Stroke Compendium

Circulation Research Compendium on Stroke

Introduction to the Stroke Compendium
Global Burden of Stroke
Cerebral Vascular Disease and Neurovascular Injury in Ischemic Stroke
Stroke Risk Factors, Genetics, and Prevention
Stroke Caused by Extracranial Disease
Stroke Caused by Atherosclerosis of the Major Intracranial Arteries
Cardioembolic Stroke
Cryptogenic Stroke: Research and Practice
Acute Ischemic Stroke Therapy Overview
Heart–Brain Axis: Effects of Neurologic Injury on Cardiovascular Function
Vascular Cognitive Impairment
Marc Fisher, Costantino Iadecola, and Ralph Sacco, Editors
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Global Burden of Stroke

Valery L. Feigin, Bo Norrving, George A. Mensah

Abstract: On the basis of the GBD (Global Burden of Disease) 2013 Study, this article provides an overview of
the global, regional, and country-specific burden of stroke by sex and age groups, including trends in stroke
burden from 1990 to 2013, and outlines recommended measures to reduce stroke burden. It shows that although
stroke incidence, prevalence, mortality, and disability-adjusted life-years rates tend to decline from 1990 to 2013,
the overall stroke burden in terms of absolute number of people affected by, or who remained disabled from,
stroke has increased across the globe in both men and women of all ages. This provides a strong argument that
“business as usual” for primary stroke prevention is not sufficiently effective. Although prevention of stroke is
a complex medical and political issue, there is strong evidence that substantial prevention of stroke is feasible
in practice. The need to scale-up the primary prevention actions is urgent.   (Circ Res. 2017;120:439-448. DOI:
10.1161/CIRCRESAHA.116.308413.)
Key Words: burden ■ epidemiology ■ GBD ■ prevention ■ stroke

E vidence-based approaches to organization and plan-

ning of stroke care and services require accurate on-
going data on stroke incidence, prevalence, and outcomes.
of time. From the public health perspective, there is also a
need to monitor stroke burden on a global scale and com-
pare burden between different countries and regions over
The best sources of such data are population-based stud- time, including trends and projections relative to other
ies that meet “gold-standard” criteria and are continuously major diseases. To address these issues and fill the gaps
repeated over time,1 as stroke epidemiology is changing in disease burden estimates across all countries, the GBD
rapidly.2 However, such studies are expensive and require (Global Burden of Disease) Study was set up in 1992
expertise for their proper design and execution. That is why within the Institute for Health Metrics and Evaluation of
no such studies have been done in most countries, espe- the University of Washington.3 During the period of time
cially in the developing countries and over a long period from 1990 to present, the GBD Study has developed (and

Original received July 11, 2016; revision received August 26, 2016; accepted September 2, 2016.
From the Faculty of Health and Environmental Studies, National Institute for Stroke and Applied Neurosciences, School of Public Health and Psychosocial
Studies, Auckland University of Technology, New Zealand (V.L.F.); Department of Clinical Sciences, Neurology, Lund University, Sweden (B.N.); and
Division of Cardiovascular Sciences, Center for Translation Research and Implementation Science (CTRIS), National Heart, Lung, and Blood Institute,
National Institutes of Health, Bethesda, MD (G.A.M.).
The views expressed in this article are those of the authors and do not necessarily represent the views of the National Heart, Lung, and Blood Institute,
National Institutes of Health, or the US Department of Health and Human Services.
Correspondence to Valery L Feigin, MD, PhD, Faculty of Health and Environmental Studies, National Institute for Stroke and Applied Neurosciences,
School of Public Health and Psychosocial Studies, Auckland University of Technology, 90 Akoranga Dr, Northcote 0627, Private Bag 92006, Auckland
1142, New Zealand. E-mail [email protected]
© 2017 American Heart Association, Inc.
Circulation Research is available at http://circres.ahajournals.org DOI: 10.1161/CIRCRESAHA.116.308413

