Global, regional, and national burden of stroke and its risk factors, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019

Abstract

Background: Regularly updated data on stroke and its pathological types, including data on their incidence, prevalence, mortality, disability, risk factors, and epidemiological trends, are important for evidence-based stroke care planning and resource allocation. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) aims to provide a standardised and comprehensive measurement of these metrics at global, regional, and national levels.

Methods: We applied GBD 2019 analytical tools to calculate stroke incidence, prevalence, mortality, disability-adjusted life-years (DALYs), and the population attributable fraction (PAF) of DALYs (with corresponding 95% uncertainty intervals [UIs]) associated with 19 risk factors, for 204 countries and territories from 1990 to 2019. These estimates were provided for ischaemic stroke, intracerebral haemorrhage, subarachnoid haemorrhage, and all strokes combined, and stratified by sex, age group, and World Bank country income level.

Findings: In 2019, there were 12·2 million (95% UI 11·0-13·6) incident cases of stroke, 101 million (93·2-111) prevalent cases of stroke, 143 million (133-153) DALYs due to stroke, and 6·55 million (6·00-7·02) deaths from stroke. Globally, stroke remained the second-leading cause of death (11·6% [10·8-12·2] of total deaths) and the third-leading cause of death and disability combined (5·7% [5·1-6·2] of total DALYs) in 2019. From 1990 to 2019, the absolute number of incident strokes increased by 70·0% (67·0-73·0), prevalent strokes increased by 85·0% (83·0-88·0), deaths from stroke increased by 43·0% (31·0-55·0), and DALYs due to stroke increased by 32·0% (22·0-42·0). During the same period, age-standardised rates of stroke incidence decreased by 17·0% (15·0-18·0), mortality decreased by 36·0% (31·0-42·0), prevalence decreased by 6·0% (5·0-7·0), and DALYs decreased by 36·0% (31·0-42·0). However, among people younger than 70 years, prevalence rates increased by 22·0% (21·0-24·0) and incidence rates increased by 15·0% (12·0-18·0). In 2019, the age-standardised stroke-related mortality rate was 3·6 (3·5-3·8) times higher in the World Bank low-income group than in the World Bank high-income group, and the age-standardised stroke-related DALY rate was 3·7 (3·5-3·9) times higher in the low-income group than the high-income group. Ischaemic stroke constituted 62·4% of all incident strokes in 2019 (7·63 million [6·57-8·96]), while intracerebral haemorrhage constituted 27·9% (3·41 million [2·97-3·91]) and subarachnoid haemorrhage constituted 9·7% (1·18 million [1·01-1·39]). In 2019, the five leading risk factors for stroke were high systolic blood pressure (contributing to 79·6 million [67·7-90·8] DALYs or 55·5% [48·2-62·0] of total stroke DALYs), high body-mass index (34·9 million [22·3-48·6] DALYs or 24·3% [15·7-33·2]), high fasting plasma glucose (28·9 million [19·8-41·5] DALYs or 20·2% [13·8-29·1]), ambient particulate matter pollution (28·7 million [23·4-33·4] DALYs or 20·1% [16·6-23·0]), and smoking (25·3 million [22·6-28·2] DALYs or 17·6% [16·4-19·0]).

Interpretation: The annual number of strokes and deaths due to stroke increased substantially from 1990 to 2019, despite substantial reductions in age-standardised rates, particularly among people older than 70 years. The highest age-standardised stroke-related mortality and DALY rates were in the World Bank low-income group. The fastest-growing risk factor for stroke between 1990 and 2019 was high body-mass index. Without urgent implementation of effective primary prevention strategies, the stroke burden will probably continue to grow across the world, particularly in low-income countries.

Funding: Bill & Melinda Gates Foundation.

