From Pages to Practice

By Amanda Fernandes, MD

Published January 5, 2022


In 1995, NEJM published a study by the National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group that found that patients with acute ischemic stroke who received alteplase within 3 hours after the onset of the symptoms were 30% more likely than patients who received placebo to have minimal-to-no disability at 3 months. However, the Chinese National Stroke Registration Study found that IV thrombolysis use in China between 2007 and 2008 was only 1.6%, compared to 3% to 5% in the United States. What accounts for these differences? Is it access to the thrombolytics? Is it access to hospitals? Are symptoms of stroke being missed?

The Global Burden of Disease (GBD) was created in 1990 to help understand global trends and differences in disease burden with the goal of informing health policies to narrow disparities. Data were collected and analyzed from 195 countries for more than 300 diseases to examine causes of premature death and disability and to identify disparities among countries.

In the December 20, 2018 issue of NEJM, Roth and colleagues used data from the GBD Study 2016 to estimate lifetime risk of a first ischemic stroke or hemorrhagic stroke. The authors reported that the global lifetime risk of stroke starting at the age of 25 years increased from 22.8% in 1990 to 24.9% in 2016. China had the highest estimated current risk (39.3%) and the eastern sub-Saharan Africa had the lowest risk (11.8%). The risk of ischemic stroke was higher than the risk of hemorrhagic stroke. The global lifetime risk of stroke did not differ significantly between men and women.

While these risk rates seem high, the authors note that the estimates are similar to those from other cohorts, including the Framingham Heart Study. These high rates, along with the large regional variation, highlight the need to explore factors that influence stroke risk and inform public health decisions.

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Amanda Fernandes is a 2018-2019 NEJM editorial fellow.