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Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease logoLink to Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease
. 2022 Oct 26;11(21):e027044. doi: 10.1161/JAHA.122.027044

Burden of Stroke and Population‐Attributable Fractions of Risk Factors in Latin America and the Caribbean

Kevin Pacheco‐Barrios 1,2,3,4,*,✉, Stefano Giannoni‐Luza 1,2,*, Alba Navarro‐Flores 1,5, Ingrid Rebello‐Sanchez 2, Joao Parente 2, Ana Balbuena 2, Paulo S de Melo 2, Ricardo Otiniano‐Sifuentes 6, Oscar Rivera‐Torrejón 7,8,9, Carlos Abanto 6, Carlos Alva‐Diaz 8,9,10,✉, Patricia L Musolino 11,12, Felipe Fregni 2,4
PMCID: PMC9673624  PMID: 36285788

Abstract

Background

Stroke burden characterization studies in low‐ and middle‐income countries are scarce. We estimated the burden of stroke and its risk factors in Latin America and the Caribbean (LAC).

Methods and Results

We extracted GBD (Global Burden of Disease) study 2019 data on overall stroke and 3 subtypes (ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage) for 20 LAC countries. We estimated absolute and age‐standardized rates of disability‐adjusted life years, years of life lost, years lived with disability, and deaths. The population‐attributable fractions of 17 risk factors were estimated. All analyses were performed at regional and national levels by stroke subtype, sex, and age subgroups. In 2019, the LAC region had the fourth largest stroke burden worldwide (6.8 million disability‐adjusted life years), predominantly attributable to premature deaths (89.5% of disability‐adjusted life years). Intracerebral hemorrhage was the primary cause of the overall stroke burden (42% of disability‐adjusted life years), but ischemic stroke was the leading cause of disability (69% of total years lived with disability). Haiti and Honduras had the highest age‐standardized rates. Older adults and men had the largest burdens, although women had the highest rate of disability. Socioeconomic development level did not influence the burden. The major risk factor clusters were metabolic (high systolic blood pressure [population‐attributable fraction=53%] and high body mass index [population‐attributable fraction=37%]), which were more influential in hemorrhagic events, women, and older adults. Household air pollution was an important risk factor in low‐income countries in LAC.

Conclusions

The stroke burden and stroke‐related mortality in LAC are higher than the worldwide averages. However, stroke is a highly preventable disease in this region. Up to 90% of the burden could be reduced by targeting 2 modifiable factors: blood pressure and body mass index. Further research and implementation of primary and secondary prevention interventions are needed, as well as integrated national stroke care programs for acute, subacute, and rehabilitation management in LAC.

Keywords: GBD (Global Burden of Disease) study, risk factors, stroke

Subject Categories: Epidemiology, Cerebrovascular Disease/Stroke

Nonstandard Abbreviations and Acronyms

PAF

population‐attributable fraction

SBP

systolic blood pressure

SDI

sociodemographic index

YLLs

years of life lost

Clinical Perspective.

What Is New?

  • For the first time, we systematically assessed the burden of stroke in Latin America and the Caribbean, showing that the burden is high, representing the fourth highest burden worldwide.

  • Hemorrhagic stroke had the largest burden in Latin America and the Caribbean (measured in disability‐adjusted life years and years of life lost), but ischemic stroke was responsible for more disability (years lived with disability) and a larger number of absolute deaths.

What Are the Clinical Implications?

  • Most of the burden (up to 90%) could be reduced by controlling high systolic blood pressure (53%) and body mass index (37%), which are highly preventable risk factors.

Stroke is the second leading cause of death and the third leading cause of disability worldwide, following heart disease. 1 , 2 In 2016, 5.5 million individuals died, 3 whereas one‐third of stroke survivors required some type of poststroke care. 4 The direct annual costs of stroke care in the United States have been reported to be $34 billion. 5

In recent years, the major contributors to the global burden of stroke have transitioned from predominantly developed countries to other regions, such as Latin America and the Caribbean (LAC). In 2017, the number of deaths attributable to stroke in LAC was estimated to be ≈26 million, whereas the number of survivors with potential disabilities was 5.5 million. 1 However, the epidemiological impact of stroke and its risk factors at the regional and national levels remains unknown.

