Nationwide Cerebrovascular Disease Morbidity Study

Transcription

1 Natinwide Cerebrvascular Disease Mrbidity Study BY LEWIS KULLER, M.D., DR. P.H., HERBERT ANDERSON, DONALD PETERSON, M.D., M.P.H., JOHN CASSEL, M.D., PHILLIP SPIERS, P.H.D., HIRAM CURRY, M.D., BERTHA PAEGEL, M.D., MILTON SASLAW, M.D., M.P.H., CHARLES SISK, M.D., M.P.H., JOSEPH WILBER, M.D., DAVID MILLWARD, M.D., WARREN WINKELSTEIN, JR., M.D., M.P.H., ABRAHAM LILIENFELD, M.D., M.P.H., AND RAYMOND SELTSER, M.D., M.P.H. Dwnladed frm by n Nvember 16, 2018 Abstract: Natinwide Cerebrvascular Disease Mrbidity Study Previus studies have nted that the gegraphic differences in strke mrtality amng areas f the United States were nt due t artifacts f certificatin practices r accuracy f the diagnsis. A study f hspitalized strke patients was cmpleted in rder t determine whether the mrtality differences were due t a higher incidence r case fatality fllwing a strke in areas with high strke death rates. Eight f the nine areas that participated in the Natinwide Mrtality Study were included in this study. A ttal f 2,619 strke cases were ascertained including 1,631 (62.3) wh were alive at the time f hspital discharge, 9 (35.8) dead at discharge, 46 (1.7) wh were discharged alive but died utside f the hspital, and five (0.2) wh were dead at discharge and certified by the medical examiner. The incidence f strke was higher in the high strke death rate areas especially fr men. The rati f the incidence f strke in men as cmpared t wmen was higher in the yunger age grups (45-54, 55-64) and in the highincidence as cmpared t lw-incidence areas. The case-fatality percentage was lwest in and highest in Suth Carlina. Presence f cma n admissin was the principal determinant f subsequent mrtality in all areas. Finally, there was n cnsistent difference in the distributin f symptms f strke amng the areas, and diagnstic prcedures were perfrmed mre ften in urban than rural areas. Apprximately 80 f the strke cases culd be substantiated by either an autpsy verifying diagnsis, arterigraphy, hemrrhagic spinal fluid, hemiplegia r cma n admissin. Several hyptheses t explain the differences have been suggested as well as the need fr new infrmatin. ADDITIONAL KEY WORDS epidemilgy strke mrtality hypertensin athersclersis hspitalizatin cma risk factrs Intrductin Large differences in cerebrvascular disease mrtality amng gegraphic areas f the United States have been reprted. Death rates were higher in the sutheastern states, especially alng the Atlantic cast, and lwer in the Frm the Department f Chrnic Diseases, The Jhns Hpkins University Schl f Hygiene and Public Health; Seattle-King Cunty Department f Public Health, Department f Epidemilgy, University f Nrth Carlina Schl f Public Health, Divisin f 86 Neurlgy, Medical Cllege f Suth Carlina, City and Cunty f Department f Health and Hspitals; Dade Cunty, Flrida Department f Public Health, University f Schl f Medicine, Gergia State Department f Public Health; State University f New Yrk at Buffal Department f Epidemilgy. This study was supprted by Cntract PH and by Prgram Prject grant NB frm the Natinal Institute f Neurlgical Diseases and Strke. Part f this wrk was dne during Dr. Kullert tenure f an established investigatrship f the American Heart Assciatin. Strk; Vl. I, March-April 1970

