Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study

Martin J O'Donnell; Denis Xavier; Lisheng Liu; Hongye Zhang; Siu Lim Chin; Purnima Rao-Melacini; Sumathy Rangarajan; Shofiqul Islam; Prem Pais; Matthew J McQueen; Charles Mondo; Albertino Damasceno; Patricio Lopez-Jaramillo; Graeme J Hankey; Antonio L Dans; Khalid Yusoff; Thomas Truelsen; Hans-Christoph Diener; Ralph L Sacco; Danuta Ryglewicz; Anna Czlonkowska; Christian Weimar; Xingyu Wang; Salim Yusuf; INTERSTROKE investigators; Helle Klingenberg Iversen

doi:10.1016/s0140-6736(10)60834-3

Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study

Martin J O'Donnell, Denis Xavier, Lisheng Liu, Hongye Zhang, Siu Lim Chin, Purnima Rao-Melacini, Sumathy Rangarajan, Shofiqul Islam, Prem Pais, Matthew J McQueen, Charles Mondo, Albertino Damasceno, Patricio Lopez-Jaramillo, Graeme J Hankey, Antonio L Dans, Khalid Yusoff, Thomas Truelsen, Hans-Christoph Diener, Ralph L Sacco, Danuta RyglewiczAnna Czlonkowska, Christian Weimar, Xingyu Wang, Salim Yusuf, INTERSTROKE investigators, Helle Klingenberg Iversen

Department of Clinical Medicine

1817 Citations (Scopus)

Abstract

BACKGROUND: The contribution of various risk factors to the burden of stroke worldwide is unknown, particularly in countries of low and middle income. We aimed to establish the association of known and emerging risk factors with stroke and its primary subtypes, assess the contribution of these risk factors to the burden of stroke, and explore the differences between risk factors for stroke and myocardial infarction.

METHODS: We undertook a standardised case-control study in 22 countries worldwide between March 1, 2007, and April 23, 2010. Cases were patients with acute first stroke (within 5 days of symptoms onset and 72 h of hospital admission). Controls had no history of stroke, and were matched with cases for age and sex. All participants completed a structured questionnaire and a physical examination, and most provided blood and urine samples. We calculated odds ratios (ORs) and population-attributable risks (PARs) for the association of all stroke, ischaemic stroke, and intracerebral haemorrhagic stroke with selected risk factors.

FINDINGS: In the first 3000 cases (n=2337, 78%, with ischaemic stroke; n=663, 22%, with intracerebral haemorrhagic stroke) and 3000 controls, significant risk factors for all stroke were: history of hypertension (OR 2.64, 99% CI 2.26-3.08; PAR 34.6%, 99% CI 30.4-39.1); current smoking (2.09, 1.75-2.51; 18.9%, 15.3-23.1); waist-to-hip ratio (1.65, 1.36-1.99 for highest vs lowest tertile; 26.5%, 18.8-36.0); diet risk score (1.35, 1.11-1.64 for highest vs lowest tertile; 18.8%, 11.2-29.7); regular physical activity (0.69, 0.53-0.90; 28.5%, 14.5-48.5); diabetes mellitus (1.36, 1.10-1.68; 5.0%, 2.6-9.5); alcohol intake (1.51, 1.18-1.92 for more than 30 drinks per month or binge drinking; 3.8%, 0.9-14.4); psychosocial stress (1.30, 1.06-1.60; 4.6%, 2.1-9.6) and depression (1.35, 1.10-1.66; 5.2%, 2.7-9.8); cardiac causes (2.38, 1.77-3.20; 6.7%, 4.8-9.1); and ratio of apolipoproteins B to A1 (1.89, 1.49-2.40 for highest vs lowest tertile; 24.9%, 15.7-37.1). Collectively, these risk factors accounted for 88.1% (99% CI 82.3-92.2) of the PAR for all stroke. When an alternate definition of hypertension was used (history of hypertension or blood pressure >160/90 mm Hg), the combined PAR was 90.3% (85.3-93.7) for all stroke. These risk factors were all significant for ischaemic stroke, whereas hypertension, smoking, waist-to-hip ratio, diet, and alcohol intake were significant risk factors for intracerebral haemorrhagic stroke.

INTERPRETATION: Our findings suggest that ten risk factors are associated with 90% of the risk of stroke. Targeted interventions that reduce blood pressure and smoking, and promote physical activity and a healthy diet, could substantially reduce the burden of stroke.

FUNDING: Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Canadian Stroke Network, Pfizer Cardiovascular Award, Merck, AstraZeneca, and Boehringer Ingelheim.

