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      Trends in stroke incidence, mortality and case fatality rates in Joinville, Brazil: 1995–2006

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          Abstract

          Background:

          Studying stroke rates in a whole community is a rational way to assess the quality of patient care and primary prevention. However, there are few studies of trends in stroke rates worldwide and none in Brazil.

          Objective:

          Established study methods were used to define the rates for first ever stroke in a defined population in Brazil compared with similar data obtained and published in 1995.

          Methods:

          All stroke cases occurring in the city of Joinville during 2005–2006 were prospectively ascertained. Crude incidence and mortality rates were determined, and age adjusted rates and 30 day case fatality were calculated and compared with the 1995 data.

          Results:

          Of the 1323 stroke cases registered, 759 were first ever strokes. The incidence rate per 100 000 was 105.4 (95% CI 98.0 to 113.2), mortality rate was 23.9 (95% CI 20.4 to 27.8) and the 30 day case fatality was 19.1%. Compared with the 1995 data, we found that the incidence had decreased by 27%, mortality decreased by 37% and the 30 day case fatality decreased by 28%.

          Conclusions:

          Using defined criteria we showed that in an industrial southern Brazilian city, stroke rates are similar to those from developed countries. A significant decrease in stroke rates over the past decade was also found, suggesting an improvement in primary prevention and inpatient care of stroke patients in Joinville.

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          Most cited references28

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          Classification and natural history of clinically identifiable subtypes of cerebral infarction.

          We describe the incidence and natural history of four clinically identifiable subgroups of cerebral infarction in a community-based study of 675 patients with first-ever stroke. Of 543 patients with a cerebral infarct, 92 (17%) had large anterior circulation infarcts with both cortical and subcortical involvement (total anterior circulation infarcts, TACI); 185 (34%) had more restricted and predominantly cortical infarcts (partial anterior circulation infarcts, PACI); 129 (24%) had infarcts clearly associated with the vertebrobasilar arterial territory (posterior circulation infarcts, POCI); and 137 (25%) had infarcts confined to the territory of the deep perforating arteries (lacunar infarcts, LACI). There were striking differences in natural history between the groups. The TACI group had a negligible chance of good functional outcome and mortality was high. More than twice as many deaths were due to the complications of immobility than to direct neurological sequelae of the infarct. Patients in the PACI group were much more likely to have an early recurrent stroke than were patients in other groups. Those in the POCI group were at greater risk of a recurrent stroke later in the first year after the index event but had the best chance of a good functional outcome. Despite the small anatomical size of the infarcts in the LACI group, many patients remained substantially handicapped. The findings have important implications for the planning of stroke treatment trials and suggest that various therapies could be directed specifically at the subgroups.
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            Change in stroke incidence, mortality, case-fatality, severity, and risk factors in Oxfordshire, UK from 1981 to 2004 (Oxford Vascular Study).

            The incidence of stroke is predicted to rise because of the rapidly ageing population. However, over the past two decades, findings of randomised trials have identified several interventions that are effective in prevention of stroke. Reliable data on time-trends in stroke incidence, major risk factors, and use of preventive treatments in an ageing population are required to ascertain whether implementation of preventive strategies can offset the predicted rise in stroke incidence. We aimed to obtain these data. We ascertained changes in incidence of transient ischaemic attack and stroke, risk factors, and premorbid use of preventive treatments from 1981-84 (Oxford Community Stroke Project; OCSP) to 2002-04 (Oxford Vascular Study; OXVASC). Of 476 patients with transient ischaemic attacks or strokes in OXVASC, 262 strokes and 93 transient ischaemic attacks were incident events. Despite more complete case-ascertainment than in OCSP, age-adjusted and sex-adjusted incidence of first-ever stroke fell by 29% (relative incidence 0.71, 95% CI 0.61-0.83, p=0.0002). Incidence declined by more than 50% for primary intracerebral haemorrhage (0.47, 0.27-0.83, p=0.01) but was unchanged for subarachnoid haemorrhage (0.83, 0.44-1.57, p=0.57). Thus, although 28% more incident strokes (366 vs 286) were expected in OXVASC due to demographic change alone (33% increase in those aged 75 or older), the observed number fell (262 vs 286). Major reductions were recorded in mortality rates for incident stroke (0.63, 0.44-0.90, p=0.02) and in incidence of disabling or fatal stroke (0.60, 0.50-0.73, p<0.0001), but no change was seen in case-fatality due to incident stroke (17.2% vs 17.8%; age and sex adjusted relative risk 0.85, 95% CI 0.57-1.28, p=0.45). Comparison of premorbid risk factors revealed substantial reductions in the proportion of smokers, mean total cholesterol, and mean systolic and diastolic blood pressures and major increases in premorbid treatment with antiplatelet, lipid-lowering, and blood pressure lowering drugs (all p<0.0001). The age-specific incidence of major stroke in Oxfordshire has fallen by 40% over the past 20 years in association with increased use of preventive treatments and major reductions in premorbid risk factors.
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              Cerebrovascular disease in the community: results of a WHO collaborative study.

              In a cooperative study coordinated by WHO, stroke was registered between 1971 and 1974 in 17 centres both in developing and developed countries. A common operating protocol was used to obtain comparable data. Age-adjusted incidence of stroke shows moderate geographical variations, cerebrovascular accidents being common in all the contrasting populations studied in various parts of the world. Data were also obtained on the types of management of stroke patients, their survival rates, and functional prognosis. Control of hypertension, although known to be effective in the prevention of stroke, seemed to be insufficient in most countries. It is concluded that stroke registers may be used as a source of information for the planning and implementation of stroke control programmes in the community.
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                Author and article information

                Journal
                J Neurol Neurosurg Psychiatry
                jnnp
                Journal of Neurology, Neurosurgery, and Psychiatry
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                0022-3050
                1468-330X
                2009
                July 2009
                15 January 2009
                15 January 2009
                : 80
                : 7
                : 749-754
                Affiliations
                [1 ]Department of Medicine of the Universidade da Região de Joinville, Joinville, Brazil and São José Municipal Hospital, Joinville, Brazil
                [2 ]Department of Preventive Medicine Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
                Author notes
                Correspondence to: Professor N L Cabral, Clinica Neurológica de Joinville, Rua Plácido O de Oliveira, 1244, CEP 892-02451, Joinville, Santa Catarina, Brazil; nlcabral@ 123456terra.com.br
                Article
                jn164475
                10.1136/jnnp.2008.164475
                2688773
                19147630
                82d15900-9726-4ec7-bf1b-02e58e4803b8
                © Cabral et al 2009

                This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 4 October 2008
                : 2 December 2008
                : 4 December 2008
                Categories
                Research Papers
                1506

                Surgery
                Surgery

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