa and Middle East, Central Europe, East Asia, South Asia and Southeast Asia. There was a significant reduction in risk in Central Asia, Southern and Tropical Latin America, high- income Asia Pacific, and Southern Sub-Saharan Africa. There were no significant changes estimated in the remaining GBD regions.
Discussion
The global lifetime risk of stroke from age 25 onward is estimated to have increased from 22% to 24% over the past three decades, with the risk of ischemic stroke exceeding the risk of hemorrhagic stroke (18% vs 8%, respectively). This increase in risk is the result of flat or increasing stroke incidence in many middle-SDI regions with simultaneous declines in the competing risks of non-stroke mortality.
The estimated global lifetime risk of stroke declined with age, due to age-related competing risks from other diseases. In low SDI countries with the youngest populations, such as Sub- Saharan Africa, estimated lower lifetime stroke risk is the result of high competing risk of mortality at both young and old ages and does not represent substantially lower stroke incidence or more effective prevention and treatment strategies.17, 2, In contrast, we estimated the highest estimated lifetime stroke risks are found in East Asia, Central and Eastern Europe.
Many of our national estimated lifetime stroke risks are similar or higher compared to what was observed for specific populations in the same country, including the Framingham Heart cohort (21.1% for women and 16.9% for men ),18 in a Japanese cohort (18.9% for men and 20.2% for women),8 and in a Chinese cohort (18.0% for men and 14.7% for women).7 Our estimates are lower than that for women in the Netherlands (29.8%) but similar to estimates there among men (22.8%).9 We estimated ischemic stroke to be more frequent than hemorrhagic stroke which is comparable to the findings of other population-based studies.6, 8, 12, 13. 19
Regional variation in lifetime cardiovascular risk across subpopulations has been shown previously by the Cardiovascular Lifetime Risk Pooling Project, and support our finding of large geographic variation in total stroke risk.10 The greater increase in the lifetime risk of ischemic stroke compared to hemorrhagic stroke from 1990 to 2016 may be related to reduction in the incidence of hemorrhagic stroke as opposed to minor increases in the incidence of ischemic stroke over the last two decades.3 Although our findings of similar lifetime risk of stroke in men and women are in concordance with some other observations, there have been studies 8-10, 19 in which the risk was greater in women compared with that in men, and the reasons for these differences between studies is unclear. The Global Burden of Disease Study Comparative Risk Assessment 4, 20 estimated that elevated blood pressure was the leading attributable risk for stroke across all levels of the SDI, with greater attribution to air pollution and low fruit intake in low-SDI countries and high body-mass index and high fasting plasma glucose in high-SDI countries.
Estimates of lifetime risk of a disease is new for the GBD study, which has previously published several other summary measures of health including years of life lost prematurely, years lives with disability,3, 21 and stroke burden associated with various risk factors.4 Lifetime risk may be useful for stroke prevention and public education. High estimates of lifetime risk of stroke suggest the possible value of intensive primary stroke prevention measures throughout the lifespan and suggest that strategies to reduce cardiovascular risk remain relevant for both younger and older adults.
The main strength of our study was that we systematically evaluated the lifetime risk of using data and methods that allow for comparable estimates between location and over time. We provided estimates of the lifetime risk of stroke for people aged 25 years and over (up to age 95) as opposed to stroke lifetime risk estimates from other studies, where the risk of stroke was estimated for people aged 45 or over.6,8-10 Furthermore, our lifetime stroke risk estimates account for competing risk of mortality from other causes of death and represent whole populations, adding to the generalizability of these results.