Original language	English
Journal	Lancet
Volume	376
Issue number	9735
Pages (from-to)	112-23
Number of pages	12
DOIs	https://doi.org/10.1016/s0140-6736(10)60834-3
Publication status	Published - 10 Jul 2010

Keywords

Atrial Fibrillation
Brain Ischemia
Case-Control Studies
Cerebral Hemorrhage
Developed Countries
Developing Countries
Female
Humans
Hypertension
Life Style
Male
Middle Aged
Myocardial Infarction
Risk Factors
Stroke
Waist-Hip Ratio

UN SDGs

This output contributes to the following UN Sustainable Development Goals (SDGs)

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10.1016/s0140-6736(10)60834-3

Cite this

O'Donnell, M. J., Xavier, D., Liu, L., Zhang, H., Chin, S. L., Rao-Melacini, P., Rangarajan, S., Islam, S., Pais, P., McQueen, M. J., Mondo, C., Damasceno, A., Lopez-Jaramillo, P., Hankey, G. J., Dans, A. L., Yusoff, K., Truelsen, T., Diener, H.-C., Sacco, R. L., ... Iversen, H. K. (2010). Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study. Lancet, 376(9735), 112-23. https://doi.org/10.1016/s0140-6736(10)60834-3

O'Donnell, MJ, Xavier, D, Liu, L, Zhang, H, Chin, SL, Rao-Melacini, P, Rangarajan, S, Islam, S, Pais, P, McQueen, MJ, Mondo, C, Damasceno, A, Lopez-Jaramillo, P, Hankey, GJ, Dans, AL, Yusoff, K, Truelsen, T, Diener, H-C, Sacco, RL, Ryglewicz, D, Czlonkowska, A, Weimar, C, Wang, X, Yusuf, S, INTERSTROKE investigators & Iversen, HK 2010, 'Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study', Lancet, vol. 376, no. 9735, pp. 112-23. https://doi.org/10.1016/s0140-6736(10)60834-3

@article{ff793a5812ec4125874713d571df055f,

title = "Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study",

abstract = "BACKGROUND: The contribution of various risk factors to the burden of stroke worldwide is unknown, particularly in countries of low and middle income. We aimed to establish the association of known and emerging risk factors with stroke and its primary subtypes, assess the contribution of these risk factors to the burden of stroke, and explore the differences between risk factors for stroke and myocardial infarction.METHODS: We undertook a standardised case-control study in 22 countries worldwide between March 1, 2007, and April 23, 2010. Cases were patients with acute first stroke (within 5 days of symptoms onset and 72 h of hospital admission). Controls had no history of stroke, and were matched with cases for age and sex. All participants completed a structured questionnaire and a physical examination, and most provided blood and urine samples. We calculated odds ratios (ORs) and population-attributable risks (PARs) for the association of all stroke, ischaemic stroke, and intracerebral haemorrhagic stroke with selected risk factors.FINDINGS: In the first 3000 cases (n=2337, 78%, with ischaemic stroke; n=663, 22%, with intracerebral haemorrhagic stroke) and 3000 controls, significant risk factors for all stroke were: history of hypertension (OR 2.64, 99% CI 2.26-3.08; PAR 34.6%, 99% CI 30.4-39.1); current smoking (2.09, 1.75-2.51; 18.9%, 15.3-23.1); waist-to-hip ratio (1.65, 1.36-1.99 for highest vs lowest tertile; 26.5%, 18.8-36.0); diet risk score (1.35, 1.11-1.64 for highest vs lowest tertile; 18.8%, 11.2-29.7); regular physical activity (0.69, 0.53-0.90; 28.5%, 14.5-48.5); diabetes mellitus (1.36, 1.10-1.68; 5.0%, 2.6-9.5); alcohol intake (1.51, 1.18-1.92 for more than 30 drinks per month or binge drinking; 3.8%, 0.9-14.4); psychosocial stress (1.30, 1.06-1.60; 4.6%, 2.1-9.6) and depression (1.35, 1.10-1.66; 5.2%, 2.7-9.8); cardiac causes (2.38, 1.77-3.20; 6.7%, 4.8-9.1); and ratio of apolipoproteins B to A1 (1.89, 1.49-2.40 for highest vs lowest tertile; 24.9%, 15.7-37.1). Collectively, these risk factors accounted for 88.1% (99% CI 82.3-92.2) of the PAR for all stroke. When an alternate definition of hypertension was used (history of hypertension or blood pressure >160/90 mm Hg), the combined PAR was 90.3% (85.3-93.7) for all stroke. These risk factors were all significant for ischaemic stroke, whereas hypertension, smoking, waist-to-hip ratio, diet, and alcohol intake were significant risk factors for intracerebral haemorrhagic stroke.INTERPRETATION: Our findings suggest that ten risk factors are associated with 90% of the risk of stroke. Targeted interventions that reduce blood pressure and smoking, and promote physical activity and a healthy diet, could substantially reduce the burden of stroke.FUNDING: Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Canadian Stroke Network, Pfizer Cardiovascular Award, Merck, AstraZeneca, and Boehringer Ingelheim.",

