Recent Global

Epidemiology in Stroke
Rusdi Lamsudin

Department of Neurology
Faculty of Medicine
Indonesia Islamic University
Yogyakarta
 Outline
Background
INTERSTROKE STUDY
Global burden of stroke
Dead from Stroke

Risk Factors

Conclusion
 Background
Increases of up 300% in older population
are expected in many developing
countries within 30 years

With increasing age, the burden of non-

communicable disease such as Stroke
increases
 Background
One of the biggest public health
challenges for many nation;

To prevent and postpone morbidity and disability

due to stroke
To maintain the health, independence and mobility
of an aging population
 Background
Along with many chronic diseases, stroke
can be prevented.

For preventive strategies to be planned

and evaluated;

It is essential to have information on pattern of

disease and exposure to risk factors in population
 Background
One of the strategies to respond the
challenges to population health and well
being due to global epidemic of stroke;

Is to provide actionable information for

development and implementation of appropriate
polices
 Background

WHO has produced for wider audience;

The Atlas of Heart Disease and Stroke
 Background
The atlas address the global epidemic of
heart disease and stroke in a clear by;

Policy makers
National and International organizations

Health professionals

General public
 Global Epidemiology of Stroke
INTERSTROKE Phase 1
Mar 26th 2010 , IHF, Dublin

Martin ODonnell MB PhD MRCP PI

HRB-Clinical Research Facility, NU
UI Galway, Galway
 GLOBAL BURDEN OF STROKE
Leading cause of adult disability in most regions
2nd leading cause of death worldwide (leading in cause of
death in many regions)
5 5.7 7 million deaths in 2005 (7 7 7.8 8 million 2030)
87% in low/moderateinco ome countries

Knowledge of stroke epidemiology lags behind CHD

Stroke has not been studied in most lowincome countries
Comparison between region ns are indirect, with studies
employing differing methodo ology
 PREVENTION OF STROKE (POPULATION LEVEL)
Mandates measurement of importance of common risk
factors for stroke within regions
High, medium and lowincom mecountries

Two Options
Large prospective cohort study (Not feasible)
Casecontrol design (Applicable to all income settings)

To date, case control studies (<1,500 pairs)

Yus suf et al INTERHEART Lancet 2004;364:93752

 INTERHEART
Population Attributable Risk > 90% f for nine easily measured risk factors

Risk factor Controls (%) Cases (%) OR (95% CI)* PAR (%)

Apo B/A1 ratio 20.0 33.5 3.3 (2.83.8) 49.2

Current smoking 26.8 45.2 2.9 (2.63.2) 35.7
Psychosocial factors 2.7 (2.23.2) 32.5
Abdominal obesity 33.3 46.3 1.6 (1.51.8) 20.1
Hypertension 21.9 39.0 1.9 (1.72.1) 17.9
Vegetables and fruit 42.6 32.8 0.7 (0.70.8) 13.7
Exercise 19.3 14.3 0.9 (0.80.97) 12.2
Diabetes 7.5 18.5 2.4 (2.12.7) 9.9
Alcohol intake 24.5 24.0 0.9 (0.81.9) 6.7
All risk factors 129.2 (90185) 90.4

Yusuf et al INTERHEART Lancet 2004;364:93752

 HETEROGENEITY OF STROKE SUBTYPE
Hemorrhagic stroke (17%) Ischemic stroke (83%)

Lacunar small vessel

Intracerebral disease (25%)
hemorrhage (59%)

Atherothrombotic
disease (20%)

Embolism (20%)

SAH (41%)
Albers GW et al. Chest. 1998;114:683S-698S. Cryptogenic (35%)
Rosamond WD et al. Stroke. 1999;30:736-743.
 EPIDEMIOLOGY (UNEXPLAINED)
Considerable regional variatio on in stroke incidence
Unexplained by HTN, Smoking and Diabetes
Proposed that 3040% of strok ke is unexplained

Johnston et al Lancet Neurol 2009

 EPIDEMIOLOGY (UNEXPLAINED)
Variation in frequency of ind dividual stroke subtypes by
region

