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    • Second the bulk of stroke burden in terms of incident

    2019-05-29

    Second, the bulk of stroke burden in terms of incident events, deaths, and DALYs lost is borne by low-income to middle-income countries. These countries were particularly disproportionally affected by burden of haemorrhagic stroke compared with high-income countries. By Fmoc-His(Trt)-OH with high-income countries, where the overall incidence, mortality, DALYs, and mortality-to-incidence ratio of both ischaemic and haemorrhagic stroke have declined in the past two decades in both younger (<75 years) and older (≥75 years) age groups, in low-income to middle-income countries incidence of both stroke types increased significantly (especially in people aged 20–65 years). The average age at which people had ischaemic and haemorrhagic strokes was 3–5 years younger in low-income to middle-income countries than in high-income countries. Roughly a quarter of all events of ischaemic stroke and about half of all those of haemorrhagic stroke are happening in people younger than 65 years, with 73% and 83% of them, respectively, residing in low-income and middle-income countries. In 1990–2010, the incidence of both stroke types increased significantly in adults aged 20–64 years in low-income and middle-income countries. Our findings of a greater proportion of haemorrhagic stroke in low-income and middle-income countries compared with high-income countries, noticeable geographical variation in the incidence of major pathological types of stroke, and diverging trends in stroke incidence between low-income countries (increase in rates) and high-income countries (decrease in rates) are in line with the results of a systematic review of population-based studies of stroke incidence. However, unlike findings from that review, we also noted significant changes in incidence of haemorrhagic stroke in the past two decades. The discrepancies between countries of different income levels are probably driven by the occurrence of the epidemiological transition. In the past few decades worldwide, life expectancy has increased, childhood mortality has reduced, and health status has improved overall in many regions. Globally, ageing populations are driving increases in the incidence of both ischaemic and haemorrhagic stroke. In low-income and middle-income countries, diseases related to infection and undernutrition have been replaced with more chronic diseases such as stroke and heart disease as the leading cause of disease burden, but unlike many low-income to middle-income countries, most high-income countries have implemented improved prevention strategies and better health care for these chronic disorders. Moreover, industrialisation and urbanisation have led to changes in the nutritional quality of foods, with high-fibre carbohydrates and fresh produce being replaced with more processed carbohydrates and high-fat diets. The resultant increase in the prevalence of diabetes, together with increases in smoking rates and increasingly sedentary lifestyles, have contributed to increased atherosclerotic disease. During different phases of epidemiological transition, increased incidence of haemorrhagic stroke is expected, particularly in low-income and middle-income countries, because hypertension is the dominant risk factor for this stroke type. We noted substantial differences between countries in incidence, mortality, DALYs, and mortality-to-incidence ratio for both stroke types. The alarmingly high stroke burden in China, particularly for haemorrhagic stroke, might be attributable to the increased prevalence of risk factors for this stroke type—namely high blood pressure and smoking—and an ageing population. A review suggested that haemorrhagic stroke contributed to more stroke burden in China than it did in high-income countries, but wide regional differences were reported in the incidence and type of stroke. Hypertension, diabetes, dyslipidaemia, and smoking are modifiable risk factors that have increased in China. In India, smoking has been attributed as the cause of many deaths, particularly in men, with vascular causes being among the main contributors to death.