keywords = "Atrial Fibrillation, Brain Ischemia, Case-Control Studies, Cerebral Hemorrhage, Developed Countries, Developing Countries, Female, Humans, Hypertension, Life Style, Male, Middle Aged, Myocardial Infarction, Risk Factors, Stroke, Waist-Hip Ratio",

author = "O'Donnell, {Martin J} and Denis Xavier and Lisheng Liu and Hongye Zhang and Chin, {Siu Lim} and Purnima Rao-Melacini and Sumathy Rangarajan and Shofiqul Islam and Prem Pais and McQueen, {Matthew J} and Charles Mondo and Albertino Damasceno and Patricio Lopez-Jaramillo and Hankey, {Graeme J} and Dans, {Antonio L} and Khalid Yusoff and Thomas Truelsen and Hans-Christoph Diener and Sacco, {Ralph L} and Danuta Ryglewicz and Anna Czlonkowska and Christian Weimar and Xingyu Wang and Salim Yusuf and {INTERSTROKE investigators} and Iversen, {Helle Klingenberg}",

year = "2010",

month = jul,

day = "10",

doi = "10.1016/s0140-6736(10)60834-3",

language = "English",

volume = "376",

pages = "112--23",

journal = "Lancet",

issn = "0099-5355",

publisher = "TheLancet Publishing Group",

number = "9735",

}

TY - JOUR

T1 - Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study)

T2 - a case-control study

AU - O'Donnell, Martin J

AU - Xavier, Denis

AU - Liu, Lisheng

AU - Zhang, Hongye

AU - Chin, Siu Lim

AU - Rao-Melacini, Purnima

AU - Rangarajan, Sumathy

AU - Islam, Shofiqul

AU - Pais, Prem

AU - McQueen, Matthew J

AU - Mondo, Charles

AU - Damasceno, Albertino

AU - Lopez-Jaramillo, Patricio

AU - Hankey, Graeme J

AU - Dans, Antonio L

AU - Yusoff, Khalid

AU - Truelsen, Thomas

AU - Diener, Hans-Christoph

AU - Sacco, Ralph L

AU - Ryglewicz, Danuta

AU - Czlonkowska, Anna

AU - Weimar, Christian

AU - Wang, Xingyu

AU - Yusuf, Salim

AU - INTERSTROKE investigators

AU - Iversen, Helle Klingenberg

PY - 2010/7/10

Y1 - 2010/7/10

N2 - BACKGROUND: The contribution of various risk factors to the burden of stroke worldwide is unknown, particularly in countries of low and middle income. We aimed to establish the association of known and emerging risk factors with stroke and its primary subtypes, assess the contribution of these risk factors to the burden of stroke, and explore the differences between risk factors for stroke and myocardial infarction.METHODS: We undertook a standardised case-control study in 22 countries worldwide between March 1, 2007, and April 23, 2010. Cases were patients with acute first stroke (within 5 days of symptoms onset and 72 h of hospital admission). Controls had no history of stroke, and were matched with cases for age and sex. All participants completed a structured questionnaire and a physical examination, and most provided blood and urine samples. We calculated odds ratios (ORs) and population-attributable risks (PARs) for the association of all stroke, ischaemic stroke, and intracerebral haemorrhagic stroke with selected risk factors.FINDINGS: In the first 3000 cases (n=2337, 78%, with ischaemic stroke; n=663, 22%, with intracerebral haemorrhagic stroke) and 3000 controls, significant risk factors for all stroke were: history of hypertension (OR 2.64, 99% CI 2.26-3.08; PAR 34.6%, 99% CI 30.4-39.1); current smoking (2.09, 1.75-2.51; 18.9%, 15.3-23.1); waist-to-hip ratio (1.65, 1.36-1.99 for highest vs lowest tertile; 26.5%, 18.8-36.0); diet risk score (1.35, 1.11-1.64 for highest vs lowest tertile; 18.8%, 11.2-29.7); regular physical activity (0.69, 0.53-0.90; 28.5%, 14.5-48.5); diabetes mellitus (1.36, 1.10-1.68; 5.0%, 2.6-9.5); alcohol intake (1.51, 1.18-1.92 for more than 30 drinks per month or binge drinking; 3.8%, 0.9-14.4); psychosocial stress (1.30, 1.06-1.60; 4.6%, 2.1-9.6) and depression (1.35, 1.10-1.66; 5.2%, 2.7-9.8); cardiac causes (2.38, 1.77-3.20; 6.7%, 4.8-9.1); and ratio of apolipoproteins B to A1 (1.89, 1.49-2.40 for highest vs lowest tertile; 24.9%, 15.7-37.1). Collectively, these risk factors accounted for 88.1% (99% CI 82.3-92.2) of the PAR for all stroke. When an alternate definition of hypertension was used (history of hypertension or blood pressure >160/90 mm Hg), the combined PAR was 90.3% (85.3-93.7) for all stroke. These risk factors were all significant for ischaemic stroke, whereas hypertension, smoking, waist-to-hip ratio, diet, and alcohol intake were significant risk factors for intracerebral haemorrhagic stroke.INTERPRETATION: Our findings suggest that ten risk factors are associated with 90% of the risk of stroke. Targeted interventions that reduce blood pressure and smoking, and promote physical activity and a healthy diet, could substantially reduce the burden of stroke.FUNDING: Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Canadian Stroke Network, Pfizer Cardiovascular Award, Merck, AstraZeneca, and Boehringer Ingelheim.