439
 440  Circulation Research  February 3, 2017

were almost 25.7 million stroke survivors (71% with IS), 6.5
Nonstandard Abbreviations and Acronyms
million deaths from stroke (51% died from IS), 113 million
DALYs disability-adjusted life-years DALYs due to stroke (58% due to IS), and 10.3 million new
GBD Global Burden of Disease strokes (67% IS). Improved stroke care, aging, and growth
HS hemorrhagic stroke of the population combined with the increased prevalence of
IS ischemic stroke many modifiable stroke risk factors16 are likely to be the main
NCDs noncommunicable diseases drivers in the increased number of stroke survivors and people
UI uncertainty intervals affected by stroke.
UN United Nations Proportional (%) contribution of DALYs from stroke to
DALYs from all other causes in 2013 (Figure 2) varied be-
tween different countries but was largest in developing coun-
continuously updated) a large database and advanced meth- tries, especially Russia, Eastern European countries, and
odologies for modeling the burden of a wide range of dis- East Asian countries, ranging from 11.6% to 12.7% in North
eases and their risk factors in 188 countries.4–6 This article Korea, Macedonia, Bulgaria, and Georgia to 8.4% to 9.7% in
summarizes GBD 2013 Study findings on stroke burden China and Indonesia. As also shown in Figure 2, proportional
recently published in the special open access issue of the contribution of stroke-related DALYs compared with 10 other
journal Neuroepidemiology7 and outlines recommended leading causes of DALYs in 2013 was the second highest and
measures to reduce stroke burden. In these publications, not statistically significantly different from ischemic heart dis-
ease, especially in developed countries.
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stroke burden is reported in terms of incidence of first-ever

stroke (ischemic stroke [IS] and hemorrhagic stroke [HS] The proportional contribution of stroke-related DALYs
separately, and total stroke), prevalence, mortality, and and deaths due to stroke compared with all diseases also in-
disability-adjusted life-years (DALYs) in children (0–19 creased from 1990 (3.5% [95% UI, 3.1–4.0] and 9.7% [95%
years of age),8 young to middle-aged adults (20–64 years UI, 8.5–10.7], respectively) to 2013 (4.6% [95% UI, 4.0–5.3]
of age),9 and overall for all ages combined2 and by sex10 and 11.8% [95% UI, 10.5–13.3], respectively), but there was a
from 1990 to 2013. All burden estimates were reported diverging trend in developed and developing countries with a
with corresponding 95% uncertainty intervals (UI). In lay significant increase in DALYs and deaths in developing coun-
terms, DALYs mean the number of years lost because of dis- tries (from 0.9 [95% UI, 0.8–1.0] and 2.1 [95% UI, 1.9–2.4]
ability. The diagnostic criteria for stroke used in the GBD for DALYs and 3.0 [95% UI, 2.6–3.4] and 5.2 [95% UI, 4.6–
analyses are based on the World Health Organization (WHO) 5.8] for deaths in 1990 to 1.7 [95% UI, 1.3–1.9], 2.8 [95% UI,
definition of stroke.11 Details on the methodology of the GBD 2.5–3.3] for DALYs and 5.2 [95% UI, 4.2–5.7], 6.4 [95% UI
stroke burden estimates, including diagnostic criteria and data 5.8–7.5] for IS and HS deaths, respectively, in 2013). There
sources, have been published elsewhere.12,13 was no measurable change in the proportional contribution of
DALYs and deaths from stroke in developed countries over
Overall Overview of the Global, Regional, and the 23-year study period.
Country-Specific Burden of Stroke, Including This GBD and other reports17,18 indicate that stroke in the
Trends in stroke Burden From 1990 to 2013 young and middle-aged adults are not decreasing or may even
In 2013, stroke was the second most common cause of deaths be increasing, likely because of increase in metabolic risk
(11.8% of all deaths [95% UI, 10.9–13.0%]) worldwide, after factors, including obesity and diabetes mellitus, among the
ischemic heart disease (14.8% of all deaths [95% UI, 13.4– young. The GBD findings also suggest that stroke should no
15.8]), and the third most common cause of disability (4.5% longer be regarded as a disease of the elderly: two thirds of all
of DALYs from all cause [95% UI, 4.1–5.2]) after ischemic strokes occur among persons <70 years of age.
heart disease (6.1% [95% UI, 5.5–6.8]). Overall, the GBD
2013 stroke burden estimates confirmed previous observations Sex Differences in Stroke Burden in the World,
about the significant increase in stroke burden in the world Including Trends From 1990 to 2013
over the last two and half decades,14 especially in develop- The GBD 2013 Study identified significant dispari-
ing countries,14,15 and substantial geographical variations in ties in stroke burden between men and women, with men
stroke burden.14,15 As shown in Figure 1, the highest stroke having consistently greater incidence of IS than wom-
DALYs and mortality rates in 2013 were observed in Russia en (133/100,000 person-years [95% UI, 125–143] and
and Eastern European countries. 99/100,000 person-years [95% UI, 92–107], respectively).
Although stroke mortality and DALYs rates have declined Although incidence rates of both IS and HS in 2013 were
from 142/100,000 person-years (95% UI, 129–154) and lower than that in 1990 for both men and women, the number
2431/100,000 person-years (95% UI, 2224–2631), respective- of incident and prevalent strokes was significantly greater in
ly, in 1990 to 110/100,000 person-years (95% UI, 102–122) 2013 compared with 1990 for both men and women, IS and
and 1807 person-years (95% UI, 1667–1992), in 2013 the HS (Table). The risk (rate of stroke) and absolute number
absolute number of people who died from stroke, remained of IS and HS events (both incident and prevalent strokes) in
disabled from stroke (as measured by DALYs), affected by 2013 were significantly greater in men than in women (ex-
stroke (as measured by incidence of new strokes), or survived cept no statistically significant excess of incident IS events
stroke has increased statistically significant (1.4- to 1.8-folds in men), suggesting changes in the sex distribution of stroke
for IS and 1.2- to 1.9-folds for HS). Globally, in 2013 there burden in the world. Age-adjusted incidence rates seemed
 Feigin et al   Global Burden of Stroke   441
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Figure 1. Age-standardized stroke disability-adjusted life-years (DALYs) and mortality rates per 100,000 person-years in various regions
of the world in 2013 (both sexes, all ages)