Feigin et al Lancet Neurol 2009

 EPIDEMIOLOGY
Variation in Temporal Trends
Variation in death and disability ( (DALY lost)

Strong et al Lancet Neurology 2006;4:269-78

Johnston et al Lancet Neurol 2009

 REGIONAL VARIATION N IN STROKE SUBTYPES
Intracerebral hemorrhage
Africa (4050%) and China Card dioembolism
3040% in some Highincome co ountries (hospital population)
Small vessel ischemic stroke
South America (4050%)
Intracranial Stenosis
South Asia (2030%)
CVST
India (4050%)

Suspect that importance of risk factors may vary by region

 EPIDEMIOLOGY (UNEXPLAINED)
Considerable regional variati ion in stroke incidence
Unexplained by HTN, Smoking g and Diabetes
Proposed that 3040% of strok ke is unexplained
Variation in incidence of indi ividual stroke subtypes by
region
Temporal trends in incidence e of MI and Stroke varying by
region
Proposed that traditional vas scular risk factors have different
magnitude of risk for stroke compared to MI

MONICA
 CHOLESTEROL
Association appears to be regional
Western countries: No convincing as ssociation for Ischemic Stroke but inconsistent
findings
Asia: Apparent association but limite ed studies (older)
Apparent inverse association with ICH
But statins prevent ischemic stroke

PAR for AMI: 50%

Stroke subtype?
Lipid subtype?
(AMORIS)
Asia Pacific Cohort Studies Collab. Int J
Epid 2003
Yusuf et al INTERHEART Lancet
2004;364:93752
 LIMITED KNOWLEDGE OF F MANY RISK FACTORS

GENETICS INFECTIONS (e.g. HIV)

LIPIDS R RH HEART DISEASE
PSYCHOSOCIAL STRESS C CHAGAS S DISEASE
PHYSCIAL ACTIVITY E ENVIRONMENTAL (Pollution)
DIET ILLICIT DRUG USE
TRAUMA/INJURY E ENVIRONMENTAL SMOKE
AUTOIMMUNE (e.g. APS) METABOLIC (e.g. Fabrys)
PREGNANCY A ALCOHOL
MIGRAINE V VASCULOPATHIES
 CHALLENGES TO STROKE EPIDEMIOLOGY STUDIES

All large global epidemiological studies are challenging

INTERHEART provided evidence of feasibility

SPECIFIC TO STROKE
Valid determination of Stroke Sub btype
(Ischemic, ICH and SAH) requires routine CT of brain
Until recently, very limited availab bility in lowincome settings

Questionnairebased research
Presents challenges, given many p patients with stroke are unable to
communicate
Surrogate respondents (Robust Questionnaire: INTERHEART)
ODonnell and Yusuf Lancet Neurol 2009
 Objectives of INTERSTROKE (Phase 1)
To determine the feasibility of u undertaking a large international
casecontrol study to identify and estimate the population
attributablerisk (%) of convent tional and emerging risk factors
for stroke.

To provide preliminary estimate es of the importance of

traditional and emerging risk factors
fa in difference regions of the
world, for stroke overall and wi ithin ischemic and ICH

Awareness of risk factors among populations

Regional variations in Practice Patterns

ODonnell et al. Neuroepidemiology 2010 In press
 DESIGN

Casecontrol study
International, multicentere ed
Hospitalbased
Prospective followup of all cases (1month)

Similar methodology of IN
NTERHEART
 CASE

Rapidly developing signs and symptoms of a focal

neurological deficit lasting mo ore than 24 hours with no
evidence of a nonvascular ca ause.
(WHO criteria for stroke)

Ischemic stroke
Intracerebral hemorrhage (ICH)
Subarachnoid hemorrhage (SAH)
 INCLUSION CRITERIA

Clinical signs and symptoms of first stroke with no obvious

nonvascular cause. (WHO definition)
Recruited within
48 (72 hours) hours of presentation to the hospital
And this will be within 120 hours (5 days) of symptom
onset.
Intention is to have CT or MRI within 72 hours of
presentation.
Informed consent.
 STANDARDIZED STROKE SUBTYPE DATA
Stroke Subtype
Ischemic, ICH and SAH