When assessing the consequences of stroke, the classic metrics of morbidity (prevalence and incidence), mortality, and cost measurements are insufficient. Those do not represent the magnitude of the disability produced by the loss of health, limiting a proper depiction of the implications for health systems. 6 Instead, the burden of disease can be estimated using the metrics of disability‐adjusted life years (DALYs), years of life lost (YLLs), and years lived with disability (YLDs). 7 The burden of disease can be understood as the loss of opportunity to live a healthy life without disabilities or a premature death. 8 These composite evaluations are more relevant for highly disabling and fatal conditions, such as stroke. This analysis is also context dependent and is affected by regional factors. Hence, regional and local estimations are needed to improve health care management, to identify prevalent modifiable risk factors, and to guide public health policies, especially in limited resource settings, such as LAC. Nevertheless, studies on stroke burden in LAC are scarce.

This study aims to assess the burden of stroke and its risk factors in LAC by analyzing GBD (Global Burden of Disease) 2019 study data 9 ; evaluating the burden by country, sex, age, and stroke type; and assessing the population‐attributable fractions (PAFs) of 17 risk factors.

METHODS

This study used open‐access GBD study 2019 platform data that were collected from country‐level surveillance, populational meta‐analyses, and indirect statistical estimations. 10 All the data used in this article are freely accessible after registration for the GBD study 2019 result tool (https://vizhub.healthdata.org/gbd‐results/). Additional information from our results is available on request from the corresponding author. Because all of the data included were aggregated and nonidentified, this study was exempted from institutional review board evaluation.

Stroke Definition

Stroke was defined as “rapidly developed clinical signs of focal (or global) disturbance of cerebral function, lasting more than 24 hours or leading to death, with no apparent cause other than of vascular origin.” 11

LAC Countries

We analyzed 20 countries from the LAC region with data available in the GBD study. 12 , 13 We included the following mainland countries: Argentina, Bolivia, Brazil, Chile, Colombia, Costa Rica, Ecuador, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru, Uruguay, and Venezuela. In addition, we included 3 representative Caribbean islands: Cuba, Dominican Republic, and Haiti. Data from the rest of the Caribbean were scarce and mostly calculated by predictive modeling, so they were not included in our analysis.

GBD Study 2019

The methods of the GBD study 2019 have been described previously. 10 Their estimations were conducted using Bayesian meta‐regression modeling (with DisMod‐MR 2.1 software). The data were retrieved from population surveys and systematic reviews with meta‐analyses available from areas and countries worldwide. Predictive estimations were conducted for countries with sparse or no data.

GBD Study Metrics

The GBD study provides new metrics adjusted for possible confounders. 14 The metrics included in this study are as follows.

Years of Life Lost

YLLs are calculated by multiplying of the number of deaths per age group by the remaining years to live, according to GBD study standard life‐expectancy values. 15

Years Lived With Disability

YLDs are defined as “the number of incident cases in a certain period of time multiplied by the average of disease duration and by a weight factor that reflects its severity, which ranges from 0 (perfect health) to 1 (deceased).” 16

Disability‐Adjusted Life Years

DALYs are calculated by summing the years of life lost because of premature mortality (YLL) and the years of healthy life lost because of disability. 16

PAF of a Risk Factor

In summary, the PAF was estimated using data for exposure, relative risk, and the theoretical‐minimum risk exposure level. This metric is interpreted as the degree of burden (expressed in percentage) explained by a certain risk factor. For systolic blood pressure (SBP), the risk was modeled considering 10 mm Hg above the theoretical‐minimum risk exposure level (115 mm Hg). High body mass index (BMI) was defined as >20 to 25 kg/m2 for adults and as obesity or overweight in children according to the International Obesity Task Force standards. The rest of the methods for the calculation of the risk factors and their definitions have been published previously. 17

Risk Factors

We analyzed 17 factors grouped into 3 clusters 18 :

  • Behavioral: smoking (including second‐hand smoking), diet (diet high in sodium, diet high in sugar‐sweetened beverages, diet low in fruits, diet low in vegetables, diet low in whole grains, and alcohol consumption), and low physical activity.

  • Environmental and occupational: ambient particulate matter pollution, household air pollution, and lead exposure.

  • Metabolic: high BMI, high fasting plasma glucose, high SBP, high total cholesterol, and low glomerular filtration rate.

The ranking of the risk factors was based on the percentage of the absolute number of DALYs that were explained by the risk factor and ranked in descending order.