to be declining worldwide at a faster rate in women than in lowest in Sub-Saharan Africa (range from 3 to 11) and Papua
men, but the reasons for that remain unclear. New Guinea (2% [95% UI, 1–3]).
In 2013, proportional (%) contribution of stroke-related There were also noticeable sex differences in the pro-
deaths to deaths from all causes (Figure 3) in women was portional contribution of stroke-related DALYs to DALYs
greater than in men and highest in Eastern European coun- from all causes (Figure 4). Although in men it was highest
tries, Asia East, and North Africa, where it ranged from 35% in Bulgaria, Macedonia, Georgia, China, and North Korea
(95% UI, 29–38) in Macedonia and 32% (95% UI, 28–35) in (11%–12%), in women it was not high in China (9% [95%
Vietnam to 16% to 18% in North Africa (95% UI, 14–20), and UI, 7–10]).
 442  Circulation Research  February 3, 2017
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Figure 2. Proportional contribution (%) of age-standardized disability-adjusted life-years (DALYs) from stroke to DALYs in 2013. COPD
indicates chronic obstructive pulmonary disease.

Overview of the Global, Regional, and Country- 2013, there were significant increases in absolute numbers and
Specific Burden of Stroke in Adults, Including prevalence rates of both HS and IS for younger adults. There
Trends in Stroke Burden From 1990 to 2013 were 1.5 million [95% UI, 1.3–1.7] stroke deaths globally
Globally, between 1990 and 2013, there were significant in- among younger adults, but the number of deaths from HS (1.0
creases in prevalent cases, total deaths, and DALYs because [95% UI, 0.9–1.2]) was significantly higher than the number
of HS and IS in younger adults aged 20 to 64 years. In 2013, of deaths from IS (0.4 million [0.4–0.5]).
in younger adults aged 20 to 64 years, the global prevalence Death and DALY rates declined in both developed and
of HS was 3.7 million cases [95% UI, 3.5–3.9] and IS was 7.3 developing countries, but a significant increase in absolute
million cases [95% UI, 7.0–7.6]. Globally, between 1990 and numbers of stroke deaths among younger adults was detected
 Feigin et al   Global Burden of Stroke   443

Table.  Absolute Number of Women and Men With Stroke (in Millions) in the World by Stroke Type in 1990 and 2013 (95%
Uncertainty Limits Are in Brackets)
Women Men
1990 2013 1990 2013
Ischemic stroke Incident 2.14 (1.96– 2.33) 3.28 (3.06–3.52) 2.17 (2.05–2.33) 3.62 (3.43–3.85)
Prevalent 4.86 (4.56–5.19) 8.66 (8.32–9.00) 5.18 (4.93–5.46) 9.65 (9.27–10.05)
Hemorrhagic Incident 0.86 (0.79–0.92) 1.53 (1.42–1.63) 1.03 (0.96–1.09) 1.84 (1.72–1.94)
stroke
Prevalent 1.78 (1.67–1.87) 3.36 (3.23–3.51) 2.11 (2.02–2.22) 4.00 (3.81–4.17)