Ischemic Stroke Subtype

Oxfordshire Community Stroke e Project (OCSP)
TACI, PACI, POCI and Lacunar r
Simple and high completion rate (CT and clinical presentation)
TOAST (diagnostic workup bias s)

Information on risk factors

Traditional Vascular Risk Facto ors
Additional (e.g. migraine, trau uma, atrial fibrillation..)
 CONTROLS
At least one control for every case e recruited.
Will be sex, ethnicity and age mat tched (+/ 5 years) without a history
of evidence of CVD.
Matched to cases by age (+ 5 years), sex and ethnicity

Communitybased controls :
Visitor or relative of a patient from a noncardiac ward, or an
unrelated (not first degree relative) visitor of a cardiac patient.
Community strategies

Hospitalbased controls :
May be an attendant or a relative of another patient in hospital
Patients admitted to the hospital or visiting the hospital for
conditions or procedures not related to stroke or TIA or ACS (on
this admission)
 INTERSTROK KE PHASE 1
REGION CASES CONTROLS TOTAL PARTICIPANTS

All Regions 2477 2063 4540

HIC 355 305 660
South America 175 108 283
China 895 800 1695
India 788 647 1435
Africa 264 203 467

Total: n=6,016 (n=4,540 fo or current analysis)

1,926 patients with ischem stroke
516 patients with intracerebral hemorrhage
2,764 controls
 INTERSTROKE-Phase 1

22 Countries
Asia
China, India, Philippines, Malay ysia and (Australia)
Africa
Mozambique, Nigeria, South Afr rica, Sudan, Uganda
America
Canada, Argentina, Brazil, Chile e, Colombia, Ecuador, Peru
Europe
Denmark, Germany, Poland, Cr roatia
Middle East
Kuwait
 VARIATION IN STROK KE MORTALITY RATES
VARIATION IN STROKE PRESE ENTATION AND MANAGEMENT
 STROKE SUBTYP PES (ISCHEMIC)
NEUROIMAGING >99%
100
90 87.3
80 77.8 74.9 77.8 77.7

70 67
60
50
40
30
20
10
0
All Regions HIC S America China India Africa
N=2477 N=355 N=175 N=895 N=788 N=264
INTERSTROKE Investigators Meeting Nov 2009
 INTRACRANIAL HEMORRHAGE

ICH SAH
50 50
45 45
40 40
35 31.8 35
30 30
25 23.4 25
20.8 21.7 20.8
20 20
15 15
9.3
10 10
5 5 3.4
1.4 1.7 0.6 1.5 1.1
0 0

INTERSTROKE Investigators Meeting Nov 2009

 STROKE SEVERITY (BY REGION)
Modified Rankin: 6=Death; 45 Severe disability
All S Stroke
50
45
40
35
30 13.8
25 6
11.4
20 4 or 5
15 6.8 9.3
3.7 3 24.5
10
12.3 16.6
5 10.5 9.3 11.5
0
All Regions HIC S America China India Africa
N=2477 N=355 N=175 N=895 N=788 N=264

INTERSTROKE Investigators Meeting Nov 2009

RESPONDENT

INTERSTROKE Investigators Meeting Nov 2009

 ACUTE THROMBOLYSIS
(ISCHEMIC C STROKE)
50
45
40
35
30 28.6
25
20
15
10 7.1
4.3
5 2.3 1.3
0
All Regions HIC S America China India Africa

INTERSTROKE Investigators Meeting Nov 2009

 Interval Between Symptom Onset and Hospital
Admission (Minutes)
900 895.36 859.38

800 765.64 752.27

700
644.04
600

500
454.08

400

300

200

100

All Regions HIC S America China India Africa

INTERSTROKE Investigators Meeting Nov 2009
 LOCATION AT 1MONTH (SEVERE STROKE)

Discharged Home Rehab Institutional Care

100
100 100 100

90 90 90

80 80 80
73.7
70 70 70

58.9
60 55.7 60 55.6 60

50 50 47.6 50
42.9
40 40 40

30 30 30
24.1
18.6
20 20 20 15.7
11.1 10.5
10 10 5.3 10 7.1 5.6
2.4
0 0 0
All HIC S China India Africa All HIC S China India Africa All HIC S China India Africa
Regions America Regions America Regions America

