Global, regional, and national burden of stroke and its risk factors, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021
Masayuki Teramoto, Melsew Dagne Abate, Yohannes Abate, Samar Abd ElHafeez, Foad Abd-Allah, Ahmed Abdelalim, Atef Abdelkader, Michael Abdelmasseh, Sherief Abd‐Elsalam, Parsa Abdi, Arash Abdollahi, Meriem Abdoun, Rami Abd‐Rabu, Deldar Morad Abdulah, Auwal Abdullahi, Mesfin Abebe, Roberto Ariel Abeldaño Zúñiga, E S Abhilash, Olugbenga Olusola Abiodun, Olumide Abiodun, Rahim Abo Kasem, Richard Gyan Aboagye, Mohamed Abouzid, Lucas Guimarães Abreu, Woldu Aberhe Abrha, Dariush Abtahi, Samir Abu‐Rumeileh, Ahmed Abualhasan, Hasan Abualruz, Eman Abu-Gharbieh, Hana J Abukhadijah, Niveen ME Abu-Rmeileh, Salahdein Aburuz, Ahmed Abu‐Zaid, Juan Acuña, Denberu Eshetie Adane, Mesafint Molla Adane, Isaac Yeboah Addo, Rufus Adesoji Adedoyin, Oyelola A. Adegboye, Victor Adekanmbi, Kishor Adhikari, Qorinah Estiningtyas Sakilah Adnani, Saryia Adra, Leticia Akua Adzigbli, Abdelrahman Yousry Afify, Aanuoluwapo Adeyimika Afolabi, Fatemeh Afrashteh, Muhammad U. Afzal, Saira Afzal, Shahin Aghamiri, Williams Agyemang‐Duah, Bright Opoku Ahinkorah, Aqeel Ahmad, Muayyad Ahmad, Sajjad Ahmad, Shahzaib Ahmad, Tauseef Ahmad, Amir Mahmoud Ahmadzade, Ali Ahmed, Ayman Ahmed, Haroon Ahmed, Syed Anees Ahmed, Marjan Ajami, Budi Aji, Essona Matatom Akara, Rufus Akinyemi, Mohammed Ahmed Akkaif, Ashley E Akrami, Salah Al Awaidy, Hanadi Al Hamad, Syed Mahfuz Al Hasan, Mohammad Al Qadire, Omar Al Ta’ani, Yazan A. Al‐Ajlouni, Samer O Alalalmeh, Tariq A. Alalwan, Ziyad Al‐Aly, Rasmieh Al‐Amer, Wafa Ali Aldhaleei, Mohammed S. Aldossary, Seyedeh Yasaman Alemohammad, Bassam Al‐Fatly, Adel Al‐Gheethi, Fadwa Alhalaiqa, Maryam Alharrasi, Abid Ali, Mohammed Usman Ali, Rafat Ali, Syed Shujait Ali, Waad Ali, Akram Al‐Ibraheem, Sheikh Mohammad Alif, Syed Mohamed Aljunid, Wael Almahmeed, Sabah Al-Marwani, Mahmoud A. Alomari, Jordi Alonso, Jaber S. Alqahtani, Rajaa M Mohammad Al-Raddadi
Abstract
BACKGROUND: Up-to-date estimates of stroke burden and attributable risks and their trends at global, regional, and national levels are essential for evidence-based health care, prevention, and resource allocation planning. We aimed to provide such estimates for the period 1990-2021. METHODS: We estimated incidence, prevalence, death, and disability-adjusted life-year (DALY) counts and age-standardised rates per 100 000 people per year for overall stroke, ischaemic stroke, intracerebral haemorrhage, and subarachnoid haemorrhage, for 204 countries and territories from 1990 to 2021. We also calculated burden of stroke attributable to 23 risk factors and six risk clusters (air pollution, tobacco smoking, behavioural, dietary, environmental, and metabolic risks) at the global and regional levels (21 GBD regions and Socio-demographic Index [SDI] quintiles), using the standard GBD methodology. 95% uncertainty intervals (UIs) for each individual future estimate were derived from the 2·5th and 97·5th percentiles of distributions generated from propagating 500 draws through the multistage computational pipeline. FINDINGS: In 2021, stroke was the third most common GBD level 3 cause of death (7·3 million [95% UI 6·6-7·8] deaths; 10·7% [9·8-11·3] of all deaths) after ischaemic heart disease and COVID-19, and the fourth most common cause of DALYs (160·5 million [147·8-171·6] DALYs; 5·6% [5·0-6·1] of all DALYs). In 2021, there were 93·8 million (89·0-99·3) prevalent and 11·9 million (10·7-13·2) incident strokes. We found disparities in stroke burden and risk factors by GBD region, country or territory, and SDI, as well as a stagnation in the reduction of incidence from 2015 onwards, and even some increases in the stroke incidence, death, prevalence, and DALY rates in southeast Asia, east Asia, and Oceania, countries with lower SDI, and people younger than 70 years. Globally, ischaemic stroke constituted 65·3% (62·4-67·7), intracerebral haemorrhage constituted 28·8% (28·3-28·8), and subarachnoid haemorrhage constituted 5·8% (5·7-6·0) of incident strokes. There were substantial increases in DALYs attributable to high BMI (88·2% [53·4-117·7]), high ambient temperature (72·4% [51·1 to 179·5]), high fasting plasma glucose (32·1% [26·7-38·1]), diet high in sugar-sweetened beverages (23·4% [12·7-35·7]), low physical activity (11·3% [1·8-34·9]), high systolic blood pressure (6·7% [2·5-11·6]), lead exposure (6·5% [4·5-11·2]), and diet low in omega-6 polyunsaturated fatty acids (5·3% [0·5-10·5]). INTERPRETATION: Stroke burden has increased from 1990 to 2021, and the contribution of several risk factors has also increased. Effective, accessible, and affordable measures to improve stroke surveillance, prevention (with the emphasis on blood pressure, lifestyle, and environmental factors), acute care, and rehabilitation need to be urgently implemented across all countries to reduce stroke burden. FUNDING: Bill & Melinda Gates Foundation.