Our approach has limitations. The accuracy of lifetime stroke risk estimates was limited by the accuracy and availability of epidemiological data from the countries studied. There was still lack of sufficient epidemiological data on stroke incidence and case fatality for most countries of the world. In countries without data on stroke incidence, estimates were dependent on geospatial statistical models incorporating data from neighboring countries and country-level risk exposure data, which is widely available. The ability to differentiate stroke from other acute neurological events and to differentiate ischemic from hemorrhagic strokes was impeded by the nature of health system in each country, by the technology available to diagnose strokes, and the customary manner of coding disease entities. We did not differentiate risk due to subarachnoid hemorrhage and intracerebral hemorrhage, which were combined as an estimate of total hemorrhagic stroke. There is significant subnational variation in stroke burden within large countries and our results represent only average national risk. Standard error was increased using a standard algorithm when data from subnational regions were used to represent an entire country. Finally, we analyzed only the lifetime risk of first-ever stroke and not recurrent stroke.
In conclusion, our study provides comprehensive global, regional, and country-specific estimates of the lifetime risk of stroke by sex, age, with imprecision introduced by limited data in many countries. The global lifetime risk of stroke is approximately 25% starting at age 25 in both men and women and there is large geographical variation, with particularly high lifetime risk in East Asia, Central and Eastern Europe.
Supplementary Materials
Acknowledgments
This research was supported by the Bill & Melinda Gates Foundation and Health Research Council of New Zealand – Dr Feigin, Dr Krishnamurthi and Dr Parmar. Dr Feigin was also partly funded by the Brain Research New Zealand Centre of Research Excellence and “Ageing Well” Program of the National Science Challenge, Ministry of Business, Innovation and Employment of New Zealand.
Disclosures
None of the other authors has competing financial interests.
Footnotes
Publisher's Disclaimer: This is an Author Final Manuscript, which is the version after external peer review and before publication in the Journal. The publisher’s version of record, which includes all New England Journal of Medicine editing and enhancements, is available at 10.1056/NEJMoa1804492..
Contributor Information
Valery L. Feigin, Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA
Grant Nguyen, Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA
Kelly Cercy, Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA
Catherine O. Johnson, Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA
Tahiya Alam, Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA
Priyakumari Ganesh Parmar, Auckland University of Technology, Auckland, New Zealand.
Amanuel Alemu Abajobir, School of Public Health, University of Queensland, Brisbane, QLD, Australia
Kalkidan Hassen Abate, Jimma University, Jimma, Ethiopia
Foad Abd-Allah, Department of Neurology, Cairo University, Cairo, Egypt
Ayenew Negesse Abejie, Debre Markos University, Debre Markos, Ethiopia
Gebre Yitayih Abyu, Mekelle University, Mekelle, Ethiopia
Zanfina Ademi, University of Basel, Basel, Switzerland
Gina Agarwal, McMaster University, Hamilton, ONT, Canada
Muktar Beshir Ahmed, Department of Epidemiology, College of Health Sciences, Jimma University, Jimma, Ethiopia
Rufus Olusola Akinyemi, University of Ibadan, Ibadan, Nigeria (R.O.A.); Newcastle University, Newcastle upon Tyne, UK; Newcastle University, Newcastle upon Tyne, UK
Rajaa Al-Raddadi, Joint Program of Family and Community Medicine, Jeddah, Saudi Arabia
Leopold N. Aminde, Faculty of Medicine, the University of Queensland, Brisbane, QLD, Australia
Catherine Amlie-Lefond, Seattle Children’s Hospital, Seattle, WA
Hossein Ansari, Health Promotion Research Center, Department of Epidemiology and Biostatistics, Zahedan University of Medical Sciences, Zahedan, Iran
Hamid Asayesh, Department of Medical Emergency, School of Paramedic, Qom University of Medical Sciences, Qom, Iran
Solomon Weldegebreal Asgedom, Mekelle University, Mekelle, Ethiopia