in developing countries, where most of the burden of stroke Between 1990 and 2013, there were significant increases in
resided. There was a 20.1% [95% UI, −23.6 to 10.3] decline the global prevalence rates of childhood IS, as well as sig-
in the number of total stroke deaths among younger adults nificant decreases in the global death and DALY rates of all
in developed countries, but a 36.7% [95% UI, 26.3–48.5] in- strokes in 0 to 19 year olds. Males showed a trend toward
crease in developing countries. Percentage changes in deaths higher childhood stroke death rates (1.5/100,000 person-years
and DALYs in younger adults between 1990 and 2013 in de- [1.3–1.8]) than females (1.1/100,000 person-years [0.9–1.5]
veloped and developing countries by 5-year age group also per 100,000) and higher childhood stroke DALYs rates
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showed diverging trends (Figure 5), that is, increase of the (120.1/100,000 person-years [100.8–143.4]) than females
percentage change toward greater burden with aging in de- (90.9/100,000 person-years [74.6–122.4]) globally in 2013.
veloping countries and decrease of the percentage change Although the gap in childhood stroke burden between de-
toward the reduction of the burden with aging in developed veloped and developing countries is closing (Figure 6), the
countries. Death rates for all strokes among younger adults 2013 childhood stroke burden in terms of absolute numbers of
declined significantly in developing countries from 47/100,00 prevalent strokes, deaths, and DALYs remained much higher
person-years [95% UI, 42.6–51.7] in 1990 to 39/100,000 in developing countries. Although prevalence rates for child-
person-years [95%UI, 35.0–43.8] in 2013. Death rates for all hood IS and HS decreased significantly in developed coun-
strokes among younger adults also declined significantly in tries, in developing countries, a decline was seen only in HS,
developed countries from 33.3 [95% UI, 29.8–37.0] in 1990 with no change in IS prevalence rates. The childhood stroke
to 23.5 [95% UI, 21.1–26.9] in 2013. Although the trends in DALY rates in 2013 were 13.3/100,000 person-years [95%
declining death and DALY rates in developing countries are UI, 10.6–17.1] for IS and 92.7/100,000 person-years [95%
encouraging, these regions still fall far behind developed re- UI, 80.5–109.7] for HS. Although globally the prevalence of
gions of the world. childhood IS compared with childhood HS was similar, the
In 2013, the greatest burden of stroke among younger death rate and DALYs rate of HS was 6- to 7-fold higher than
adults was because of HS. A significant decrease in HS death that of IS. In 2013, the prevalence rate of childhood IS and HS
rates for younger adults was seen only in developed countries was significantly higher in developed countries than that in
between 1990 and 2013 (19.8 [95% UI, 16.9–22.6] and 13.7 developing countries. Conversely, both death and DALY rates
[95% UI, 12.1–15.9]) per 100,000). No significant change for all strokes were significantly lower in developed countries
was detected in IS death rates among younger adults. The to- than in developing countries in 2013.
tal DALYs from all strokes in 20 to 64 year olds were 51.0
million [95% UI, 46.6–57.3]. Globally, there was a 24.4% Call for Action
[95%UI, 16.6–33.8] increase in total DALYs for this age The patterns of the main categories of diseases have shifted
group, with a 20% [95% UI, 11.7–31.1] and 37.3% [95% UI, considerably during the last few decades. The GBD project
23.4–52.2] increase in HS and IS numbers, respectively. and other studies have shown a decline in infectious and
nutritional disorders, and a rise in noncommunicable dis-
Overview of the Global, Regional, and Country- eases (NCD), such as stroke, heart disease, cancer, diabe-
Specific Burden of Stroke in Children, Including tes mellitus, and chronic obstructive pulmonary disease.6
Trends in Stroke Burden From 1990 to 2013 The most recent GBD estimates showed that during the last
Globally, between 1990 and 2013, there was a significant in- two and half decades, the number of stroke survivors and
crease in the absolute number of prevalent childhood strokes people with incident stroke have increased 50% to 100%,
while absolute numbers and rates of both deaths and DALYs thus indicating that currently used primary stroke preven-
declined significantly. In 2013, there were almost 100,000 tion strategies are not sufficiently effective and require a
prevalent cases [95% UI, 91,000–106,000] of childhood serious revision. Projections demonstrate that the NCDs
IS and 68,000 [95% UI, 63,000–72,000] prevalent cases of will be increasingly prevalent in the next decades and will
childhood HS, reflecting an increase of ≈35% in the absolute reach epidemic proportions, which will seriously influence
numbers of prevalent childhood strokes since 1990. There global public health, and furthermore have substantial ef-
were ≈33,000 [95% UI, 29,000–39,000] deaths and 2.6 mil- fects on social and economic development—unless urgent
lion [95% UI, 2.3–3.1] DALYs because of childhood stroke actions are undertaken. Fortunately, the core NCDs share
in 2013 globally, reflecting ≈200% decrease in the absolute one important element: they are all highly preventable. In
numbers of death and DALYs in childhood stroke since 1990. the past, epidemiological global data on stroke have often
 444  Circulation Research  February 3, 2017
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Figure 3. Proportional (%) contribution of stroke-related deaths to deaths from all causes in men and women in 2013.