Modified Rankin 45 (Severe disability)

 RISK FACTORS S FOR STROKE
EPIDEMIOLOGIC TRANSITION
 Stages of Epidemiologic Transition
Stage Description Risk Factors CVD (%)

Pestilence and Famine Infectious disease Rheumatic heart disease 510%

Highinfant mortality
Receding pandemics Infectious disease Hypertension 1035%
CHD and Stroke (+ICH)
Increased life expectancy y
Degenerative CHD and Stroke (+IS) Obesity, diabetes mellitus, < 50%
Manmade disease Premature disease lipids, metabolic syndrome
Age of delayed Risk factor modification Modification of risk factors 3555%
degenerative disease Acute management Primary prevention
Older age of onset Lifestyle modification

Industrialization Rate of Transition Double burden effect

OmranAR MMFQ 1971;49:509-38
Yusuf et al Circulation 2001;104:2746-53
 Epidemiologic Transition (2 an 3)

Increasing life expectancy

Urbanization

Socioeconomic change

Lifestyle changes
More sedentary lifestyles
Dietary changes (increas sed fat intake)
Tobacco
Yusuf et al Circulation 2001;104:274653
 Increased Li ife Expectancy

Leading Causes of Mortality Globally (2002)

1559 years 60 and over

2279 HIV/AIDS 5823 IHD
1331 IHD 4692
1037 Tuberculosis 2399
Stroke
Chronic lung disease
811 RTAs 1398
RTI
783 929
Stroke RT cancers
672 754
Self-inflicted injuries Diabetes mellitus
475 735
Violence Hypertensive
382 606
Cirrhosis of the liver Stomach cancer
352 496
Lower RTI Tuberculosis
343 3 478
COPD Coloectal cancers

WHO 2003
 INTERSTROKE
AGE OF CASES (< 45 YEAR OR >65 YEARS)

N=2477 N=355 N=175 N=895 N=788 N=264

 Hypertension (Burden)
Increasing burden
Determinants of hypertension in different regions

Other Asia represents data from data from Korea, Thailand and Taiwan
Kearney et al. Lancet 12004; 35: 1248
 SELFREPORTED HYPERTENSION
5.0

4.0

OR 3.0

2.0

Adjusted for Age, Sex, Region, DM, Smoking, , Alcohol, Chol, Fruit/Veg, WHR, Stress, Physical Activity
0 1.0
All Stroke Ischemic Strok ke ICH

2.96 (2.533.48) 2.65 (2.283.0 08) 4.46 (3.555.61)

INTERSTROKE Investigators Meeting Nov 2009
 SELFREPORTED HYPERTENSION (ALL STROKE)
4.0

3.0

OR2.0

1.0

8 0.8

All Regions HIC S Americ ca China India Africa

2.96 (2.533.48) 1.94 (1.282.94) 1.85 (0.963 3.59) 3.57 (2.864.46) 3.08 (2.374.02) 3.38 (2.115.41)
TOBACCO TRANSITION N
3/5 top consumers
China, Japan and Indonesia

Gender
Predominantly male

Non-smoked tobacco
e e.g. India: Beedies

WHO http://www.who.int/tobacco/statistics/tobacco_atlas/en/
 SMOKING AND STROKE
Korean study (n= 648,346 men) 30-64 years (1992)
Follow-up of 10 years (9,475 h had stroke)

Never Previous < 10 1019 20

All Stroke 1.00 (0.901.10) 1.36 6 (1.241.50) 1.52 (1.391.66) 1.56 (1.421.72)
Ischemic 1.02 (0.901.16) 1.39 9 (1.211.58) 1.63 (1.451.85) 1.76 (1.552.00)
ICH 0.90 (0.751.08) 1.16 6 (0.951.41) 1.17 (0.971.41) 1.03 (0.841.27)
SAH 1.13 (0.761.67) 1.89 9 (1.292.79) 2.11 (1.483.01) 2.45 (1.703.54)
Lawlor et al Stroke (2008).
Passive smoking
Bonita et al TobControl (1999))

