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September 05, 2017; 89 (10) Article

Sex-specific stroke incidence over time in the Greater Cincinnati/Northern Kentucky Stroke Study

Tracy E. Madsen, Jane Khoury, Kathleen Alwell, Charles J. Moomaw, Eric Rademacher, Matthew L. Flaherty, Daniel Woo, Jason Mackey, Felipe De Los Rios La Rosa, Sharyl Martini, Simona Ferioli, Opeolu Adeoye, Pooja Khatri, Joseph P. Broderick, Brett M. Kissela, Dawn Kleindorfer
First published August 9, 2017, DOI: https://doi.org/10.1212/WNL.0000000000004325
Tracy E. Madsen
From the Department of Emergency Medicine (T.E.M.), The Alpert Medical School of Brown University, Providence, RI; Division of Biostatistics and Epidemiology (J.K.), Cincinnati Children's Hospital Medical Center, OH; Neuroscience Institute (J.K., M.L.F., D.W., F.D.L.R.L.R., S.F., O.A., P.K., J.P.B., B.M.K., D.W.), Department of Neurology and Rehabilitation Medicine (K.A., C.J.M., M.L.F., D.W., P.K., J.P.B., B.M.K., D.K.), and Department of Emergency Medicine (O.A.), University of Cincinnati College of Medicine; Institute for Policy Research (E.R.), University of Cincinnati, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; and Department of Neurology (S.M.), Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX.
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Jane Khoury
From the Department of Emergency Medicine (T.E.M.), The Alpert Medical School of Brown University, Providence, RI; Division of Biostatistics and Epidemiology (J.K.), Cincinnati Children's Hospital Medical Center, OH; Neuroscience Institute (J.K., M.L.F., D.W., F.D.L.R.L.R., S.F., O.A., P.K., J.P.B., B.M.K., D.W.), Department of Neurology and Rehabilitation Medicine (K.A., C.J.M., M.L.F., D.W., P.K., J.P.B., B.M.K., D.K.), and Department of Emergency Medicine (O.A.), University of Cincinnati College of Medicine; Institute for Policy Research (E.R.), University of Cincinnati, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; and Department of Neurology (S.M.), Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX.
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Kathleen Alwell
From the Department of Emergency Medicine (T.E.M.), The Alpert Medical School of Brown University, Providence, RI; Division of Biostatistics and Epidemiology (J.K.), Cincinnati Children's Hospital Medical Center, OH; Neuroscience Institute (J.K., M.L.F., D.W., F.D.L.R.L.R., S.F., O.A., P.K., J.P.B., B.M.K., D.W.), Department of Neurology and Rehabilitation Medicine (K.A., C.J.M., M.L.F., D.W., P.K., J.P.B., B.M.K., D.K.), and Department of Emergency Medicine (O.A.), University of Cincinnati College of Medicine; Institute for Policy Research (E.R.), University of Cincinnati, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; and Department of Neurology (S.M.), Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX.
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Charles J. Moomaw
From the Department of Emergency Medicine (T.E.M.), The Alpert Medical School of Brown University, Providence, RI; Division of Biostatistics and Epidemiology (J.K.), Cincinnati Children's Hospital Medical Center, OH; Neuroscience Institute (J.K., M.L.F., D.W., F.D.L.R.L.R., S.F., O.A., P.K., J.P.B., B.M.K., D.W.), Department of Neurology and Rehabilitation Medicine (K.A., C.J.M., M.L.F., D.W., P.K., J.P.B., B.M.K., D.K.), and Department of Emergency Medicine (O.A.), University of Cincinnati College of Medicine; Institute for Policy Research (E.R.), University of Cincinnati, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; and Department of Neurology (S.M.), Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX.
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Eric Rademacher
From the Department of Emergency Medicine (T.E.M.), The Alpert Medical School of Brown University, Providence, RI; Division of Biostatistics and Epidemiology (J.K.), Cincinnati Children's Hospital Medical Center, OH; Neuroscience Institute (J.K., M.L.F., D.W., F.D.L.R.L.R., S.F., O.A., P.K., J.P.B., B.M.K., D.W.), Department of Neurology and Rehabilitation Medicine (K.A., C.J.M., M.L.F., D.W., P.K., J.P.B., B.M.K., D.K.), and Department of Emergency Medicine (O.A.), University of Cincinnati College of Medicine; Institute for Policy Research (E.R.), University of Cincinnati, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; and Department of Neurology (S.M.), Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX.
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Matthew L. Flaherty