been included under the term “cardiovascular disease” with- the prevention of NCDs share many common features be-
out further subdivision into the 2 main constituents, such as cause the main risk factors are mostly similar. For stroke,
heart disease and stroke. The major implications of each of heart disease, diabetes mellitus, cancer, and pulmonary dis-
these disorders for global health warrant their recognition eases, 4 modifiable lifestyle risk factors are of major impor-
as stand-alone diseases that should be accounted for sepa- tance: tobacco use, unhealthy diet, physical inactivity, and
rately, rather than embedded under an umbrella term that is harmful use of alcohol. The WHO has established the “4 by
often not well understood. 4” principle of 4 core NCDs (cardiovascular disease, cancer,
A key to reducing the global burden of stroke is renewed diabetes mellitus, pulmonary diseases) and 4 major modifi-
emphasis on stroke prevention. Whereas each of the NCDs able risk factors in their list of “best buys”: (mass actions on
require specific management and treatment when they occur, the lifestyle risk factors are the most cost- effective means
 Feigin et al   Global Burden of Stroke   445
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Figure 4. Proportional contribution (%) of age-standardized disability-adjusted life-years (DALYs) from stroke to DALYs from all causes in
2013 by sex.

of prevention).19 This cluster of diseases and risk factors are in September 2011.22 This event clearly marked that stroke
prioritized by the WHO in its Global Action Plan on NCDs.20 and NCDs not only constitute a medical but also a politi-
For stroke, other major risk factors include hypertension, cal and developmental issue of global importance. With the
which is twice as important for stroke as for coronary heart political declaration, the UN member states committed to
disease21; and atrial fibrillation, which increases in impor- take strong action on the NCDs. The task to lead the imple-
tance with increasing age. mentation and monitoring of the UN declaration was given
The major threat to global health and the implications to the WHO, who issued the WHO Global Action plan that
for society was increasingly recognized from around the included a set of global targets for lifestyle risk factors and
year 2000 onwards and lead to the landmark event of the health system improvements to achieve the overall goal
adoption of the United Nations (UN) declaration on NCDs of a 25% reduction in premature NCD mortality by the
 446  Circulation Research  February 3, 2017

Figure 5. Percentage change in age-

standardized death and disability-
adjusted life-year rates in younger adults
between 1990 and 2013 by 5-year age
group in developed and developing
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countries.

year 2025. Stroke prevention should not be a stand-alone attack surgical management (if indicated), medications, and
isolated issue, but be a part of the common actions now lifestyle modifications. The world’s first global stroke ser-
in progress on the major NCD risk factors. Only by joining vices guidelines (The World Stroke Organization Global
forces with other initiatives for NCDs prevention will stroke Stroke Services Guidelines and Action Plan) have recently
prevention have its full impact. The major principles in pre- been published and provide a listing of essential components
vention are similar for stroke and other types of cardiovascular of care at different levels of services.24 The document recog-
disease.23 nizes 3 levels of stroke care: minimal (stroke care delivery
The UN declaration called for a 25% relative reduction is based at a local clinic staffed predominantly by nonphysi-
in premature mortality from NCDs, including stroke, by the cians, and much of the emphasis is placed bedside clinical
year 2025. However, the other stroke epidemiological met- skills, on teaching, and prevention; there is a lack of diag-
rics should not be forgotten. The most important primary nostics, such as computed tomographic scan, stroke units,
health goal for stroke is clearly a reduction in stroke inci- thrombolytic therapies, basic secondary stroke prevention,
dence—prevention is always better than cure. However, the and rehabilitation), essential (offers access to a computed
need for effective therapies in the acute phase (stroke unit tomographic scan, physicians, and the potential for acute
management, thrombolytic, and other reperfusion therapies), thrombolytic therapy; however, stroke expertise may still be
as well as rehabilitation and long-term follow-up efforts to difficult to access; the bulk of evidence-based therapies for
prevent stroke recurrence and improve functional outcomes stroke is available at that level), and advanced (availability of
should be recognized as important measures to substantially multidisciplinary stroke expertise, multimodal imaging, and
reduce the burden of stroke in people who have developed or comprehensive therapies, eg, neurosurgical interventions
survived stroke. As one-third of all strokes occur in persons and thrombectomy). The world map of stroke services is not
who have had a previous cerebrovascular event, adequate at- precisely known at present, but a high proportion of popu-
tention should be paid to secondary stroke prevention. This lations is estimated to have access only to minimal stroke
should include measures to ensure adherence to the recom- services. It is now urgent to change minimal services to es-
mended (evidence based) poststroke and transient ischemic sential services in all regions.
 Feigin et al   Global Burden of Stroke   447