Tesfay Mehari Atey, Mekelle University, Mekelle, Ethiopia
Henok Tadesse Ayele, Department of Epidemiology, Biostatiststics, and Occupational Health, McGill University, Montreal, QC, Canada
Maciej Banach, Department of Hypertension, Medical University of Lodz, Poland, and Polish Mother’s Memorial Hospital Research Institute, Lodz, Poland
Amitava Banerjee, Farr Institute of Health Informatics Research, University College London, London, UK
Aleksandra Barac, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
Suzanne L. Barker-Collo, School of Psychology, University of Auckland, Auckland, New Zealand
Till Bärnighausen, Africa Health Research Institute, Mtubatuba, South Africa
Lars Barregard, Department of Occupational and Environmental Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
Sanjay Basu, Stanford University, Stanford, CA
Neeraj Bedi, College of Public Health and Tropical Medicine, Jazan University, Jazan, Saudi Arabia
Masoud Behzadifar, Social Determinants of Health Research Center, Lorestan University of Medical Sciences, Khorramabad, Iran, and Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
Yannick Béjot, University Hospital and Medical School of Dijon, University of Burgundy, Dijon, France
Derrick A. Bennett, Nuffield Department of Population Health, University of Oxford, Oxford, UK
Isabela M. Bensenor, University of São Paulo, São Paulo, Brazil
Derbew Fikadu Berhe, School of Pharmacy, Mekelle University, Mekelle, Ethiopia
Dube Jara Boneya, Department of Public Heatlh, Debre Markos University, Debre Markos, Ethiopia
Michael Brainin, Danube-University Krems, Krems, Austriaa
Ismael Ricardo Campos-Nonato, Harvard T H Chan School of Public Health, Boston, MA
Valeria Caso, University of Perugia, Perugia, Italy
Carlos A. Castañeda-Orjuela, Colombian National Health Observatory, Instituto Nacional de Salud, Bogota, Colombia, and Epidemiology and Public Health Evaluation Group, Public Health Department, Universidad Nacional de Colombia, Bogota, Colombia.
Jacquelin Castillo Rivas, Caja Costarricense de Seguro Social, San Jose, Costa Rica, and Universidad de Costa Rica, San Pedro, Montes de Oca, Costa Rica
Ferrán Catalá-López, Department of Medicine, University of Valencia, INCLIVA Health Research Institute and CIBERSAM, Valencia, Spain; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
Hanne Christensen, Bispebjerg University Hospital, Copenhagen, Denmark.
Michael H. Criqui, University of California, San Diego, La Jolla, CA
Albertino Damasceno, Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
Lalit Dandona, Public Health Foundation of India, Gurugram, India
Rakhi Dandona, Public Health Foundation of India, Gurugram, India
Kairat Davletov, School of Public Health, Kazakh National Medical University, Almaty Kazakhstan
Barbora de Courten, Monash University, Melbourne, VIC, Australia, and Monash Medical Center, Clayton, VIC, Australia
Gabrielle deVeber, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
Klara Dokova, Department of Social Medicine, Faculty of Public Health, Medical University – Varna, Varna, Bulgaria
Dumessa Edessa, Haramaya University, Harrar, Ethiopia
Matthias Endres, Charité University Medicine Berlin, Berlin, Germany
Emerito Jose Aquino Faraon, College of Public Health, University of the Philippines Manila, Manila, Philippines, and Department of Health, Manila, Philippines
Maryam S. Farvid, Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, and Harvard/MGH Center on Genomics, Vulnerable Populations, and Health Disparities, Mongan Institute for Health Policy, Massachusetts General Hospital, Boston, MA
Florian Fischer, School of Public Health, Bielefeld University, Bielefeld, Germany
Kyle Foreman, Imperial College London, London, UK
Mohammad H. Forouzanfar, Seattle Genetics, Seattle, WA
Seana L. Gall, University of Tasmania, Hobart, TAS, Australia
Tsegaye Tewelde Gebrehiwot, Jimma University, Jimma, Ethiopia
Richard F. Gillum, Howard University, Washington, DC
Maurice Giroud, University Hospital of Dijon, Dijon, France
Alessandra C. Goulart, Center for Clinical and Epidemiological Research Center, Hospital Universitario, University of São Paulo, São Paulo, Brazil
Rahul Gupta, West Virginia Bureau for Public Health, Charleston, WV
Rajeev Gupta, Eternal Heart Care Centre and Research Institute, Jaipur, India
Vladimir Hachinski, Western University, London, ON, Canada.