From the Department of Emergency Medicine (T.E.M.), The Alpert Medical School of Brown University, Providence, RI; Division of Biostatistics and Epidemiology (J.K.), Cincinnati Children's Hospital Medical Center, OH; Neuroscience Institute (J.K., M.L.F., D.W., F.D.L.R.L.R., S.F., O.A., P.K., J.P.B., B.M.K., D.W.), Department of Neurology and Rehabilitation Medicine (K.A., C.J.M., M.L.F., D.W., P.K., J.P.B., B.M.K., D.K.), and Department of Emergency Medicine (O.A.), University of Cincinnati College of Medicine; Institute for Policy Research (E.R.), University of Cincinnati, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; and Department of Neurology (S.M.), Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX.
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Daniel Woo
From the Department of Emergency Medicine (T.E.M.), The Alpert Medical School of Brown University, Providence, RI; Division of Biostatistics and Epidemiology (J.K.), Cincinnati Children's Hospital Medical Center, OH; Neuroscience Institute (J.K., M.L.F., D.W., F.D.L.R.L.R., S.F., O.A., P.K., J.P.B., B.M.K., D.W.), Department of Neurology and Rehabilitation Medicine (K.A., C.J.M., M.L.F., D.W., P.K., J.P.B., B.M.K., D.K.), and Department of Emergency Medicine (O.A.), University of Cincinnati College of Medicine; Institute for Policy Research (E.R.), University of Cincinnati, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; and Department of Neurology (S.M.), Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX.
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Jason Mackey
From the Department of Emergency Medicine (T.E.M.), The Alpert Medical School of Brown University, Providence, RI; Division of Biostatistics and Epidemiology (J.K.), Cincinnati Children's Hospital Medical Center, OH; Neuroscience Institute (J.K., M.L.F., D.W., F.D.L.R.L.R., S.F., O.A., P.K., J.P.B., B.M.K., D.W.), Department of Neurology and Rehabilitation Medicine (K.A., C.J.M., M.L.F., D.W., P.K., J.P.B., B.M.K., D.K.), and Department of Emergency Medicine (O.A.), University of Cincinnati College of Medicine; Institute for Policy Research (E.R.), University of Cincinnati, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; and Department of Neurology (S.M.), Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX.
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Felipe De Los Rios La Rosa
From the Department of Emergency Medicine (T.E.M.), The Alpert Medical School of Brown University, Providence, RI; Division of Biostatistics and Epidemiology (J.K.), Cincinnati Children's Hospital Medical Center, OH; Neuroscience Institute (J.K., M.L.F., D.W., F.D.L.R.L.R., S.F., O.A., P.K., J.P.B., B.M.K., D.W.), Department of Neurology and Rehabilitation Medicine (K.A., C.J.M., M.L.F., D.W., P.K., J.P.B., B.M.K., D.K.), and Department of Emergency Medicine (O.A.), University of Cincinnati College of Medicine; Institute for Policy Research (E.R.), University of Cincinnati, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; and Department of Neurology (S.M.), Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX.
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Sharyl Martini
From the Department of Emergency Medicine (T.E.M.), The Alpert Medical School of Brown University, Providence, RI; Division of Biostatistics and Epidemiology (J.K.), Cincinnati Children's Hospital Medical Center, OH; Neuroscience Institute (J.K., M.L.F., D.W., F.D.L.R.L.R., S.F., O.A., P.K., J.P.B., B.M.K., D.W.), Department of Neurology and Rehabilitation Medicine (K.A., C.J.M., M.L.F., D.W., P.K., J.P.B., B.M.K., D.K.), and Department of Emergency Medicine (O.A.), University of Cincinnati College of Medicine; Institute for Policy Research (E.R.), University of Cincinnati, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; and Department of Neurology (S.M.), Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX.
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Simona Ferioli
From the Department of Emergency Medicine (T.E.M.), The Alpert Medical School of Brown University, Providence, RI; Division of Biostatistics and Epidemiology (J.K.), Cincinnati Children's Hospital Medical Center, OH; Neuroscience Institute (J.K., M.L.F., D.W., F.D.L.R.L.R., S.F., O.A., P.K., J.P.B., B.M.K., D.W.), Department of Neurology and Rehabilitation Medicine (K.A., C.J.M., M.L.F., D.W., P.K., J.P.B., B.M.K., D.K.), and Department of Emergency Medicine (O.A.), University of Cincinnati College of Medicine; Institute for Policy Research (E.R.), University of Cincinnati, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; and Department of Neurology (S.M.), Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX.