Conflict of interest statement

Declaration of interests V Feigin reports support for the present manuscript from PreventS web app and free Stroke Riskometer app, which are owned and copyrighted by Auckland University of Technology, New Zealand. V Feigin reports grants received from the Brain Research New Zealand Centre of Research Excellence (16/STH/36), National Health & Medical Research Council (NHMRC, Australia APP1182071) and World Stroke Organization to their institution; leadership or fiduciary role in board, society, committee or advocacy group, paid or unpaid with World Stroke Organization as Executive Committee member, New Zealand Stroke Education (charitable) Trust as CEO, Stroke Central New Zealand as Honorary Medical Director, all of which are honorary unpaid roles; all outside the submitted work. O Adebayo reports grants or contracts from Merck Foundation; support for attending meetings and/or travel from Novartis; all outside the submitted work. R Akinyemi reports grants or contracts from NIH (U01HG010273), and GCRF (GCRFNGR6\1498), all outside the submitted work. R Ancuceanu consulting fees from AbbVie and AstraZeneca; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from AbbVie, Sandoz, and B. Braun; support for attending meetings and/or travel from AbbVie and AstraZeneca; all outside the submitted work. J Ärnlöv reports payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from AstraZeneca and Novartis; participation on a Data Safety Monitoring Board or Advisory Board with AstraZeneca and Boehringer Ingelheim; all outside the submitted work. Z Aryan reports support for the present manuscript from American Heart Association as funding to their institution, and from Brigham and Women's Hospital as an employee. M Ausloos reports grants or contracts from [Romanian National Authority for Scientific Research and Innovation, CNDS-UEFISCDI project number PN-III-P4-ID-PCCF-2016-0084, research grant (Oct 2018–Sept 2022), grant title “Understanding and modelling time-space patterns of psychology-related inequalities and polarization” outside the submitted work. T Bärnighausen reports grants or contracts from Research grants from the European Union (Horizon 2020 and EIT Health), German Research Foundation (DFG), US National Institutes of Health, German Ministry of Education Research, Alexander von Humboldt Foundation, Else-Kröner-Fresenius-Foundation, Wellcome Trust, Bill & Melinda Gates Foundation, KfW, UNAIDS, and WHO; consulting fees from KfW on the OSCAR initiative in Vietnam; participation on a Data Safety Monitoring Board or Advisory Board with the NIH-funded study “Healthy Options” (PIs: Smith Fawzi, Kaaya), Chair of the Data Safety and Monitoring Board (DSMB), German National Committee on the “Future of Public Health Research and Education”, Chair of the scientific advisory board to the EDCTP Evaluation, Member of the UNAIDS Evaluation Expert Advisory Committee, National Institutes of Health Study Section Member on Population and Public Health Approaches to HIV/AIDS (PPAH), US National Academies of Sciences, Engineering, and Medicine's Committee for the “Evaluation of Human Resources for Health in the Republic of Rwanda under the President's Emergency Plan for AIDS Relief (PEPFAR)”, and University of Pennsylvania (UPenn) Population Aging Research Center (PARC) External Advisory Board Member; leadership or fiduciary role in board, society, committee or advocacy group, paid or unpaid as the co-chair of the Global Health Hub Germany (which was initiated by the German Ministry of Health); all outside the submitted work. E Beghi reports grants or contracts from Italian Health Ministry, American ALS Association, and SOBI Pharmaceutical Company made to their institution; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from University of Rochester; support for attending meetings and/or travel from ILAE; participation on a Data Safety Monitoring Board or Advisory Board with Arvelle Therapeutics; all outside the submitted work. Y Béjot reports payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Medtronic, Boehringer-Ingelheim, Pfizer, BMS, Servier, and Amgen; support for attending meetings and/or travel from Servier; all outside the submitted work. A Catapano reports grants or contracts from Sanofi, Eli Lilly, Mylan, Sanofi Regeneron, Menarini, and Amgen; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Akcea, Amgen, AstraZeneca, Aegerion, Amryt, Daiichi, Sankyo, Esperion, Kowa, Ionis Pharmaceuticals, Mylan, Merck, Menarini, Novartis, Recordati, Regeneron, Sandoz, and