2 CEREBROVASCULAR DISEASE MORBIDITY STUDY Dwnladed frm by n Nvember 16, 2018 TABLE 1 Gegraphic Areas Included in Natinwide Cerebrvascular Disease Mrbidity Study and Age-Adjusted 2 Strke Death Rates in Each Area (Ages 35-74), Area, Flrida, Clrad Flint Hills,* Seattle, Washingtn Buffal, New Yrk Upper Castal Plain,* N. C. Savannah, Gergia Pee-Dee,* S. C. WM Descriptin f Rural State Ecnmic area. WF plains and Rcky Muntain regins. 1 A study f death certificates in nine areas f the United States including three with high, three with intermediate, and three with lw strke death rates had shwn that the gegraphic differences were nt due t certificatin practices r t criteria fr the clinical diagnsis f strke. 2 " 6 Hwever, these variatins in mrtality culd result frm differences in either the incidence f strke r the case-fatality ratis fllwing a strke. Fr example, the incidence f strke culd be higher and the case-fatality percentage the same, r the incidence culd be the same but the case fatality greater in the high rates areas. The study f strke incidence presents a frmidable prblem. First, the incidence f strke is relatively lw fr the age grups which shw the greatest mrtality differences between the areas; it is nly abut 2/0 fr ages 45-54, and 4/0 fr ages SS-^ A large ppulatin sample fllwed fr a reasnably lng perid is necessary in rder t have enugh cases t estimate an TABLE 2 incidence at this level. Secnd, a crsssectinal r surveillance apprach necessitates the cperatin f physicians because an unknwn percentage f strke cases are nt admitted t a hspital r ther medical facilities. Differences in reprting by physicians culd substantially affect the incidence rates. Furthermre, the accuracy f the diagnsis f the reprted cases by physicians is difficult t evaluate. Restricting the study t hspitalized cases wuld prvide a reasnable estimate f the incidence f strke and allw cmparisn amng areas if: (1) a high percentage f strke cases were hspitalized; (2) the percentage f all strke cases hspitalized were similar amng the areas r were knwn s that adjustments fr the differences in hspital admissin rates culd be made; and (3) the hspital admissin plicies were unbiased fr the variables being cmpared such as age, sex, race, etc. Methds A study f strke mrbidity in eight f the nine areas (table 1) which had participated in the Natinwide Mrtality Study was cmpleted in rder t cmpare: (1) the incidence f strke based n hspitalized cases nly; (2) the case fatality fllwing a strke; and (3) the clinical characteristics f the strke cases. Hspitals in each area were asked t participate in the study. In several areas, hspitals in the surrunding majr medical centers were als included. Strke cases were then ascertained frm the hspital discharge indices. Nurses r ther trained persnnel abstracted the hspital recrds f all discharges listing strke fr whites aged during Deaths were als ascertained frm the lists f hspital deaths reprted in the Natinwide Cerebrvascular Disease Mrtality Study. Cases were cllected fr a tw-year perid in Nrth Carlina and fr ne year in the ther areas. Over 90 f the hspital Distributin f Strke Cases in Natinwide Mrbidity Study by Area and Categry (Ages 45-69), 1965 Cat* gry Living Died in hspital Died ut f hspital Certified by M.E *Data cllected fr tw-year perid in Nrth Carlina. Seattle Buffal N. C.» Gergia s. c , ,619 Strke, Vl. I, March-April

3 KULLER, ANDERSON, PETERSON, ET AL. TABLE 3 Distributin f Strkes in Mrbidity Study by Area and by Categry f Diagnsis (Ages 45-69), J965 Area Seattle Buffal Nrth Carlina Gergia Suth Carlina Past Hx nly Categry Past Hx and Strke f Strke N Hx ,663 pa ft strke Unknwn past Hx strke ,619 Dwnladed frm by n Nvember 16, 2018 recrds culd be reviewed in six f the eight areas including the three lw (, and part f ) and the three high (parts f Nrth Carlina, Suth Carlina and Savannah, Gergia) strke death rate areas. Since the accuracy f the methd f case ascertainment frm hspital discharge indices was nt knwn in each area r within each hspital, a sample f recrds fr which strke was nt listed as a discharge diagnsis in the diagnstic index was als reviewed t determine if a strke diagnsis was cntained in the hspital chart. The denminatr fr estimating the incidence f strke was based n the 1960 census f the ppulatin. Changes in the ppulatin fr thse years f age between 1960 and 1965 shuld have little effect n these estimates, except perhaps in where the incidence will prbably be verestimated because f the relatively mre marked increase in the ppulatin. Estimates f incidence and case-fatality rates will be reprted nly fr the six areas in which ascertainment f cases was practically cmplete. Results A ttal f 2,619 strke cases were ascertained, including 1,631 (62.3) wh were alive at the time f hspital discharge, 9 (35.8) wh were dead at discharge, 46 (1.7) wh were discharged alive but died utside the hspital accrding t the death certificate btained in the mrtality study, and five (0.2) wh were dead at discharge and certified by the medical examiner (table 2). The 2,619 strkes were subdivided int the fllwing fur grups accrding t whether there was a new strke n the current admissin and/r a past histry f strke 88 (table 3): (1) 255 (9.7) with a past histry f strke nly; (2) 2 (14.2) with a past histry f strke and a new strke n the current admissin; (3) 1,663 (63.5) with a new strke and n past histry f strke; and (4) 329 (12.6) with a new strke and an unknwn past histry f strke. Unless therwise nted, the 255 strkes with a past histry nly were excluded frm the analysis. Of 3,305 hspital recrds in which the hspital discharge index did nt include a strke diagnsis, nly 52 (1.6) had a strke listed n the hspital recrd. Of these 52 strke recrds, (71.2) listed strke in the past histry, three (5.8) were admitting diagnses, (19.2) ccurred during hspitalizatin, and nly tw (3.8) were discharge diagnses. N differences between the areas were nted. The hspital discharge indices were therefre felt t be reasnably cmplete. The incidence f strke was higher in areas with high strke mrtality (Nrth Carlina, Suth Carlina, and Savannah) as cmpared t the lw areas (,, ). These differences were present when the rates were based n either all strke diagnses including the strkes mentined in the past histry nly (cl. 1, table 4), r excluded strkes listed nly in the past histry (cl. 2, table 4), r included nly new strke cases wkhut a past histry f strke (cl. 4, table 4). Fr men, the age-specific incidence f strke was greater in the high as cmpared t the lw Strke, Vl. I, March-April 7970