Sociodemographic Index

The sociodemographic index (SDI) was calculated as a composite of the income per capita, the years of school education, and the fertility rate in women aged <25 years. 14

A summary of the definitions of these metrics is presented in able S1 through S5.

Data Extraction Procedure

All the information was downloaded from the GBD study 2019 open‐access website (http://ghdx.healthdata.org/gbd‐results‐tool) and extracted independently by 2 researchers (KPB and SGL). For location, we selected the global values and the LAC countries mentioned above. LAC values were obtained by adding the value from all the included countries and not from the default data set, which excludes Argentina and Uruguay. We downloaded data for DALYs, YLDs, YLLs, and deaths in absolute values as well as by age‐standardized rates (per 100 000 habitants); for overall stroke and by subtype (ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage); and by country and sex (women, men, and both). Furthermore, we chose the following age intervals: <5, 5 to 14, 15 to 49, 50 to 69, and ≥70 years and all ages. Interval values were added to create the <50 and >50 years subgroups. Finally, we classified LAC countries by income as presented in the GBD study platform (high, upper‐middle, lower‐middle, and low income) and extracted the SDI value per country. The data, tables, and figures were processed with Microsoft Excel v.16.35.

Statistical Analysis

For the descriptive analysis, the number, rates, and their 95% uncertainty intervals (UIs) were included. The UIs were generated for every metric using the 25th and 975th ordered 1000 draw values of the posterior distribution. We included the age‐standardized rates, which account for only corrections on the participants' age. Sex differences were analyzed separately. We performed an exploratory analysis of the correlation between the burden metrics (DALYs, YLDs, and YLLs) and the countries' SDIs. We used Spearman correlation test because of the normality violation of the aggregated data. We considered a significance level of 0.05 for all the analyses. The analyses were conducted using R version 4.0.2.

RESULTS

Burden of Stroke

In 2019, the total number of DALYs attributable to overall stroke in Latin America and the Caribbean was 6 787 612.1, which represented 4.7% of the global estimate. The age‐standardized rate of DALYs for the region was 1184.7 per 100 000 habitants, which was lower than the average worldwide rate (1768.1). This burden was YLL predominant (89.5%), with YLDs contributing to only 10.5% of the number of DALYs and 8.8% to the described rate. The number of deaths attributable to stroke in LAC was 311 793 and represented 4.8% of the global deaths attributable to this condition. These absolute values indicate that the LAC region has the fourth highest burden of stroke in the world (after East Asia, Southeast Asia, and South Asia).

Country Level

When compared by absolute numbers, Brazil had the highest estimates in LAC, representing 42.2% of the total DALYs, 39.9% of the YDLs, 42.4% of YLLs, and 42.0% of the total deaths of the region, followed by Mexico and Argentina. The age‐standardized DALY rate of stroke per country ranged from 563.7 (Costa Rica) to 3593.6 (Haiti). Haiti's DALY estimate doubled globally (3593.6; 95% UI, 2437.3–5116.5), followed by Honduras, the Dominican Republic, Bolivia, Paraguay, and Brazil. Those countries also had the highest rates of YLLs and deaths. For YLDs, Uruguay, Haiti, Paraguay, the Dominican Republic, Chile, and Brazil had the highest estimates. The lowest rates of DALYs, YLLs, and deaths were found in Peru, Costa Rica, and Colombia. The lowest rates of YLDs were found in El Salvador, Peru, Guatemala, Colombia, and Honduras.

A summary of the estimates of numbers and in age‐standardized rates of DALYs, YLLs, YLDs, and deaths worldwide, in the LAC region, and in individual countries, is presented in Table S2. In addition, the geographical representation of the burden of stroke according to age‐standardized rates of the 4 metrics is displayed in Figure 1.

Figure 1.

Figure 1

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Age‐standardized burden of stroke per 100 000 habitants in Latin America and the Caribbean during 2019.

A, Disability‐adjusted life years (DALYs). B, Years lived with disability (YLDs). C, Years of life lost (YLLs). D, Deaths. The 5 most affected countries, as measured by DALYs, YLLs, and deaths, were Haiti, the Dominican Republic, Paraguay, Bolivia, and Brazil. The 5 countries with the highest YLD burdens were Uruguay, Chile, Argentina, Haiti, and Brazil. The country with the lowest burden in the region according to DALYs, YLDs, YLLs, and deaths was Peru.