Sanofi; all outside the submitted work. S Costanzo reports grants or contracts from ERAB (the European Foundation for Alcohol Research; id. EA1767; 2018–2020 and Italian Ministry of Health (grant RF-2018-12367074, CoPI), both paid to their institution; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from as a member of the Organizing Committee and speaker for the 9th European Beer and Health Symposium (Bruxelles 2019) and for given lecture at the 13th European Nutrition Conference FENS 2019 (Dublin), sponsored by the Beer and Health Initiative (The Dutch Beer Institute foundation—The Brewers of Europe); all outside the submitted work. M Endres reports grants or contracts from Bayer as an unrestricted grant to Charité for MonDAFIS study and Berlin AFib registry; consulting fees from Bayer paid to their institution; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Bayer, Boehringer Ingelheim, Pfizer, Amgen, GSK, Sanofi, and Novartis, all paid to their institution; participation on a Data Safety Monitoring Board or Advisory Board with BMS as a Country PI for Axiomatic-SSP, Bayer as Country PO for NAVIGATE-ESUS, AstraZeneca, Boehringer Ingelheim, Daiichi Sankyo, Amgen, Covidien, with all fees paid to their institution; leadership or fiduciary role in board, society, committee or advocacy group, paid or unpaid with EAN as part of the Board of Directors, DGN, ISCBFM, AHA/ASA, ESO, WSO, DZHK (German Centre of Cardiovascular Research) as a PI, all of which are unpaid positions, and with DZNE (German Center of Neurodegenerative Diseases) as a paid PI; receipt of PCSK9 inhibitors for mouse studies from Amgen; all outside the submitted work. I Filip reports payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Avicenna Medical and Clinical Research Institute, outside the submitted work. A Gialluisi reports grants or contracts from Italian Ministry of Economic Development (PLATONE project, bando “Agenda Digitale” PON I&C 2014–2020; Prog. n. F/080032/01-03/X35) paid to their institution, outside the submitted work. C Herteliu reports grants or contracts from Romanian National Authority for Scientific Research and Innovation, CNDS-UEFISCDI project number PN-III-P4-ID-PCCF-2016-0084 research grant (Oct 2018–Sept 2022) “Understanding and modelling time-space patterns of psychology-related inequalities and polarization,” and project number PN-III-P2-2.1-SOL-2020-2-0351 research grant (June–Oct, 2021) “Approaches within public health management in the context of COVID-19 pandemic,” and from the Ministry of Labour and Social Justice, Romania, project number 30/PSCD/2018 research grant (Sept 2018–June 2019) “Agenda for skills Romania 2020–2025;” all outside the submitted work. S Islam reports grants or contracts from National Heart Foundation Vanguard grant, Postdoctoral Fellowship and NHMRC Emerging Leadership Fellowship, outside the submitted work. Y Kalkonde reports grants or contracts from DBT/Wellcome Trust India Alliance as a DBT/Wellcome Trust India Alliance fellow in Public Health (grant number IA/CPHI/14/1/501514). M Kivimäki reports support for the present manuscript from The Wellcome Trust (221854/Z/20/Z) and Medical Research Council (MR/S011676/1), as research grants paid to their institute. K Krishnan reports non-financial support from UGC Centre of Advanced Study, Phase II, Department of Anthropology, Panjab University, Chandigarh, India, outside the submitted work. P Lavados reports grants or contracts from Boehringer Ingelheim as grant support to their institute for RECCA stroke registry, and from ANID as personal grant support for ADDSPISE trial; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Boehringer Ingelheim as personal honoraria for lectures; support for attending meetings and/or travel from Boehringer Ingelheim as support for attending Global Stroke Netowrk meeting in 2020; all outside the submitted work. W Lo reports grants or contracts from 1U01NS106655-01A1 (MPI: S Ramey, Lo), 5U24NS1072050-02 (PI: Kolb), and 1P2CHD101912-01 (PD: S. Ramey), all outside the submitted work. S Lorkowski reports grants or contracts from Akcea Therapeutics Germany as payments made to their institution; consulting fees from Danone, Swedish Orphan Biovitrum (SOBI), and Upfield; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Akcea Therapeutics Germany, AMARIN Germany, Amedes Holding, AMGEN, Berlin-Chemie, Boehringer Ingelheim Pharma, Daiichi Sankyo Deutschland, Danone, Hubert Burda Media Holding, Lilly