4 CEREBROVASCULAR DISEASE MORBIDITY STUDY TABU 4 Sex-Specific Incidence f Strke by Area and by Whether Past Histry f Strke Reprted n Hspital Chart (Ages 45-69), 1965 Area Nrth Carlina Gergia Suth Carlina Sex Male Female Male Female Male Female Male Female Male Female Male Female (l) All cses Incidence/,000 (2) Excluding past Hx nly (3) Recent ttrkes and pst Hx (4) Recent strke and n r unknwn past Hx Dwnladed frm by n Nvember 16, r FIGURE 1 The incidence f strke fr males is higher in the high death rate areas. areas in all three age grups (fig. 1) but nly fr the lder ages fr wmen (fig. 2). Als, the rati f the incidence in men t that in wmen within an area was much greater in the high areas, especially Nrth Carlina and Savannah amng thse under 55 years f age, than in the lw areas (fig. 3); n differences between areas were nted amng thse years f age. Cmparisns f incidence and death rates are shwn in figure 4. The rati f the age and sex-specific incidence rates in the high as cmpared t the lw areas was generally smaller than the crrespnding ratis f the death rates previusly reprted. 2 Fr men bth the incidence and mrtality ratis were greatest fr ages 45-54, while fr wmen the ratis were greatest fr ages I0O0 g H Crflw KMtU "69 AGE FIGURE 2 The incidence f strke is higher fr females in the high death rate areas nly in the lder age grup (65-69). Strke, Vl. I, March-April

5 KULLER, ANDERSON, PETERSON, ET AL. AGE MIAMI DENVER KANSAS NORTH CAROLINA GEORGIA SOUTH CAROLINA ACit MIAMI OENVER KANSAS NORTH CAROLINA GEORGIA SOUTH CAROLINA - ^ M i i AGE MIAMI DENVER KANSAS NORTH CAROLINA.GEORGIA SOUTH CAROLINA 0 _ RATIO MALE/FEMALE 5 6 FIGURE 3 The sex rati f the incidence f strke in males as cmpared t females is higher in areas with high incidence, especially ages 45 t 54. Dwnladed frm by n Nvember 16, 2018 Finally, the age-specific incidence rates fr men in Savannah (high incidence area) based nly n new strke cases withut a past histry f strke were higher than the incidence rates reprted in several ther cmmunity studies,0"9 while the incidence in (lw incidence area) was generally lwer (fig. 5). This is especially interesting since higher incidence rates in Savannah were based n hspitalized cases nly, while the ther studies used mre cmplete methds f case ascertainment. Therefre, the incidence f strke was (1) greater in high than lw strke death rate areas, (2) higher fr men than wmen, especially in the high incidence areas, and (3) als apparently greater in the high areas than in ther cmmunities in the United States. The case-fatality percentage was defined as the percentage f strke cases wh were dead at the time f hspital discharge. The case-fatality percentage varied frm 28 in t 49 in Suth Carlina (table 5). N cnsistent differences were nted in the case-fatality percentage by age r sex. Because 90 the dead cases culd be ascertained frm tw surces (hspital indices and the death certificates) while the living cases culd be identified frm the hspital indices nly, the case-fatality percentage may be inflated. Hwever, as previusly nted, practically n strke cases were lcated that were nt listed in the indices. Althugh the case-fatality percentage was similar in mst f the areas, deaths tended t ccur earlier in the hspitalizatin in the high areas. Apprximately 8 f the strke admissins had died within tw days f admissin in and (lw incidence areas), while nearly 20 had died in the three high strke incidence areas. By the time f hspital discharge, hwever, there was much less difference between the high and lw areas (table 6). Pssible explanatins fr this bservatin are: (1) differences in the distributins f the specific types f strke amng the areas, deaths in the first few days being attributed t hypertensive cerebral hemrrhage and the later deaths t cerebral thrmbsis r emblism; (2) greater delay between the nset Strk; Vl. I, March-April 1970