Randah Ribhi Hamadeh, Arabian Gulf University, Manama, Bahrain
Graeme J Hankey, School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia; Harry Perkins Institute of Medical Research, Nedlands, WA, Australia; and Western Australian Neuroscience Research Institute, Nedlands, WA, Australia
Habtamu Abera Hareri, Addis Ababa University, Addis Ababa, Ethiopia
Rasmus Havmoeller, Karolinska Institutet, Stockholm, Sweden
Simon I Hay, Oxford Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, UK.
Mohamed I Hegazy, Faculty of Medicine, Cairo University, Cairo, Egypt
Desalegn Tsegaw Hibstu, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
Spencer Lewis James, Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA
Panniyammakal Jeemon, Centre for Chronic Disease Control, New Delhi, India, and Centre for Control of Chronic Conditions, Public Health Foundation of India, Gurugram, India
Denny John, Campbell Collaboration, New Delhi, India
Jost B. Jonas, Department of Ophthalmology, Medical Faculty Mannheim, Ruprecht-Karls-University Heidelberg, Mannheim, Germany
Jacek Jóźwiak, Institute of Health and Nutrition Sciences, Czestochowa University of Technology, Czestochowa, Poland
Rizwan Kalani, University of Washington, Seattle, WA
Amit Kandel, University at Buffalo, Buffalo, NY.
Amir Kasaeian, Hematology-Oncology and Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran, and Hematologic Malignancies Research Center, Tehran University of Medical Sciences, Tehran, Iran
Andre P. Kengne, South African Medical Research Council, Cape Town, South Africa
Yousef Saleh Khader, Department of Community Medicine, Public Health and Family Medicine, Jordan University of Science and Technology, Irbid, Jordan.
Abdur Rahman Khan, University of Cape Town, Cape Town, South Africa
Young-Ho Khang, Department of Health Policy and Management, Seoul National University College of Medicine, Seoul, South Korea, and Institute of Health Policy and Management, Seoul National University Medical Center, Seoul, South Korea
Jagdish Khubchandani, Department of Nutrition and Health Science, Ball State University, Muncie, IN
Daniel Kim, Department of Health Sciences, Northeastern University, Boston, MA.
Yun Jin Kim, School of Medicine, Xiamen University Malaysia Campus, Sepang, Malaysia
Mika Kivimaki, Department of Epidemiology and Public Health, University College London, London, UK; Clinicum, Faculty of Medicine, University of Helsinki, Helsinki, Finland
Yoshihiro Kokubo, Department of Preventive Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
Dhaval Kolte, Division of Cardiology, Brown University, Providence, RI
Jacek A. Kopec, University of British Columbia, Vancouver, BC, Canada
Soewarta Kosen, Center for Community Empowerment, Health Policy and Humanities, National Institute of Health Research & Development, Jakarta, Indonesia
Rita Krishnamurthi, National Institute for Stroke and Applied Neurosciences (V.L.F.); Auckland University of Technology, Auckland, New Zealand
G Anil Kumar, Public Health Foundation of India, Gurugram, India
Alessandra Lafranconi, University of Milano Bicocca, Monza, Italy
Pablo M. Lavados, Servicio de Neurologia, Clinica Alemana, Universidad del Desarrollo, Santiago, Chile
Yirga Legesse, Debre Markos University, Debre Markos, Ethiopia (A.N.A.); Mekelle University, Mekelle, Ethiopia
Yongmei Li, San Francisco VA Medical Center, San Francisco, CA
Xiaofeng Liang, Chinese Center for Disease Control and Prevention, Beijing, China
Warren D. Lo, Departments of Pediatrics and Neurology, Ohio State University, Columbus, OH, and Nationwide Children’s Hospital, Columbus, OH
Stefan Lorkowski, Institute of Nutrition, Friedrich Schiller University Jena, Jena, Germany, and Competence Cluster for Nutrition and Cardiovascular Health (nutriCARD) Halle-Jena-Leipzig, Jena, Germany
Paulo A. Lotufo, University of São Paulo, São Paulo, Brazil.