Non-smoked tobacco
Teo et al. Lancet 2006
CURRENT SMOKING

INTERSTROKE Investigators Meeting Beijing Nov 2009)

 SMO OKINGG
2.5

2.0

OR1.5

1.0

5 0.5Adjusted for Age, Regions, Sex, HTN, DM, Chol, Frui it/Veg, Alcohol, WHR, Stress, P Activity
All Stroke Ischemic ICH
Never 1 1 1
Former 0.89 (0.721.11) 0.89 (0.711.13) 0.93 (0.641.35)
Current 2.06 (1.752.44) 2.24 (1.872.68) 1.37 (1.031.82)
 CIGARETTES (NUMBER/D DAY AND TYPE): ALL STROKE

4.0

3.0

OR2.0

1.0

Adjusted for Age, Regions, Sex, HTN, DM, Chol, Frui it/Veg, Alcohol, WHR, Stress, P Activity
No per Day TYPE
Never/Former 1 Never/Former 1
19 1.56 (1.172.09) ) Filter (17.6%) 2.01 (1.662.44)
1019 1.93 (1.482.51) ) NonFilter (3.6%) 3.08 (2.244.25)
>19 2.94 (2.303.76) )
 ENVIRONMENTAL SMOKE (NONSMOKERS)
Adjusted for Age, Sex, Region, Hypertensio on, DM, Alcohol
2.5

2.0

OR1.5

1.0

Frequency Duration

None None
13/month 1.23 (0.991.59) 12 hour rs 1.38 (1.131.68)
16/week 1.44 (1.171.78) > 2 Hour rs 1.66 (1.362.03)
Daily 1.75 (1.382.20)
 Movement from Rural to Urban
Transition to urban living
1900 (10%) and 2005 (50%)
Varying stages in Asian countries

Region 1970 1994 2025

Global 36.6 44.8 61.1
Highincome 67.5 74.4 84.0
Transition 25.1 37.0 57.0
Lowincome 12.6 21.9 43.5
More sedentary lifestyle Yusuf et al Circulation 2001;104:2746-53
Structure of Communities
Transport (e.g. India 33-67 Million n vehicles 96-03)
Pendyala et al Transportation 2007

Nutritional Transition
Metabolic Transition
BMI (19892000) Children

Jaipur Heart Watch: Obesity in wom men from 15.7% (92-4) to 57.7% (05-6)
Gupta et al Heart (2008);94:16-26
APCSC: Continuous relationship with h CVD
Ni Mhurchu et al Int J Epidemiol (2004);33:751-8

Yangfeng Wu; Overweight & obesity in China BMJ 2006 6 Wang H et al International Journal of Obesity 31(2007):272278.
WAISTHIP RATIO

Women >0.95

Men >1.0
 WAISTHIP RATIO
Adjusted for Age, Sex, Hypertension, DM, Smoking, Cholesterol, Fruit and Vegetable Intake, BMI
2.5

2.0

OR1.5

1.0

5 0.5
Tertile All Stroke Ischemic ICH
Tertile 1
Tertile 2 1.44 (1.221.71) 1.44 (1.201.73) 1.34 (1.021.76)
Tertile 3 1.63 (1.381.95) 1.72 (1.442.05) 1.20 (0.911.60)
 PHYSICAL L ACTIVITY
Adjusted for Age, Sex, Region, HTN, DM, Smoking, Fruit t and Veg Intake, WHR, Alcohol, Psychosocial stress
1.5

1.0

OR0.8

0.6

OR ( (95%CI) ) All Stroke Ischemic ICH

Sedentary
Mild Activity 0.85 (0.740.98) 0.82 (0.700.95) 1.03 (0.811.30)
Moderate Activity 0.83 (0.631.08) 0.79 (0.591.04) 0.80 (0.511.25)
Strenuous Activity 0.72 (0.550.93) 0.73 (0.550.96) 0.79 (0.491.27)
 FRUITS
2.0
Adjusted for Age, Sex, Region, Smoking, Alcohol, BMI, Education