Burden of Stroke Subtypes

Intracerebral hemorrhage was the main contributor to stroke burden (42% of DALYs), as measured by absolute numbers and age‐standardized rates of DALYs and YLLs, followed by ischemic stroke (40%) and subarachnoid hemorrhage (18%). Ischemic stroke was the main contributor to YLDs and deaths (68.7% and 52.9% of LAC absolute numbers, respectively). According to age‐standardized rates, Haiti had the highest burden attributable to all stroke subtypes, followed by Honduras (for ischemic stroke and subarachnoid hemorrhage) and the Dominican Republic (for intracerebral hemorrhage). A summary of the estimates by stroke subtype in both numbers and age‐standardized rates per country is presented in Table S3. The geographical representation of stroke burden according to the 4 age‐standardized rate metrics can be found in Figures S1 through S5.

The relative contribution of the LAC stroke burdens (overall and subtypes) to the global values in absolute numbers ranged from 4.2% to 9.8%.

Age and Sex

In LAC, people aged between 50 and 75 years had the highest stroke burden, with 3 435 397 DALYs (95% UI, 2 983 856–3 980 453), representing 50.6% of DALYs (95% UI, 43.9%–58.6%); 3 096 039 YLLs (95% UI, 2 657 707–3 617 275), representing 51% of YLLs (95% UI, 43.8%–59.6%); and 339 357 YLDs (95% UI, 247 668–432 400), representing 47.7% of YLDs (95% UI, 34.8%–60.8%). People aged >75 years had the highest stroke mortality, with 167 713 deaths (95% UI, 138 108–193 262), representing 53.8% of deaths (95% UI, 44.3%–62%); followed by individuals aged between 50 and 75 years, with 120 504 deaths (95% UI, 103 500–140 522), representing 38.6% of deaths (95% UI, 33.2%–45%). In addition, people in the 50 to 75 years range accounted for the largest burden attributable to hemorrhagic and subarachnoid stroke subtypes and the second largest burden attributable to ischemic stroke. Older people (aged >75 years) accounted for the largest burden attributable to ischemic stroke.

According to sex, men contributed slightly more to the total burden of stroke in terms of DALYs (50.8% [95% UI, 43.9%–58.9%], 3 445 199 [95% UI, 2 974 238–3 996 537]). In addition, for the components of the burden, men had a higher YLL rate (52.2% [95% UI, 44.6%–61.1%], 3 171 235 [95% UI, 2 710 125–3 711 778]), whereas women had higher YLDs (61.5% [95% UI, 44.9%–78.1%], 437 032 [95% UI, 318 915–554 729]) and death rates (50.8% [95% UI, 44.3%–59.3%], 158 522 [95% UI, 132 106–185 200]). The sex distributions in LAC and globally were similar for ischemic stroke (men had higher DALY and YLL rates, whereas women had higher YLDs and mortality rates) and intracerebral hemorrhage (women had higher YLD rates). For subarachnoid hemorrhage, women accounted for a larger burden in the global estimates of YLDs and mortality than men. In LAC, women accounted for a larger burden of subarachnoid hemorrhage in all estimates (DALYs, YDLs, YLLs, and mortality).

Risk Factor Clusters

Globally and in LAC, the metabolic risk factor cluster was the main contributor to the stroke burden, at 70.97% and 70.14% DALYs, respectively. Worldwide, men had a larger attributable burden because of the behavioral risk factor cluster, whereas women had a larger burden because of the metabolic risk factor cluster. In LAC, the metabolic risk factor cluster was the largest contributor to the burden in both sexes. Men had an ≈10% larger burden attributable to the behavioral risk factor cluster than women. Globally and in LAC, the stroke burden attributable to the behavioral risk factor cluster was larger in patients aged <50 years, whereas the burden attributable to the metabolic risk factor cluster was larger in patients aged >50 years. According to income in LAC, upper‐middle income countries had the largest (67.8% DALYs) stroke burden attributable to the behavioral risk cluster, whereas high‐income countries had the smallest (34.4% DALYs). In addition, we observed that countries with lower incomes had higher risk attributable to the environmental/occupational risk factor cluster. The ranking of risk factors for total DALYs attributable to overall stroke according to country, income classification, sex, and age is presented in Figure 2.

Figure 2.

Figure 2

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Stroke risk factor rankings and population‐attributable fractions of high systolic blood pressure (SBP) and high body mass index (BMI) in Latin America and the Caribbean.