Deutschland, Novo Nordisk Pharma, Roche Pharma, Sanofi-Aventis, and SYNLAB Holding Deutschland & SYNLAB Akademie as personal payments; support for attending meetings and/or travel from Amgen as personal payments; participation on a Data Safety Monitoring Board or Advisory Board with Akcea Therapeutics Germany, Amgen, Daiichi Sankyo Deutschland, and Sanofi-Aventis as personal payments; all outside the submitted work. N Manafi reports support for the present manuscript from BMGF as funding to IHME for this project. B Norrving reports consulting fees from AstraZeneca and Bayer as personal payments outside the submitted work. O Odukoya reports grants or contracts from the Fogarty International Center of the National Institutes of Health as protected time towards the research reported in this publication was supported under the Award Number K43TW010704. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. A Pana reports grants or contracts from Romanian National Authority for Scientific Research and Innovation, CNDS-UEFISCDI project number PN-III-P4-ID-PCCF-2016-0084 research grant (Oct 2018–Sept 2022) “Understanding and modelling time-space patterns of psychology-related inequalities and polarization,” and project number PN-III-P2-2·1-SOL-2020-2-0351 research grant (June–Oct 2021) “Approaches within public health management in the context of COVID-19 pandemic,” all outside the submitted work. M Postma reports leadership or fiduciary role in other board, society, committee or advocacy group, paid or unpaid with the UK's JCVI as an unpaid member, outside the current manuscript. A Radfar reports payment or honoraria for lectures, presentations, speakers' bureaus, manuscript writing or educational events from Avicenna Medical and Clinical Research Institute. S Sacco reports grants or contracts from Novartis and Allergan-AbbVie; consulting fees from Allergan-AbbVie, Novartis, Eli Lilly, AstraZeneca, and Novo Nordisk; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Allergan-AbbVie, Novartis, Eli Lilly, TEVA, Abbott, Medscape, and Olgology; support for attending meetings and/or travel from Allergan, Eli Lilly, Abbott, Novartis, and Teva; leadership or fiduciary role in other board, society, committee or advocacy group, paid or unpaid with Guideline Board European Stroke Organization as Co-chair, and with the European Headache Federation as a board member; all outside the submitted work. A Schutte reports payment or honoraria for lectures, presentations, speaker's bureaus, manuscript writing or educational events from Sanofi, Takeda, Abbott, Servier, and Omron Healthcare as honoraria for lectures during educational events; support for attending meetings and/or travel from Takeda and Omron; all outside the submitted work. J Singh reports consulting fees from Crealta/Horizon, Medisys, Fidia, Two labs, Adept Field Solutions, Clinical Care options, Clearview healthcare partners, Putnam associates, Focus forward, Navigant consulting, Spherix, MedIQ, UBM LLC, Trio Health, Medscape, WebMD, and Practice Point communications; and the National Institutes of Health and the American College of Rheumatology; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Simply Speaking; support for attending meetings and/or travel from OMERACT, an international organization that develops measures for clinical trials and receives arm's length funding from 12 pharmaceutical companies, when traveling to OMERACT meetings; participation on a Data Safety Monitoring Board or Advisory Board as a member of the FDA Arthritis Advisory Committee; leadership or fiduciary role in other board, society, committee or advocacy group, paid or unpaid, with OMERACT as a member of the steering committee, with the Veterans Affairs Rheumatology Field Advisory Committee as a member, and with the UAB Cochrane Musculoskeletal Group Satellite Center on Network Meta-analysis as a director and editor; stock or stock options in TPT Global Tech, Vaxart pharmaceuticals, Charlotte's Web Holdings and previously owned stock options in Amarin, Viking, and Moderna pharmaceuticals; all outside the submitted work. S Stortecky reports grants or contracts from Edwards Lifesciences, Medtronic, Abbott, and Boston Scientific as grants made to their institution; consulting fees from Boston Scientific/BTG Teleflex; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Boston Scientific; all outside the submitted work. M Woodward reports consulting fees from Amgen as personal payment. All other authors declare no competing interests.