1.5

OR1.0

0.8

0.6
All Stroke Ischemic ICH
Q1 1 1 1
Q2 0.88 (0.74 1.06) 0.99 (0.79 1.23) 0.80 (0.57 1.12)
Q3 0.83 (0.69 1.00) 0.82 (0.66 1.00) 0.65 (0.47 0.90)
Q4 0.74 (0.61 0.90) 0.74 (0.61 0.91) 0.62 (0.45 0.86)
 RAW VEGETABLES

2.0
Adjusted for Age, Sex, Region, Smoking, Alcohol, BMI, Education

1.5

OR1.0

0.8

6 0.6
All Stroke Ischemic ICH
Q1 1 1 1
Q2 0.86 (0.73 1.03) 0.94 (0.78 1.14) 0.76 (0.57 1.01)
Q3 1.00 (0.80 1.25) 1.08 (0.85 1.37) 0.93 (0.65 1.34)
Q4 0.97 (0.80 1.18) 1.10 (0.89 1.37) 0.68 (0.48 0.96)
 ALCOHOL (DRINKS PER MONTH)
Adjusted for Age, Sex, Region, HTN, DM, Smoking, Fruit/Veg, WHR, Exerc cise, Psychosocial stress
2.0

1.5

OR1.0

0.8

6 0.6
OR (95%CI) All Stroke Ischemic ICH
Never 1 1 1
115/month 0.87 (0.701.08) 0.82 (0.651.04) 1.07 (0.731.57)
1630/month 1.02 (0.691.52) 0.83 (0.541.28) 1.88 (1.033.44)
>30/month 1.43 (1.151.79) 1.30 (1.021.66) 1.74 (1.212.50)
 Consequent Risk Fa actors
Cholesterol (19841999) Diabetes Mellitus
5
250
4.9 Male High-income
Female Low-income
4.8
200
4 4.7 7
4.6 150
4.5
m illions
4.4 100
4 4.3 3

4.2 50
4.1

4 0
1984 1988 1993 1996 1999 2000 2025
WHO MONICA survey, Beijing Lag Phase
Earlier onset in Asians (South Asians) INTERHEART
Joshi et al JAMA (2007)

Inconsistent relationship between n cholesterol and ischemic stroke

Prospective Studies Collaboration Lancet (2007) Easte ern Stroke Collaboration Lancet (1998) Ebrahim et al BMJ (2006)
HYPERCHOLESTEROLEMIA
(SELFR REPORTED)

INTERSTROKE Investigators Meeting Nov 2009

 Old and Emerging Risk Factors
Old Risk Factors (Infection relate ed)
Rheumatic heart disease
Chagas disease

Secondary Risk Factors

Atrial fibrillation
CHD/CHF

Lee et al AJM 2007 (Taiwan)

Novel Risk Factors (Triple burde en)

Hu et al JACC 2008
HIV
Ambient Pollution
Tsai et al Stro oke 2003
 ATRIAL FIBRILATION/FLUTTER

50
45
40
35
30
25
20
20
15 13.1
10 7.4 6.4
4 4.8 8 3.7
5
0
All Regions HIC S America China India Africa

INTERSTROKE Investigators Meeting Nov 2009

 Old and Emer rging Risk Factors
Old Risk Factors (Infection relate ed)
Rheumatic heart disease
Chagas disease

Secondary Risk Factors

Atrial fibrillation
CHD/CHF

Lee et al AJM 2007 (Taiwan)

Novel Risk Factors (Triple burde en)

Hu et al JACC 2008
HIV
Ambient Pollution
Tsai et al Stro oke 2003
 GLOBAL STRESS

2.5
Increased Stress

2.0

OR1.5

1.0

Adjusted for Age, Sex, Region, HTN, DM, Smoking, Fruit an nd Vegetable Intake, WHR, Physical activity
All Stroke Ischemic ICH
None
Some Periods 1.04 (0.891.22) 1.05 (0.891.24) 1.07 (0.821.39)
Several Periods 1.53 (1.221.91) 1.58 (1.242.01) 1.29 (0.891.88)
Permanent 1.73 (1.112.70) 1.83 (1.142.96) 1.53 (0.713.30)
 Why does Stroke Predominate in Some Regions?

