Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2024 Mar 4;81(4):394-404.
doi: 10.1001/jamaneurol.2024.0190. Online ahead of print.

Burden of Ischemic and Hemorrhagic Stroke Across the US From 1990 to 2019

Daniela Renedo  1   2 , Julian N Acosta  1 , Audrey C Leasure  1 , Richa Sharma  3 , Harlan M Krumholz  4   5   6 , Adam de Havenon  1 , Fares Alahdab  7 , Aleksandr Y Aravkin  8   9   10 , Zahra Aryan  11   12 , Till Winfried Bärnighausen  13   14 , Sanjay Basu  15   16 , Katrin Burkart  9   10 , Kaleb Coberly  9 , Michael H Criqui  17 , Xiaochen Dai  9   10 , Rupak Desai  18 , Samath Dhamminda Dharmaratne  9   10   19 , Rajkumar Doshi  20 , Islam Y Elgendy  21   22 , Valery L Feigin  9   22   23 , Irina Filip  24 , Mohamed M Gad  25   26 , Sherief Ghozy  27 , Nima Hafezi-Nejad  28 , Rizwan Kalani  29 , Ibraheem M Karaye  30   31 , Adnan Kisa  24   32 , Vijay Krishnamoorthy  33   34 , Warren Lo  35   36 , Tomislav Mestrovic  9   37 , Ted R Miller  38   39 , Awoke Misganaw  10   40 , Ali H Mokdad  9   10 , Christopher J L Murray  9   10 , Zuhair S Natto  41   42 , Amir Radfar  32 , Pradhum Ram  43 , Gregory A Roth  9   10   44 , Allen Seylani  45 , Nilay S Shah  46 , Purva Sharma  47 , Aziz Sheikh  48 , Jasvinder A Singh  49   50 , Suhang Song  51 , Houman Sotoudeh  52 , Dominique Vervoort  53 , Cong Wang  54 , Hong Xiao  55 , Suowen Xu  56   57 , Ramin Zand  58 , Guido J Falcone  1   3 , Kevin N Sheth  1   2   3
Affiliations

Burden of Ischemic and Hemorrhagic Stroke Across the US From 1990 to 2019

Daniela Renedo et al. JAMA Neurol. .

Abstract

Importance: Stroke is a leading cause of death and disability in the US. Accurate and updated measures of stroke burden are needed to guide public health policies.

Objective: To present burden estimates of ischemic and hemorrhagic stroke in the US in 2019 and describe trends from 1990 to 2019 by age, sex, and geographic location.

Design, setting, and participants: An in-depth cross-sectional analysis of the 2019 Global Burden of Disease study was conducted. The setting included the time period of 1990 to 2019 in the US. The study encompassed estimates for various types of strokes, including all strokes, ischemic strokes, intracerebral hemorrhages (ICHs), and subarachnoid hemorrhages (SAHs). The 2019 Global Burden of Disease results were released on October 20, 2020.

Exposures: In this study, no particular exposure was specifically targeted.

Main outcomes and measures: The primary focus of this analysis centered on both overall and age-standardized estimates, stroke incidence, prevalence, mortality, and DALYs per 100 000 individuals.

Results: In 2019, the US recorded 7.09 million prevalent strokes (4.07 million women [57.4%]; 3.02 million men [42.6%]), with 5.87 million being ischemic strokes (82.7%). Prevalence also included 0.66 million ICHs and 0.85 million SAHs. Although the absolute numbers of stroke cases, mortality, and DALYs surged from 1990 to 2019, the age-standardized rates either declined or remained steady. Notably, hemorrhagic strokes manifested a substantial increase, especially in mortality, compared with ischemic strokes (incidence of ischemic stroke increased by 13% [95% uncertainty interval (UI), 14.2%-11.9%]; incidence of ICH increased by 39.8% [95% UI, 38.9%-39.7%]; incidence of SAH increased by 50.9% [95% UI, 49.2%-52.6%]). The downturn in stroke mortality plateaued in the recent decade. There was a discernible heterogeneity in stroke burden trends, with older adults (50-74 years) experiencing a decrease in incidence in coastal areas (decreases up to 3.9% in Vermont), in contrast to an uptick observed in younger demographics (15-49 years) in the South and Midwest US (with increases up to 8.4% in Minnesota).

Conclusions and relevance: In this cross-sectional study, the declining age-standardized stroke rates over the past 3 decades suggest progress in managing stroke-related outcomes. However, the increasing absolute burden of stroke, coupled with a notable rise in hemorrhagic stroke, suggests an evolving and substantial public health challenge in the US. Moreover, the significant disparities in stroke burden trends across different age groups and geographic locations underscore the necessity for region- and demography-specific interventions and policies to effectively mitigate the multifaceted and escalating burden of stroke in the country.