A, Individual risk factors ranked by number of disability‐adjusted life years (DALYs) attributable to overall stroke in 2019. B, Risk attributable to high SBP for overall stroke. C, Risk attributable to high BMI for overall stroke. LDL indicates low‐density lipoprotein.

Metabolic risk factors were the principal contributors in all stroke subtypes globally and in LAC and were not affected by sex or age. People aged <50 years had a larger burden attributable to behavioral risk factors than metabolic risk factors. This trend was prominent in upper‐middle income countries. On the other hand, people aged >50 years had a larger burden attributable to metabolic risk factors. This trend was not affected by country income.

PAFs of Individual Risk Factors

In LAC, high SBP was the leading risk factor in all countries, except Bolivia and Ecuador. In those countries, the leading cause was high BMI, which was the second leading cause in most LAC countries. The percentage of DALYs attributable to high SBP was 53%. This means that if controlled, the total number of DALYs would decrease from 6 787 612 to 3 157 022. Similarly, the percentage of DALYs attributable to high BMI was 37%, indicating that if controlled, DALYs would be reduced to 4 298 890. These values suggest that DALYs attributable to stroke could be reduced by up to 90% by controlling only these 2 main modifiable risk factors. Similar patterns were found for YLDs, YLLs, and mortality (Table S4). According to stroke subtypes, SBP and BMI control could particularly reduce the hemorrhagic stroke and subarachnoid hemorrhage burdens (up to a 98% DALY reduction) (Table S5).

High fasting plasma glucose, smoking, and ambient particulate matter pollution exposure were the following highest ranked risks in LAC (Figure 2). Household air pollution from solid fuels was among the top 5 risk factors in lower‐middle and low‐income countries.

Globally and in LAC, high SBP was the main individual risk factor for all stroke subtypes. The rankings of risk factors by stroke subtype are presented in Figures S4 to S6.

Correlations

No significant correlation was found between total DALYs and SDI or between SDI and risk factor PAFs after adjustments for sex and age.

DISCUSSION

Main Findings

According to the GBD study collaborators, regional‐ and country‐level subanalyses of GBD study data are encouraged to explore and understand trends of disease dynamics to establish priorities for interventions. 19 Nevertheless, comprehensive burden assessments at the regional level in LAC remain scarce. 20 To the best of our knowledge, this is the first assessment of the stroke burden in LAC. We organized a hierarchy of stroke risk factors according to country and stroke subtype. That information was not available directly from the GBD study platform and was the result of extensive data extraction, data cleansing, and processing in the current study.

In 2019, LAC had the fourth largest burden of stroke globally (≈6.8 million absolute DALYs). This is predominantly attributable to premature deaths, representing ≈90% of the burden. Intracerebral hemorrhage was the main contributor to DALYs, YLLs, and deaths, but ischemic stroke was the main cause of disability (69% of all YLDs). Older adults and men had the largest stroke burdens, whereas women had the highest disability rate.

Finally, metabolic factors were the most important risk factors. Interestingly, up to 90% of the burden could be reduced by targeting 2 modifiable factors: high SBP (53%) and BMI (37%). Overall, these results are aligned with those previously reported globally. 2 , 3 However, the potential burden reduction in LAC is larger than the global estimation, 3 with a particular benefit to the hemorrhagic stroke burden. Our results underscore the need for integrated national strategies for stroke awareness and prevention in LAC.

Country‐Level Findings

Haiti, Honduras, and the Dominican Republic were the most affected countries in the region in terms of density of age‐standardized rates per 100 000 inhabitants. Haiti had double the global stroke burden density and was among the top 5 countries with the highest YLDs for all stroke subtypes, except for subarachnoid hemorrhage, for which it had the lowest burden. This suggests that in Haiti, a small number of patients survive after subarachnoid hemorrhage. This could likely be explained by their weak health care system and limited resources, which reduce the effectiveness of preventive and therapeutic policies. 21 In the case of hemorrhagic stroke, which has greater severity and a higher risk of mortality than ischemic stroke, 22 positive outcomes rely on specialized intensive care. 23 , 24 , 25 Intensive care units are scarce and poorly equipped in Haiti, 26 and accessibility to high‐quality primary care services is limited for most of the population. 27 Education about what to do when someone presents common stroke symptoms via the primary care system is key to mitigating or decreasing the modifiable risk factors associated with hemorrhagic stroke. 28 , 29 , 30 High‐income countries, such as Uruguay and Chile, had the largest age‐standardized YLD values for stroke and all its subtypes, suggesting a large number of survivors with some type of disability and a potential lack of a systematic poststroke rehabilitation program. 1