AB - BACKGROUND: The contribution of various risk factors to the burden of stroke worldwide is unknown, particularly in countries of low and middle income. We aimed to establish the association of known and emerging risk factors with stroke and its primary subtypes, assess the contribution of these risk factors to the burden of stroke, and explore the differences between risk factors for stroke and myocardial infarction.METHODS: We undertook a standardised case-control study in 22 countries worldwide between March 1, 2007, and April 23, 2010. Cases were patients with acute first stroke (within 5 days of symptoms onset and 72 h of hospital admission). Controls had no history of stroke, and were matched with cases for age and sex. All participants completed a structured questionnaire and a physical examination, and most provided blood and urine samples. We calculated odds ratios (ORs) and population-attributable risks (PARs) for the association of all stroke, ischaemic stroke, and intracerebral haemorrhagic stroke with selected risk factors.FINDINGS: In the first 3000 cases (n=2337, 78%, with ischaemic stroke; n=663, 22%, with intracerebral haemorrhagic stroke) and 3000 controls, significant risk factors for all stroke were: history of hypertension (OR 2.64, 99% CI 2.26-3.08; PAR 34.6%, 99% CI 30.4-39.1); current smoking (2.09, 1.75-2.51; 18.9%, 15.3-23.1); waist-to-hip ratio (1.65, 1.36-1.99 for highest vs lowest tertile; 26.5%, 18.8-36.0); diet risk score (1.35, 1.11-1.64 for highest vs lowest tertile; 18.8%, 11.2-29.7); regular physical activity (0.69, 0.53-0.90; 28.5%, 14.5-48.5); diabetes mellitus (1.36, 1.10-1.68; 5.0%, 2.6-9.5); alcohol intake (1.51, 1.18-1.92 for more than 30 drinks per month or binge drinking; 3.8%, 0.9-14.4); psychosocial stress (1.30, 1.06-1.60; 4.6%, 2.1-9.6) and depression (1.35, 1.10-1.66; 5.2%, 2.7-9.8); cardiac causes (2.38, 1.77-3.20; 6.7%, 4.8-9.1); and ratio of apolipoproteins B to A1 (1.89, 1.49-2.40 for highest vs lowest tertile; 24.9%, 15.7-37.1). Collectively, these risk factors accounted for 88.1% (99% CI 82.3-92.2) of the PAR for all stroke. When an alternate definition of hypertension was used (history of hypertension or blood pressure >160/90 mm Hg), the combined PAR was 90.3% (85.3-93.7) for all stroke. These risk factors were all significant for ischaemic stroke, whereas hypertension, smoking, waist-to-hip ratio, diet, and alcohol intake were significant risk factors for intracerebral haemorrhagic stroke.INTERPRETATION: Our findings suggest that ten risk factors are associated with 90% of the risk of stroke. Targeted interventions that reduce blood pressure and smoking, and promote physical activity and a healthy diet, could substantially reduce the burden of stroke.FUNDING: Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Canadian Stroke Network, Pfizer Cardiovascular Award, Merck, AstraZeneca, and Boehringer Ingelheim.

KW - Atrial Fibrillation

KW - Brain Ischemia

KW - Case-Control Studies

KW - Cerebral Hemorrhage

KW - Developed Countries

KW - Developing Countries

KW - Female

KW - Humans

KW - Hypertension

KW - Life Style

KW - Male

KW - Middle Aged

KW - Myocardial Infarction

KW - Risk Factors

KW - Stroke

KW - Waist-Hip Ratio

U2 - 10.1016/s0140-6736(10)60834-3

DO - 10.1016/s0140-6736(10)60834-3

M3 - Journal article

C2 - 20561675

SN - 0099-5355

SN - 1474-547X

VL - 376

SP - 112

EP - 123

JO - Lancet

JF - Lancet

IS - 9735

ER -

Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study

Abstract

Keywords

UN SDGs

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