Miller School Researchers Discuss Positive Stroke Trends and Future Challenges in JAMA Editorial

Although both the incidence of stroke and the mortality rate have declined in the past decade, obesity, diabetes and lack of physical activity could reverse those trends in the future, according to two Miller School of Medicine researchers in an editorial published in the Journal of the American Medical Association (JAMA).

“Successes in the control of cholesterol levels, blood pressure, and smoking habits over the last decades are likely partially responsible for the decline in stroke incidence,” said Ralph L. Sacco, M.D., M.S., professor of neurology, public health sciences, human genetics and neurological surgery, Olemberg Family Chair of Neurological Diseases, and executive director of the Evelyn McKnight Brain Institute at the University of Miami Miller School of Medicine.

In the editorial, Sacco and Chuanhui Dong, M.D., Ph.D., associate professor of neurology, discussed the implications of two recent stroke studies that were also published in the July 16 issue of JAMA, and warned of future challenges.

“Unless health disparities are addressed and innovative strategies to change behavior are developed and adopted, the cerebrovascular health of the population will be unlikely to improve,” said Sacco and Dong. “Greater improvements in brain health, especially with controllable risk factors such as diet, exercise, smoking and obesity, among younger segments of the population are required to reduce the risk of stroke and enhance the chance of successful cognitive aging for all adults.”

In their editorial, “Declining Stroke Incidence and Improving Survival in U.S. Communities – Evidence for Success and Future Challenges,” Sacco and Dong noted that greater use of heart medications, along with improvements in acute stroke treatment at many institutions, are likely responsible for reductions in stroke incidence and mortality.

However, one recent study found that the decline in stroke incidence rates was evident only among those age 65 and older – not among those younger than 65. The study, “Stroke Incidence and Mortality Trends in U.S. Communities, 1987 to 2011” by lead author Silvia Koton, Ph.D., MOccH, Tel Aviv University in Israel, was also published in the current issue of JAMA.

Koton’s study evaluated trends in stroke incidence and mortality among more than 14,000 black and white adults who participated in the long-term Atherosclerosis Risk in Communities (ARIC) study. During the 24-year study period, 1,051 participants had a stroke incident, with strokes more common in men than women and in blacks than whites. The new results demonstrated a substantial decrease in stroke incidence over each 10-year interval for men, women, whites and blacks.

In their editorial, Sacco and Dong pointed to the need for more stroke studies focusing on Hispanics, the largest minority group in the nation. “While Hispanics have higher rates of stroke, community-based studies on Hispanic-white disparities remain scarce,” they said.

The Miller School researchers also commented on a second study reported in the JAMA issue, “Time Elapsed After Ischemic Stroke and Risk of Adverse Cardiovascular Events and Mortality Following Elective Noncardiac Surgery,” by lead author Mads E. Jørgenson, M.B., University of Copenhagen, Denmark. That study examined the risk of major adverse cardiovascular outcomes – stroke, myocardial infarction and cardiovascular mortality — up to 30 days after elective non-cardiac surgery.

The Jørgenson study, which covered 481,183 Danish patients age 20 or older from 2005 to 2011, found that a prior stroke significantly increased the risk of a major adverse cardiac event.

“Although mortality after stroke may be declining, patients who experienced prior stroke remain at substantially elevated risk of a stroke recurrence or an adverse outcome after surgery,” noted Sacco and Dong in their editorial.

Looking ahead to the coming decade, Sacco and Dong said that the aging of the U.S. population is likely to lead to a substantial increase in the prevalence of stroke. “These stroke survivors will be at increased risk of adverse outcomes after other surgical procedures,” Sacco said. “Vascular problems also have a major influence on the risk of cognitive decline and dementia in older populations. Therefore, healthcare providers will need to devote more resources and deploy new strategies to reduce the risk of stroke for Americans of all ages.”

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