Sources of Burden Heterogeneity

It has been reported that male individuals and older adults are more likely to be affected by stroke and related sequelae 4 , 31 , 32 ; however, our results showed that women in LAC had a larger burden of subarachnoid hemorrhage in 2019 than global values. In addition, metabolic risk factors were predominant in women and in people aged >50 years, whereas behavioral risk factors were predominant in men and people aged <50 years. It has been reported that stroke outcomes vary according to socioeconomic status 33 and that stroke risk and mortality in developing countries could be associated with socioeconomic status. 34 Nevertheless, our results did not show any correlation between the socioeconomic development level and stroke burden in LAC. This could be explained by the epidemiological transitions of some LAC countries or by the fact that socioeconomic development is not necessarily associated with appropriate allocation toward health care.

Stroke Risk Factors in LAC

LAC is a multicultural geographic region that has several other potential risk factors, some of which (ethnic and cultural factors) were not assessed in the GBD study. 35 However, similar to the results of previous studies in the region, 36 our results showed that most of the attributable risk factors for stroke were modifiable. High SBP was the primary contributor, followed by high BMI, similar to the global estimations. However, the PAF in LAC was higher (90%) than that worldwide (<80%). 3 The relationship between these 2 factors and cardiovascular disease and stroke has already been established, 37 but preventive strategies have not yet been successfully implemented. Reducing salt intake remains one of the most relevant interventions. 38 In addition, community‐based multicomponent interventions are potential solutions in need of testing.

Smoking is an important risk factor in the region despite previous efforts by certain countries to establish smoke‐free policies. 39 Smoke‐free policies have been indicated to be successful in reducing the frequency of smoking and its cardiovascular consequences. 36 , 40 , 41 Stronger smoke‐free measures should be established and implemented throughout the region.

Environmental risk factors have increased worldwide, especially in limited‐resource settings. As in LAC, countries with low and middle incomes have higher disease burdens associated with environmental risk factors compared with high‐income countries. 36 Future studies need to explore the effect of ambient pollution on stroke in LAC, especially in countries with intense mining activities and constant vehicle fleet growth.

Implications for Public Health Practice and Research

According to our findings, the most important modifiable risk factors for stroke were elevated SBP, high BMI, smoking, and environmental factors. Primary prevention policies to address chronic conditions have been proven to be cost‐efficient for the health care system 42 and to reduce the stroke burden at the individual level. 29 Some measures, such as the labeling of processed food to reduce salt intake, 43 governmental control agreements for processed food and product labeling to reduce trans‐fatty acid consumption, 44 , 45 and incremental tobacco taxation 46 and restriction of smoking areas 47 for reducing smoking, have been proven to be useful in resource‐constrained settings. 48 Instruments for the evaluation of such interventions have been proposed and are useful for producing standardized national reports on stroke risk factors. 49

At the country level, national programs should target control of high SBP (>115 mm Hg) and BMI (>25 kg/m2), which are the 2 most important risk factors. In LAC, there has been evidence of the success of multicomponent programs focused on self‐registration of blood pressure, healthy food consumption, reduction in salt, and physical activity. 50 , 51 However, those were focal efforts without continuity. Mobile telephone‐based interventions could be useful for promoting weight loss and increasing physical activity. 52 , 53 For the early detection and treatment of stroke, educational interventions about initial symptoms and access to care are fundamental. Many tools have been tested, such as video lessons, information presentations, and even one‐on‐one counseling, but their efficacy was moderate, and most of them were conducted in developed countries. 54 In Argentina, an 18‐month primary care intervention in a low‐resource setting significantly reduced blood pressure values and was cost‐effective. This randomized controlled cluster trial included physician‐guided education, a community health care provider component (health coaching and home blood pressure monitoring and audit), blood pressure feedback, and tailored text messages. 55 The protective effects and cost‐effectiveness related to cardiovascular risks and stroke were sustained long‐term. 56 Multinational collaboration and coordinated efforts are needed to implement similar programs in primary care systems across LACs.