Copyright © 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.

Figures

Figure 1

Age-standardised stroke incidence rates per 100 000 people by stroke type and country, for both sexes, 2019 (A) All strokes. (B) Ischaemic stroke. (C) Intracerebral haemorrhage. (D) Subarachnoid haemorrhage.

Figure 1

Age-standardised stroke incidence rates per 100 000 people by stroke type and country, for both sexes, 2019 (A) All strokes. (B) Ischaemic stroke. (C) Intracerebral haemorrhage. (D) Subarachnoid haemorrhage.

Figure 2

Age-standardised incidence, prevalence, mortality, and DALY rates (per 100 000 people per year) in seven GBD super regions, 1990–2019, for both sexes and all ages DALY=disability-adjusted life-year. GBD=Global Burden of Diseases, Injuries, and Risk Factors Study.

Figure 3

Age-standardised stroke-related DALYs attributable to all risk factors combined, for both sexes, 2019 (A) All strokes. (B) Ischaemic stroke. (C) Intracerebral haemorrhage. (D) Subarachnoid haemorrhage. DALY=disability-adjusted life-year.

Figure 3

Age-standardised stroke-related DALYs attributable to all risk factors combined, for both sexes, 2019 (A) All strokes. (B) Ischaemic stroke. (C) Intracerebral haemorrhage. (D) Subarachnoid haemorrhage. DALY=disability-adjusted life-year.

Figure 4

Age-standardised stroke-related DALYs attributable to risk factors by 21 GBD regions, for both sexes, 2019 (A) All strokes. (B) Ischaemic stroke. (C) Intracerebral haemorrhage. (D) Subarachnoid haemorrhage. Numbers show the ranking level (1=highest, 15=lowest) by the number of DALYs attributable to the corresponding risk factors. Red shows 1st ranking; light brown, 2nd and 3rd ranking; very light yellow, 4–7 ranking; very light blue, 8–13 ranking; and dark blue, 14–15 ranking. Diet low in whole grains, low physical activity, and high LDL cholesterol were not assessed for intracerebral haemorrhage. Diet low in whole grains, alcohol use, low physical activity, high LDL cholesterol, and kidney dysfunction were not assessed for subarachnoid haemorrhage. DALY=disability-adjusted life-year. GBD=Global Burden of Diseases, Injuries, and Risk Factors Study.

Figure 4

Age-standardised stroke-related DALYs attributable to risk factors by 21 GBD regions, for both sexes, 2019 (A) All strokes. (B) Ischaemic stroke. (C) Intracerebral haemorrhage. (D) Subarachnoid haemorrhage. Numbers show the ranking level (1=highest, 15=lowest) by the number of DALYs attributable to the corresponding risk factors. Red shows 1st ranking; light brown, 2nd and 3rd ranking; very light yellow, 4–7 ranking; very light blue, 8–13 ranking; and dark blue, 14–15 ranking. Diet low in whole grains, low physical activity, and high LDL cholesterol were not assessed for intracerebral haemorrhage. Diet low in whole grains, alcohol use, low physical activity, high LDL cholesterol, and kidney dysfunction were not assessed for subarachnoid haemorrhage. DALY=disability-adjusted life-year. GBD=Global Burden of Diseases, Injuries, and Risk Factors Study.

Figure 5

Proportion of DALYs attributable to risk factors by pathological type of stroke for both sexes combined, 2019 Proportion of DALYs attributable to household air pollution from solid fuels are not shown in this figure. DALY=disability-adjusted life-year.