Clement T. Loy, The University of Sydney, Sydney, NSW, Australia
Mark T. Mackay, Royal Children's Hospital Melbourne, Melbourne, VIC, Australia
Mahdi Mahdavi, National Institute of Health Research, Tehran University of Medical Sciences, Tehran, Iran; Erasmus University Rotterdam, Rotterdam, Netherlands
Azeem Majeed, Department of Primary Care & Public Health, Imperial College London, London, UK
Reza Malekzadeh, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
Deborah Carvalho Malta, Universidade Federal de Minas Gerais, Minas Gerais, Brazil
Abdullah A. Mamun, The University of Queensland, Brisbane, QLD, Australia
Lorenzo G. Mantovani, University of Milano Bicocca, Monza, Italy.
Sheila Cristina Ouriques Martins, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil, and Hospital Moinhos de Vento, Porto Alegre, Brazil
Kedar K. Mate, McGill University, Montreal, QC, Canada.
Mohsen Mazidi, Department of Biology and Biological Engineering, Food and Nutrition Science, Chalmers University of Technology, Gothenburg, Sweden
Suresh Mehata, Ipas Nepal, Kathmandu, Nepal
Toni Meier, Competence Cluster for Nutrition and Cardiovascular Health (nutriCARD), Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
Yohannes Adama Melaku, School of Public Health, Mekelle University, Mekelle, Ethiopia
Walter Mendoza, United Nations Population Fund, Lima, Peru
George A. Mensah, Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
Atte Meretoja, Department of Medicine, University of Melbourne, Melbourne, VIC, Australia; Department of Neurology, Helsinki University Hospital, Helsinki, Finland
Haftay Berhane Mezgebe, Mekelle University, Mekelle, Ethiopia
Tomasz Miazgowski, Pomeranian Medical University, Szczecin, Poland
Ted R. Miller, Pacific Institute for Research & Evaluation, Calverton, MD; School of Public Health, Curtin University, Perth, WA, Australia
Norlinah Mohamed Ibrahim, Department of Medicine, Universiti Kebangsaan Malaysia Medical Center, Bandar Tun Razak, Malaysia.
Shafiu Mohammed, Health Systems and Policy Research Unit, Ahmadu Bello University, Zaria, Nigeria
Ali H. Mokdad, Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA
Mahmood Moosazadeh, Health Science Research Center, Addiction Institute, Mazandaran University of Medical Sciences, Sari, Iran
Andrew E. Moran, Columbia University, New York, NY
Kamarul Imran Musa, School of Medical Sciences, University of Science Malaysia, Kubang Kerian, Malaysia
Ruxandra Irina Negoi, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
Minh Nguyen, Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA
Quyen Le Nguyen, Institute for Global Health Innovations, Duy Tan University, Da Nang, Vietnam
Trang Huyen Nguyen, Institute for Global Health Innovations, Duy Tan University, Da Nang, Vietnam.
Tung Thanh Nguyen, Institute for Global Health Innovations, Duy Tan University, Da Nang, Vietnam
Thanh Trung Nguyen, Institute for Global Health Innovations, Duy Tan University, Da Nang, Vietnam
Dina Nur Anggraini Ningrum, Department of Public Health, Semarang State University, Semarang City, Indonesia
Bo Norrving, Skane University Hospital, Department of Clinical Sciences Lund, Neurology, Lund, Sweden
Jean Jacques N. Noubiap, Medical Diagnostic Centre, Yaoundé, Cameroon
Martin J. O’Donnell, National University of Ireland Galway, Galway, Ireland
Andrew Toyin Olagunju, Discipline of Psychiatry, School of Medicine, University of Adelaide, Adelaide, SA, Australia; Department of Psychiatry, College of Medicine, University of Lagos, Lagos, Nigeria; and Department of Psychiatry, Lagos University Teaching Hospital, Lagos, Nigeria
Oyere K. Onuma, World Health Organization, Geneva, Switzerland
Mayowa O. Owolabi, Department of Medicine, University of Ibadan, Ibadan, Nigeria, and Blossom Specialist Medical Center, Ibadan, Nigeria.