Figure 6. Trends in age-standardized

death and disability-adjusted life-year
(DALY) rates (per 100,000 people per
year) in childhood stroke between 1990
and 2013 in developed and developing
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countries.

Several actors are responsible for ensuring that the call Stroke Organisation and academia, have important responsi-
for action on stroke will be effective and lead to improve- bilities in providing adequate scientifically based advice on
ments in stroke metrics. Governments have the main respon- prevention, practices, management, and therapies. Academia
sibility and have the power to influence environmental (eg, also has the responsibility to develop technological advanc-
air pollution), social (eg, poverty, racial/ethnic inequality in es, such as the Stroke Riskometer app,26 to help individuals
health care, education, employment, housing, etc.), medical to recognize their own risk factors, calculate the future risk
(provision of adequate health services), and lifestyle factors of stroke, and provide targeted advice on how to lower the
(eg, smoking, nutrition, and physical activity) through leg- risk.27 Thus, the responsibilities to a decreased global burden
islation and taxation of tobacco, alcohol, and food contents of stroke are shared.
(salt, sugar, and saturated fats). One still unmet need also It has been estimated that with effective actions on com-
within the responsibility of governments is adequate fund- mon lifestyle factors, at least half of all strokes may be pre-
ing of stroke research, including primary stroke prevention vented.28 Prevention of stroke is a complex medical and a
research. However, in spite of stroke being a leading cause political issue—but there is strong evidence that substantial
of death and disability, the volume of funding for stroke re- prevention of stroke is feasible in practice. The need to scale-
search (including primary stroke prevention research) is low up the actions is urgent. Stroke prevention has entered a new
in comparison with that spent on cancer or coronary heart era, with stroke being identified as one of the prioritized NCDs
disease.25 Health systems have the responsibility to identify in the WHO and UN actions on NCDs.
risk factors that require medical contacts for their detection
and treatment (eg, elevated blood pressure, atrial fibrillation,
Sources of Funding
and symptomatic carotid artery stenosis) to influence risk
This article and some reported figures were based on research sup-
factors for the substantial part of the population that already ported by the Bill and Melinda Gates Foundation; Prof Feigin was
have an NCD or a risk factor that requires regular medical partly funded by the Health Research Council of New Zealand, the
contacts. Nongovernmental organizations, such as the World Brain Research New Zealand Centre of Research Excellence and
 448  Circulation Research  February 3, 2017

Ageing Well Programme of the National Science Challenge, Ministry cerebrovascular diseases. Neuroepidemiology. 2015;45:146–151. doi:
of Business, Innovation and Employment of New Zealand. 10.1159/000441083.
14. Feigin VL, Forouzanfar MH, Krishnamurthi R, et al; Global Burden of
Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010) and the GBD
Disclosures Stroke Experts Group. Global and regional burden of stroke during 1990–
None. 2010: findings from the Global Burden of Disease Study 2010. Lancet.
2014;383:245–254.
15. Feigin VL, Lawes CM, Bennett DA, Barker-Collo SL, Parag V. Worldwide
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2. Feigin VL, Krishnamurthi RV, Parmar P, et al; GBD 2013 Writing Group; 16. Feigin VL, Roth GA, Naghavi M, Parmar P, Krishnamurthi R, Chugh
GBD 2013 Stroke Panel Experts Group. Update on the Global Burden of S, Mensah GA, Norrving B, Shiue I, Ng M, Estep K, Cercy K, Murray
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 Global Burden of Stroke
Valery L. Feigin, Bo Norrving and George A. Mensah
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Circ Res. 2017;120:439-448

doi: 10.1161/CIRCRESAHA.116.308413
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