PubMed Disclaimer

Conflict of interest statement

Conflict of Interest Disclosures: Dr Acosta reported being an employee of Rad AI outside the submitted work. Dr R. Sharma reported receiving grants from the National Institutes of Health outside the submitted work and having a patent to classify ischemic stroke etiology pending. Dr Krumholz reported receiving grants from National Institutes of Health, American Heart Association, Pfizer, Janssen, Johnson & Johnson, Centers for Disease Control and Prevention, contracts from Centers for Medicare & Medicaid Services through Yale New Haven Hospital, grants from Agency for Healthcare Research and Quality, editorial/consultant/advisor and/or nonfinancial support from Massachusetts Medical Society as coeditor of Journal Watch Cardiology, UpToDate, Eyedentify, F-Prime Consultant, Ensight AI, Element Science, Hugo Health, and served as cofounder of Refactor Health, and Ensight AI outside the submitted work. Dr de Havenon reported receiving grants from National Institutes of Health/National Institute of Neurological Disorders and Stroke and personal fees from Novo Nordisk, Certus, TitinKM, and UpToDate outside the submitted work. Dr Basu reported receiving grants from the National Institutes of Health and personal fees from University of California and Waymark outside the submitted work. Dr Burkart reported receiving grants from the University of Washington and funding from the Bill & Melinda Gates Foundation during the conduct of the study. Dr Coberly reported being a research engineer for the Institute for Health Metrics and Evaluation during the conduct of the study. Dr Dai reported receiving grants from the Bill & Melinda Gates Foundation during the conduct of the study. Drs Filip and Radfar reported being employees of the Avicenna Medical and Clinical Research Institute during the conduct of the study. Dr Roth reported receiving grants from the Bill & Melinda Gates Foundation during the conduct of the study. Dr Singh reported receiving personal fees from Schipher, Crealta/Horizon, Medisys, Fidia, PK Med, Two Labs Inc, Adept Field Solutions, Clinical Care Options, Clearview Healthcare Partners, Putnam Associates, Focus Forward, Navigant Consulting, Spherix, MedIQ, Jupiter Life Science, UBM LLC, Trio Health, Medscape, WebMD, Practice Point Communications, and the National Institutes of Health; consulting fees from the American College of Rheumatology; institutional research support from Zimmer Biomet Holding; food and beverage payments from Intuitive Surgical Inc/Philips Electronics North America; and stock options in Atai Life Sciences, Kintara Therapeutics, Intelligent Biosolutions, Acumen Pharmaceutical, TPT Global Tech, Vaxart Pharmaceuticals, Atyu Biopharma, Adaptimmune Therapeutics, GeoVax Labs, Pieris Pharmaceuticals, Enzolytics Inc, Seres Therapeutics, Tonix Pharmaceuticals Holding Corp, and Charlotte’s Web Holdings Inc outside the submitted work. Dr Sheth reported receiving grants from National Institutes of Health, American Heart Association, Hyperfine; personal fees/monitoring board fees/equity from Astrocyte, CSL Behring, Zoll, Sense, Bexorg, Rhaeos, and Alva; and having a patent for Alva licensed. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Temporal Trends in US-Wide Age-Standardized Incidence, Prevalence, Disability-Adjusted Life-Years, and Mortality Rates Caused by Stroke per 100 000 Persons per Year for Stroke From 1990 to 2019
Figure 2.
Figure 2.. Change in Stroke Incidence, Prevalence, Mortality Caused by Stroke per 100 000 Persons, and Disability-Adjusted Life-Years From 1990 to 2019 Across the US, by Age Group
See this image and copyright information in PMC

References

    1. Virani SS, Alonso A, Benjamin EJ, et al. ; American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee . Heart disease and stroke statistics—2020 update: a report from the American Heart Association. Circulation. 2020;141(9):e139-e596. doi:10.1161/CIR.0000000000000757 - DOI - PubMed
    1. Fang MC, Chang Y, Hylek EM, et al. . Advanced age, anticoagulation intensity, and risk for intracranial hemorrhage among patients taking warfarin for atrial fibrillation. Ann Intern Med. 2004;141(10):745-752. doi:10.7326/0003-4819-141-10-200411160-00005 - DOI - PubMed
    1. Johnson CO, Nguyen M, Roth GA, et al. ; GBD 2016 Stroke Collaborators . Global, regional, and national burden of stroke, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 2019;18(5):439-458. doi:10.1016/S1474-4422(19)30034-1 - DOI - PMC - PubMed
    1. Ekker MS, Verhoeven JI, Vaartjes I, van Nieuwenhuizen KM, Klijn CJM, de Leeuw FE. Stroke incidence in young adults according to age, subtype, sex, and time trends. Neurology. 2019;92(21):e2444-e2454. doi:10.1212/WNL.0000000000007533 - DOI - PubMed
    1. Kissela BM, Khoury JC, Alwell K, et al. . Age at stroke: temporal trends in stroke incidence in a large, biracial population. Neurology. 2012;79(17):1781-1787. doi:10.1212/WNL.0b013e318270401d - DOI - PMC - PubMed