Mahboubeh Parasaeian, Non-Communicable Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran; Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
George C. Patton, Murdoch Childrens Research Institute, Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
Michael Piradov, Research Center of Neurology, Moscow, Russia.
Martin A. Pletcher, Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA
Farshad Pourmalek, University of British Columbia, Vancouver, BC, Canada
V Prakash, Charotar University of Science and Technology, Anand, India.
Mostafa Qorbani, Non-Communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran
Mahfuzar Rahman, BRAC, Dhaka, Bangladesh
Muhammad Aziz Rahman, Austin Clinical School of Nursing, La Trobe University, Melbourne, VIC, Australia
Rajesh Kumar Rai, Society for Health and Demographic Surveillance, Suri, India
Annemarei Ranta, University of Otago, Wellington, New Zealand
David Rawaf, WHO Collaborating Centre, Imperial College London, London, UK; North Hampshire Hospitals, Basingstroke, UK; University College London Hospitals, London, UK
Salman Rawaf, Imperial College London, London, UK
Andre M. N. Renzaho, Western Sydney University, Penrith, NSW, Australia
Stephen R. Robinson, RMIT University, Bundoora, VIC, Australia
Ramesh Sahathevan, Ballarat Health Services, Ballarat, VIC, Australia; Florey Institute of Neuroscience and Mental Health, Parkville, VIC, Australia
Amirhossein Sahebkar, Mashhad University of Medical Sciences, Mashhad, Iran; University of Western Australia, Perth, WA, Australia
Joshua A. Salomon, Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA
Paola Santalucia, Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA ; Foundation IRCCS Maggiore Hospital Policlinico, Milan, Italy; Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
Itamar S. Santos, Internal Medicine Department, University of São Paulo, São Paulo, Brazil
Benn Sartorius, Public Health Medicine, School of Nursing and Public Health, University of KwaZulu- Natal, Durban, South Africa
Aletta E. Schutte, Hypertension in Africa Research Team (HART), North-West University, Potchefstroom, South Africa; South African Medical Research Council, Potchefstroom, South Africa
Sadaf G. Sepanlou, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
Azadeh Shafieesabet, Department of Rehabilitation Medicine, New York University Langone Medical Center, New York, NY
Masood Ali Shaikh, Independent Consultant, Karachi, Pakistan
Morteza Shamsizadeh, Department of Medical Surgical Nursing, School of Nursing and Midwifery, Hamadan University of Medical Sciences, Hamadan, Iran
Kevin N. Sheth, School of Medicine, Yale University, New Haven, CT
Mekonnen Sisay Shiferaw, Haramaya University, Harar, Ethiopia
Min-Jeong Shin, Department of Public Health Sciences, Korea University, Seoul, South Korea
Ivy Shiue, Institut für Medizinische Epidemiologie, Biometrie und Informatik, Martin-Luther-Universität Halle-Wittenberg, Bonn, Germany
Diego Augusto Santos Silva, Federal University of Santa Catarina, Florianopolis, Brazil
Eugene Sobngwi, University of Yaoundé, Yaoundé, Cameroon
Michael Soljak, Department of Primary Care & Public Health, Imperial College London, London, UK
Reed J. D. Sorensen, Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA
Luciano A. Sposato, Department of Clinical Neurological Sciences, Western University, London, ON, Canada
Saverio Stranges, Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
Rizwan Abdulkader Suliankatchi, Ministry of Health, Kingdom of Saudi Arabia, Riyadh, Saudi Arabia
Rafael Tabarés-Seisdedos, Department of Medicine, University of Valencia, INCLIVA Health Research Institute and CIBERSAM, Valencia, Spain
David Tanne, Chaim Sheba Medical Center, Tel Hashomer, Israel
Cuong Tat Nguyen, Institute for Global Health Innovations, Duy Tan University, Da Nang, Vietnam.