6 CEREBROVASCULAR DISEASE MORBIDITY STUDY < UJ r 4r - Mrtality W.M A- A Incidence W.M Mrtality W.F. O- Incidence W.F X 2 - ^ "...X FIGURE 4 AGE i Fr males, bth the rati f incidence f strke and mrtality in the high as cmpared t lw areas is greater in the yungest age grup (45-54) while fr females the rati tends t increase with age. Dwnladed frm by n Nvember 16, 2018 TABLE 5 Age and Sex-Specific Case-Fatality Percentages by Areas* Sex WM WF GRAND Age TOTAL Excludes cases with strke in past histry nly. f the strke and admissin t the hspital in the high rate areas s that the patient died shrtly after reaching the hspital in the high areas; (3) differences in treatment within the hspital, delaying the time f death withut changing the case-fatality percentage. Infrmatin abut the time between nset f strke and admissin t the hspital was felt t be unreliable. As fr difference in treatment, n accurate measure f the effect f medical care Cn Fatality Percentage Nrth Carlina Gergia Suth Carlina was available. Thus the reasns fr the differences in distributin f time f death cannt be determined. Only 19 f the patients were cmatse n admissin t the hspital in as cmpared t 33 in Suth Carlina. As shwn in figure 6, case fatality was cnsiderably higher amng thse cmatse n admissin in all areas: 77 f cmatse patients died as cmpared t 29 f nncmatse individuals. Sfrlce, Vl. I, March-April

7 KULLER, ANDERSON, PETERSON, ET AL. I2OO 1 Svnnh, G. Frminghm Rchester, Minn. Dupnt Middlesex * *- * ' 600 _ LJ Dwnladed frm by n Nvember 16, AGE FIGURE The age-specific incidence f strke fr white males in Savannah is higher than that reprted in ther studies, while the age-specific incidence is lwer in. The case-fatality percentage fr cmatse patients was similar amng the areas, but nly 18 f nncmatse patients had died in as cmpared t in Suth Carlina. Thus, differences in case fatality between and Suth Carlina were related t bth the percentage f cmatse patients n admissin (19 as cmpared t 33) and the higher case fatality fr nncmatse patients (18 as cmpared t ). The distributin f the specific types f strke was similar amng the areas (table 7). Apprximately half the cases were attributed t thrmbsis and/r emblism, and fr anther 25, n specific type f strke was reprted in the chart. As previusly reprted in 92 the mrtality study, the accuracy f the diagnsis f the specific type f strke was suspect because f the paucity f diagnstic prcedures such as spinal puncture, arterigram, r pstmrtem examinatin. 5 There was n evidence frm this study, hwever, t suggest that any specific type f strke accunted fr the differences in incidence amng the areas. The frequency f symptms f strke n admissin t the hspital is shwn in table 8. Althugh there was cnsiderable variatin in the distributin f individual symptms amng the areas, n cnsistent pattern emerged. In general, the frequency f cma, cnvulsins and headache n admissin was higher in the high incidence areas. Hwever, there appeared Strk; Vl. I, March-April 1970