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Opeolu Adeoye
From the Department of Emergency Medicine (T.E.M.), The Alpert Medical School of Brown University, Providence, RI; Division of Biostatistics and Epidemiology (J.K.), Cincinnati Children's Hospital Medical Center, OH; Neuroscience Institute (J.K., M.L.F., D.W., F.D.L.R.L.R., S.F., O.A., P.K., J.P.B., B.M.K., D.W.), Department of Neurology and Rehabilitation Medicine (K.A., C.J.M., M.L.F., D.W., P.K., J.P.B., B.M.K., D.K.), and Department of Emergency Medicine (O.A.), University of Cincinnati College of Medicine; Institute for Policy Research (E.R.), University of Cincinnati, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; and Department of Neurology (S.M.), Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX.
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Pooja Khatri
From the Department of Emergency Medicine (T.E.M.), The Alpert Medical School of Brown University, Providence, RI; Division of Biostatistics and Epidemiology (J.K.), Cincinnati Children's Hospital Medical Center, OH; Neuroscience Institute (J.K., M.L.F., D.W., F.D.L.R.L.R., S.F., O.A., P.K., J.P.B., B.M.K., D.W.), Department of Neurology and Rehabilitation Medicine (K.A., C.J.M., M.L.F., D.W., P.K., J.P.B., B.M.K., D.K.), and Department of Emergency Medicine (O.A.), University of Cincinnati College of Medicine; Institute for Policy Research (E.R.), University of Cincinnati, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; and Department of Neurology (S.M.), Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX.
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Joseph P. Broderick
From the Department of Emergency Medicine (T.E.M.), The Alpert Medical School of Brown University, Providence, RI; Division of Biostatistics and Epidemiology (J.K.), Cincinnati Children's Hospital Medical Center, OH; Neuroscience Institute (J.K., M.L.F., D.W., F.D.L.R.L.R., S.F., O.A., P.K., J.P.B., B.M.K., D.W.), Department of Neurology and Rehabilitation Medicine (K.A., C.J.M., M.L.F., D.W., P.K., J.P.B., B.M.K., D.K.), and Department of Emergency Medicine (O.A.), University of Cincinnati College of Medicine; Institute for Policy Research (E.R.), University of Cincinnati, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; and Department of Neurology (S.M.), Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX.
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Brett M. Kissela
From the Department of Emergency Medicine (T.E.M.), The Alpert Medical School of Brown University, Providence, RI; Division of Biostatistics and Epidemiology (J.K.), Cincinnati Children's Hospital Medical Center, OH; Neuroscience Institute (J.K., M.L.F., D.W., F.D.L.R.L.R., S.F., O.A., P.K., J.P.B., B.M.K., D.W.), Department of Neurology and Rehabilitation Medicine (K.A., C.J.M., M.L.F., D.W., P.K., J.P.B., B.M.K., D.K.), and Department of Emergency Medicine (O.A.), University of Cincinnati College of Medicine; Institute for Policy Research (E.R.), University of Cincinnati, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; and Department of Neurology (S.M.), Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX.
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Dawn Kleindorfer
From the Department of Emergency Medicine (T.E.M.), The Alpert Medical School of Brown University, Providence, RI; Division of Biostatistics and Epidemiology (J.K.), Cincinnati Children's Hospital Medical Center, OH; Neuroscience Institute (J.K., M.L.F., D.W., F.D.L.R.L.R., S.F., O.A., P.K., J.P.B., B.M.K., D.W.), Department of Neurology and Rehabilitation Medicine (K.A., C.J.M., M.L.F., D.W., P.K., J.P.B., B.M.K., D.K.), and Department of Emergency Medicine (O.A.), University of Cincinnati College of Medicine; Institute for Policy Research (E.R.), University of Cincinnati, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; and Department of Neurology (S.M.), Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX.
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Citation
Sex-specific stroke incidence over time in the Greater Cincinnati/Northern Kentucky Stroke Study
Tracy E. Madsen, Jane Khoury, Kathleen Alwell, Charles J. Moomaw, Eric Rademacher, Matthew L. Flaherty, Daniel Woo, Jason Mackey, Felipe De Los Rios La Rosa, Sharyl Martini, Simona Ferioli, Opeolu Adeoye, Pooja Khatri, Joseph P. Broderick, Brett M. Kissela, Dawn Kleindorfer
Neurology Sep 2017, 89 (10) 990-996; DOI: 10.1212/WNL.0000000000004325

