Stroke (Seventh Edition): Pathophysiology, Diagnosis, and Management: Chapter 15 - Stroke Disparities

Stroke (Seventh Edition): Pathophysiology, Diagnosis, and Management, 2022, Pages 179-186.e3
George Howard, Louise D. McCullough, Virginia J. Howard

Despite dramatic temporal declines in stroke mortality for all race/ethnic groups, the black–white disparity in stroke has been persistent (or even perhaps growing). While the black–white disparity in mortality averages 40% across the age spectrum, this pooling across ages obscures a much larger (200%–300%) excess mortality for blacks aged 45–65. This excess mortality is largely attributable to a higher incidence of stroke in blacks (with stroke case fatality playing a smaller role). Approximately one-half of the excess incidence in blacks appears to be attributable to “traditional” stroke risk factors and differences in socioeconomic status, with a potentially differential and larger impact of hypertension also contributing to the disparity. Stroke mortality disparities in the Hispanic population are more complex, with lower stroke mortality in Hispanics than whites, but with evidence from two independent studies showing substantially higher stroke incidence in Hispanics than whites. While the age-adjusted burden of stroke mortality falls heavier on men, this sex-specific burden of stroke differs by age and race; however, an absolute larger number of women die from stroke because of their longer life expectancy. Despite a requirement for the National Institutes of Health to investigate urban–rural disparities in disease, there are strikingly few data describing this disparity for stroke. However, there appears to be approximately a 20% higher stroke mortality in rural than urban regions, with higher incidence in rural regions contributing to the excess (while differences in case fatality are playing a smaller role). The “stroke belt” region of higher stroke mortality in the southeastern United States has existed for over a half-century and persists today with a stroke mortality as great as 300% higher in some regions, with higher incidence (and perhaps higher case fatality) in rural regions that are more common in the stroke belt contributing to the excess. There is strong evidence that lower socioeconomic status is associated with both higher incidence of stroke and worse outcomes following stroke.