JS Thakur, School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
Amanda G. Thrift, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia
David L. Tirschwell, Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA
Roman Topor-Madry, Institute of Public Health, Faculty of Health Sciences, Jagiellonian University Medical College, Kraków, Poland; Faculty of Health Sciences, Wroclaw Medical University, Wroclaw, Poland
Bach Xuan Tran, Hanoi Medical University, Hanoi, Vietnam
Luong Thanh Tran, Institute for Global Health Innovations, Duy Tan University, Da Nang, Vietnam.
Thomas Truelsen, Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
Nikolaos Tsilimparis, University Heart Center of Hamburg, Hamburg, Germany
Stefanos Tyrovolas, Parc Sanitari Sant Joan de Déu, Fundació Sant Joan de Déu, Universitat de Barcelona, CIBERSAM, Barcelona, Spain
Kingsley N. Ukwaja, Department of Internal Medicine, Federal Teaching Hospital, Abakaliki, Nigeria
Olalekan A. Uthman, Warwick Medical School, University of Warwick, Coventry, UK
Tommi Vasankari, UKK Institute for Health Promotion Research, Tampere, Finland
Narayanaswamy Venketasubramanian, Raffles Neuroscience Center, Raffles Hospital, Singapored.
Vasiliy Victorovich Vlassov, National Research University Higher School of Economics, Moscow, Russia
Wenzhi Wang, Beijing Neurosurgical Institute, Beijing, China
Andrea Werdecker, Competence Center Mortality-Follow-Up of the German National Cohort, Federal Institute for Population Research, Wiesbaden, Germany
Charles D.A. Wolfe, Division of Health and Social Care Research, King’s College London, London, UK
Gelin Xu, Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
Yuichiro Yano, Department of Preventive Medicine, Northwestern University, Chicago, IL
Naohiro Yonemoto, Department of Biostatistics, School of Public Health, Kyoto University, Kyoto, Japan
Chuanhua Yu, Department of Epidemiology and Biostatistics, School of Public Health, Wuhan University, Wuhan, China; Global Health Institute, Wuhan University, Wuhan, China
Zoubida Zaidi, University Hospital of Setif, Setif, Algeria (.
Maysaa El Sayed Zaki, Faculty of Medicine, Mansoura University, Mansoura, Egypt
Maigeng Zhou, National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
Boback Ziaeian, University of California Los Angeles, Los Angeles, CA
Ben Zipkin, Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA
Theo Vos, Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA
Michael Kravchenko, Research Center of Neurology, Moscow, Russia
Mohsen Naghavi, Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA
Yuri Varakin, Research Center of Neurology, Moscow, Russia
Chirstopher J. L. Murray, Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA
Gregory A. Roth, Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA; Department of Medicine, University of Washington, Seattle, WA
Disclaimer
The views expressed in this article are those of the authors and do not necessarily represent the views of the National Heart, Lung, and Blood Institute, National Institutes of Health, or the US Department of Health and Human Services.
Funding
Bill & Melinda Gates Foundation. The funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit the manuscript.
Authors' contributions
VLF prepared the first draft. GN, GR and CJLM developed the lifetime stroke risk formula. GR analyzed data and reviewed and edited the first draft and final versions of the manuscript. KC analyzed data and prepared maps and figures. PP prepared tables. VLF, GR, and CJLM reviewed all drafts, finalized the draft, and approved the final version of the manuscript. All other authors provided key contributions to data, methods, or analysis, reviewed the manuscript, and approved the final version of the manuscript.
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