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Abstract

Objective: Recent data suggest stroke incidence is decreasing over time, but it is unknown whether incidence is decreasing in women and men to the same extent.

Methods: Within our population of 1.3 million, all incident strokes among residents ≥20 years old were ascertained at all hospitals during July 1993–June 1994 and calendar years 1999, 2005, and 2010. A sampling scheme was used to ascertain out-of-hospital cases. Sex-specific incidence rates per 100,000 among black and white participants, age- and race-adjusted, were standardized to the 2000 US Census population. Trends over time by sex were compared; a Bonferroni correction was applied for multiple comparisons.

Results: Over the 4 study periods, there were 7,710 incident strokes; 57.2% (n = 4,412) were women. Women were older than men (mean ± SE 72.4 ± 0.34 vs 68.2 ± 0.32, p < 0.001). Incidence of all strokes decreased over time in men (263 [confidence interval 246–281] to 192 [179–205], p < 0.001) but not in women (217 [205–230] to 198 [187–210], p = 0.15). Similar sex differences were seen for ischemic stroke (men, 238 [223–257] to 165 [153–177], p < 0.01; women, 193 [181–205] to 173 [162–184], p = 0.09). Incidence of all strokes and of ischemic strokes was similar between women and men in 2010. Incidence of intracerebral hemorrhage and subarachnoid hemorrhage were stable over time in both sexes.

Conclusions: Decreases in stroke incidence over time are driven by a decrease in ischemic stroke in men. Contrary to previous study periods, stroke incidence rates were similar by sex in 2010. Future research is needed to understand why the decrease in ischemic stroke incidence is more pronounced in men.

GLOSSARY

ARIC=
Atherosclerosis Risk in Communities;
GCNKSS=
Greater Cincinnati/Northern Kentucky Stroke Study;
ICD-9=
International Classification of Diseases–9;
ICH=
intracerebral hemorrhage;
mRS=
modified Rankin Scale;
SAH=
subarachnoid hemorrhage

Footnotes

  • Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • Supplemental data at Neurology.org

  • Editorial, page 982

  • Received September 9, 2016.
  • Accepted in final form May 3, 2017.
  • © 2017 American Academy of Neurology
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Disputes & Debates: Rapid online correspondence

  • Author response to Dr. Kuller & Dr. Zedde
    • Tracy E. Madsen, Assistant Professor of Emergency Medicine, Alpert Medical School of Brown UniversityTracy_Madsen@brown.edu
    • Jane Khoury, Heidi Sucharew, Dawn Kleindorfer (Cincinnati)
    Submitted January 05, 2018
  • Women and stroke: A matter of education?
    • Marialuisa Zedde, vascular neurologist, Neurology Unit-Stroke Unit, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia (Italy)zedde.marialuisa@ausl.re.it
    • Francesca Romana Pezzella, Rome, Italy; Zuzana Gdovinova, Kosice, Slovak Republic; Christine Kremer, Lund, Sweden; Valeria Caso, Perugia, Italy
    Submitted November 03, 2017
  • Stroke Trends By Age and Sex May Be Misinterpreted
    • Lewis H. Kuller, Professor Emeritus, Department of Epidemiology, Graduate School of Public Health, University of Pittsburghkullerl@edc.pitt.edu
    Submitted August 21, 2017
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