8 CEREBROVASCULAR DISEASE MORBIDITY STUDY COMA ON ADMISSION MIAMI DENVER KANSAS NORTH CAP" GEORGIA SOUTH CAROLINA NO COMA ON ADMISSION MIAMi ENVER KANSAS RTH CAROLINAGEORGIA SOUTH CAROLINA CASE FATALITY RATE IN. HOSPITAL FIGURE 6 The presence f cma n admissin t the hspital was assciated with a higher case-fatality rate. Areas in lw incidence and mrtality generally have lwer case-fatality rates, especially fr nncmatse individuals. Dwnladed frm by n Nvember 16, 2018 t be just as great a variatin between areas within the high incidence grup (Nrth Carlina, Gergia and Suth Carlina) as between high and lw incidence areas. Thus the frequency f cma n admissin between tw high areas varied frm 32.7 in Suth Carlina t 24.3 in Nrth Carlina and between tw lw areas frm 27.5 in t 17.7 in. Any difference in the distributin f symptms amng the areas may be due t either differences in type f strke, adequacy f clinical examinatin, r cmpleteness f the recrd. Apprximately 955 (41.2) f the 2,320 recrds listed a spinal puncture, 351 (15.1) an arterigram, and 54 (2.3) a cranitmy (table 9). The frequency f diagnstic prcedures was much higher in the cities (,, Seattle, Buffal, Savannah) than in the rural areas ( and Nrth and Suth Carlina). Hwever, there was n difference between urban high r lw incidence areas (Savannah and ) r rural high and lw areas ( and Nrth and Suth Carlina). Finally, the accuracy f the strke diagnsis was based n a cmbinatin f Strk; Vl. I, March-April 1970 diagnstic prcedures and strke symptms. Apprximately 80 f the strke diagnses culd be substantiated by either an autpsy, an arterigram, hemrrhagic spinal fluid, hemiplegia r cma n admissin nt apparently due t ther causes. There was n cnsistent difference between the high and lw areas (table ). Over half f the strke recrds als listed either hypertensin, arterisclertic heart disease, r diabetes (table 11). The distributin f these three diseases was similar amng the areas except fr the lw frequency reprted in Suth Carlina. Whether the frequency f these diseases is greater than wuld be expected can nly be determined by a special study cmparing these diseases in a strke-free ppulatin. Other studies have als reprted an increased risk f cerebrvascular disease amng patients with hypertensin, diabetes, r heart disease Discuss/n The high strke mrtality areas in the sutheastern United States apparently als have a higher incidence f strke than the lw strke mrtality areas. Pssible differences in 93

9 KULLER, ANDERSON, PETERSON, ET AL. TABLE 6 Cumulative Area Nrth Carlina Gergia Suth Carlina Case-Fatality Cses ,452 Percentage <2 Dyj in Hspital by <8 Days Area and by Length f Hspitalizatin (Ages 45-69) Length f Hiplralizattn DEATHS < 30 Day> i«* Cumulative percentage dead by stated number f days f hspitalizatin > 30 Days All cases (Includes Unknwn f Days) TABLE 7 Distributin f (Ages 40-69)* Type f Sfrke as Admitting and Discharge Diagnses n Hspital Recrd by Area Dwnladed frm by n Nvember 16, 2018 a ral rrhg fi ' _ it ; h S sl 11 l c e 31 e S Area Seattle Buffal Nrth Carlina Gergia Suth Carlina Lw areas High areas , ral ibili ,014 Excludes cases with strke in past histry nly r during hspitajizatin. the percentage f all strke cases that were hspitalized might explain the variatins in incidence amng the areas. If a high percentage f all strke cases were admitted t the hspital in the high areas, the incidence based n nly hspitalized cases wuld be inflated relative t the ther areas. A higher percentage f less severely ill strke cases wuld, therefre, be admitted in the Suth and this shuld result in lwer case-fatality percentage. Hwever, it was fund that the case-fatality percentage was either the same r higher in the 94 s :tln * H!{ high areas as cmpared t the lw areas. Certainly bth a higher case-fatality percentage and a higher frequency f cma in Suth Carlina as cmpared t wuld suggest a mre selective admissin plicy in Suth Carlina. The difference in the incidence f strke between these tw areas was, therefre, prbably underestimated. Furthermre, the greater difference in incidence fr men as cmpared t wmen amng the areas wuld als rule ut an effect f a hspital admissin bias unless there were selective admissin Strke, Vl. I, March-April 1970