Stage of Epidemiologic Transition

Relative prevalence of commo on risk factors (China v India)
Temporal relationship (lag pha ase)
Estimated benefit of programs s (PAF of risk factors)
Gorelick PB. Arch Neurol.

Difference in Interventions
Modifiability of risk factors (ev vidence and resources)
Awareness Truelsen ESC 20 010

Effectiveness of acute interventions

Availability (Stroke Unit vs CU)
Risk reduction of effective the erapy (ACS vs Acute stroke)
Therapeutic effect (ASA)
MONICA Stroke 2003;320:915-21
 Why does Stroke Predominate in Some Regions?

Different vulnerability to risk k factors

More potent effect of hypertension/lipids
?Genetics

Different vulnerability to stroke subtypes

Increased case-fatality
Intracerebral hemorrhage e

Large vessel disease (intr racranial)

Indirect comparisons
Non-standardized methodology
Liu et al Lancet Neurol 2007;6:456-64
Ebrahim et al BMJ (2006)
 Ireland (Burden of Vas scular Risk Factors)
Hypertension
SLAN 2007 Survey
60% had hypertension (57% no ot on medications)
70% were not controlled to targ get
Smoking
1998-2006 (33% to 24.5%)
Obesity
1990-2000: Women (13-16%) a and Men (8-20%)
Physical Activity
National Health Promotion Stra ategy 1998-2002
Men (21% to 30%) and Women n (20% to 25%)
 Future Plans

INTERSTROKE-Phase 1
Preliminary estimates of PAR of common risk factors
Explore genetics (preliminary) )

INTERSTROKE-Phase 2
20,000 participants (10,000 ca ase-control pairs)
Importance of risk factors within regions/countries

Important and unimpor rtant

Importance of risk factors within stroke subtypes

Genetic contribution to stro oke (risk and recovery)

Expanded section on prac ctice patterns

 INTERSTROKE-Phase 2
30 Countries
Asia
China, India, Philippines, Malays sia and (Australia)
To Start: Thailand, Sri Lanka
Africa
Mozambique, Nigeria, South Afr rica, Sudan, Uganda
America
Canada, Argentina, Brazil, Chile e, Colombia, Ecuador, Peru
Europe
Denmark, Germany, Poland, Cro oatia
To Start: Ireland, Italy, Swede en, UK
Middle East
Iran, Kuwait, Saudi Arabia
 INTERSTROKE Investigators
Salim Yusuf (Canada) and Denis Xavier (India)
 RECRUI ITMENT
No. of Sites
Country National Leader Date Started
(Recruiting)
Liu Lisheng/
China 21 (17) Mar 2007
Zhang Hongye
Denis Xavier/
India 24 (15) Apr 2007
Prem Pais
Canada Martin ODonnell 6 (4) Jan 2007

Uganda Charles Mondo 2 (2) Sept 2007

Danuta Ryglewicz/
Poland Anna Czlonkowska
4 (2) Aug 2008

Mozambique Albertino Damasceno 1 (1) Sept 2007

South Africa Linda DeVilliers 3 (2) Jun 2007

Ecuador Ernesto Peaherrera 3 (1) Jun 2009

John Varigos/
Australia 1 (1) Mar 2008
Graeme Hankey
Denmark Thomas Truelsen 3 (1) Apr 2007

Colombia Patricio LopezJaramillo o 8 (4) Feb 2008

 RECRUI ITMENT
No. of Sites
Country National Leader Date Started
(Recruiting)
Chile Fernando Lanas 3 (1) J Jan 2008

Germany HansChristoph Diener 3 (1) May 2007

Brazil Alvaro Avezum 9 (5) Feb 2008

Sudan Ahmed El Sayed 2 (1) Apr 2009

Philippines Tony Dans 3 (1) Oct 2009

Okechukwu Ogah/
Nigeria 4 (3) Apr 2009
Adesola Ogunniyi
Malaysia Khalid Yusoff 1 (1) Oct 2009

Argentina Rafael Diaz 6 (2) Dec 2008

Croatia Zvonko Rumboldt 4 (1) Aug 2009

Kuwait Osamah AlBaker 1 (1) Jul 2009