Standardized evaluations of the burden of neuropsychiatric diseases at regional levels are scarce. 20 , 57 , 58 In addition to the global stroke estimation, 2 estimations for Europe, Mexico, Brazil, and China have been updated. 59 , 60 , 61 , 62 In Europe, the age‐standardized DALY rate was 1340 per 100 000 habitants, 62 which was slightly higher than our estimate (1184.7) but lower than the global estimate (1768.1). 2 However, mortality was higher in LAC than in Europe. China had higher age‐standardized DALY rates (2412.5 per 100 000 habitants) 59 compared with global and LAC estimates, confirming the predominant stroke burden in the South Asia region. 2 All the regional analyses, including ours, were in accordance with the global trends of larger burdens in men and older adults. For stroke subtypes, global and Chinese reports showed that intracerebral hemorrhage had the highest burden, as in our study. 2 , 59 However, ischemic stroke was the main contributor to the age‐standardized DALY rates in Mexico and Brazil. 60 , 61 A European analysis did not report estimates by stroke subtype. Finally, a global study reported high SBP, high BMI, and smoking as the top risk factors. In China, the most important risk factors were high SBP, ambient particulate matter pollution exposure, and smoking. In LAC, the pattern was similar to the global pattern, with high SBP and high BMI being the top risk factors.

A systematic review including studies from high‐income countries and regions (the United Kingdom, United States, Canada, Australia, and Scandinavia) and Iran concluded that the perception of patients with stroke and caregivers toward training on identifying early signs and symptoms of stroke provided by primary health care providers was a weak link in the treatment chain. Poststroke patients reported feeling that their primary care physicians and health care providers did not provide appropriate management for prompt recovery. 63 These primary studies were not conducted in LAC and support our argument that this is a worldwide issue. In addition, in many countries in LAC, primary care or preventive care is not a role assumed by physicians but by other health care professionals or health care workers, and it is a less used component of the health system. Moreover, physicians have admitted that many barriers (infrastructure, professional competencies, and patients' awareness and beliefs) limit them in providing evidence‐based care for their patients. 64 Finally, the use of telemedicine for stroke, as recommended by the American Heart Association/American Stroke Association stroke guidelines, 65 is limited by access to digital health technologies in LAC. 66 However, the current COVID‐19 pandemic, which has initiated telemedicine reform, could make this approach more feasible in the region. 67

Further research is needed to evaluate and develop context‐tailored interventions for modifiable stroke risk factors to reduce the stroke burden in LAC. 1 There is much need for improvement, as the interplay of multidimensional social, economic, and political aspects creates a unique set of challenges in LAC.

Limitations

This was a secondary analysis, and the quality of the results was dependent on the quality of the primary information (GBD study data). As stated, certain countries had scarce data and relied on epidemiological prediction models. Other countries, especially in the Caribbean, still lack primary data, preventing us from performing a full regional assessment. Finally, there is a need to improve the national registration of diseases. This would prevent underdiagnosis or misclassification of stroke and its subtypes. Thus, these estimates should be interpreted with caution, especially those with the lowest rates in the region because of potential underreporting.

CONCLUSIONS

In summary, in 2019, the LAC region had the fourth largest stroke burden worldwide, predominantly attributable to premature deaths (≈90% of the total burden). Intracerebral hemorrhage was the main contributor to this burden, but ischemic stroke was the main cause of disability. Within LAC, the distribution of the burden of stroke was heterogeneous. Developed and developing LAC countries experience similar stroke burdens. Metabolic risk factors (high SBP and high BMI) were the main contributors to the overall stroke burden and its subtypes. These modifiable risk factors make stroke a highly preventable disease in the region. Investment in primary prevention should be a public health priority. Multinational stroke awareness campaigns for prompt recognition, screening of comorbidities, and education about healthy lifestyles might be effective in reducing the burden of stroke and its associated high‐cost impact.

Sources of Funding

None.

Disclosures

None.

Supporting information

Tables S1–S5

Figures S1–S6

Click here for additional data file. (791.6KB, pdf)

For Sources of Funding and Disclosures, see page 9.

Supplemental Material for this article is available at https://www.ahajournals.org/doi/suppl/10.1161/JAHA.122.027044

Contributor Information

Kevin Pacheco‐Barrios, Email: kevin.pacheco.barrios@gmail.com.

Carlos Alva‐Diaz, Email: alvacarl@crece.uss.edu.pe.

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