10 CEREBROVASCULAR DISEASE MORBIDITY STUDY TABLE 8 Percentage f Symptms f Strke n Admissin t Hspital by Area (Ages 45-69)' Symptm Cma Cnfusin Cnvulsin Headache Stiff neck Hemiplegia Aphasia Lss f visin 2, Seattle New Yrk Nrth Carlina Gergia Suth Carlina Excludes deaths certified by the medical examiner (five), cases discharged alive frm hspital but subsequently fund dead n mrtality study (40), and strke in past histry nly TABLE 9 Distributin f Diagnstic Prcedures Listed in Hspital Chart by Area (Ages 45-69)* Prcedure! Dwnladed frm by n Nvember 16, 2018 Area Seattle Buffal Nrth Carlina Gergia Suth Carlina ,320 Spinal puncture Arterrgram Cranltiny Excludes deaths certified by medical examiner (five), cases discharged alive frm hspital but subsequently fund dead in mrtality study (40), and strke in past histry nly. plicies fr men in the high areas. Again, the absence f a difference in case fatality between men and wmen in each area wuld be strng evidence against differential admissin plicies. Differences in case fatality between the areas was small except fr that nted between and Suth Carlina. Mst f the differences in mrtality between areas f the United States are prbably a manifestatin f a higher incidence f strke rather than f differences in case fatality fllwing a strke. The reasns fr the differences in incidence amng the areas f the United States is nt knwn. Internatinal differences between the United States and Japan are being studied and suggest that the higher rates in Japan are due t bth cerebral thrmbemblism and hemrrhage Als, the Japanese have as much r mre athersclersis f the circle f Strk; Vl. I, March-April Willis as an age, sex-matched cmparisn grup in Minnesta, 13 but little athersclersis f the crnary arteries and lw arterisclertic heart disease death rates. Areas f the United States with high strke death rates, n the ther hand, als have higher death rates frm arterisclertic heart disease as cmpared t the lw strke areas. 2 Als, within the United States, Negres have much higher strke rates than whites, 17 but either the same r lwer mrtality and mrbidity frm arterisclertic heart disease. 18 " 20 Whether ne specific type f strke accunts fr the race, sex and area difference within the United States is unknwn. Lack f adequately detailed clinical and pathlgical studies in these areas f the United States precluded a careful separatin f hemrrhage and thrmbemblism. 5 Perhaps a better methd f classifying 95

11 KULLER, ANDERSON, PETERSON, ET AL. Dwnladed frm by n Nvember 16, 2018 * -Q res - CD u O a! TJ c "5. E>. CO»*. tfin sir Q a> TABLE Cumu, 96 "a s u*- z» E^ u c ". u f a -< gj EE lil X Iptagla X E tal H 4- d Z 4- d Z -< d Z 4- d Z # * z Z 4- Ar ^ - r^>i^ COO CO^CO COKCJr CN CO S? 8 CN CO CN 8 88 CO IO CO *ONOcstOtN CN CO O O <) O. «05 (O P) iqpj S 'I-WOC/W'USCOCN csicccrvcc d «OI ^ rv»-*c ^- i i O CN i CN i dv^i.^ CN CS CO i CN CN CO 0NO -^ 00 I O K I CN CN O* O* T ^ CO CO CO I MOOMNaKTOM "I CN "t K CN CN a c 2 _ Illi! c E? II c 23 strke disease shuld include (1) the lcatin f the invlved vessel (intracranial r extracranial), (2) size f the vessel, and (3) type f pathlgy. Differences in the characteristics f athersclertic disease in the intracranial and extracranial vessels have been nted 21 " 28 as well as the pssible assciatin f intracerebral vascular disease with bth hemrrhage and cclusin. 24 Three risk factrs appear t be f majr imprtance fr strke: elevated bld pressure, 11 ' 14 elevated lipids, 11 and high bld sugar r diabetes. 11 ' 2 " Cnsidering the gegraphic differences in strke incidence and mrtality and the reprted distributin f these variables, a reasnable hypthesis might be that: (1) ppulatins characterized by a high prevalence f hypertensin but lw lipid levels wuld have high rates f primary intracranial disease, cnsisting f bth thrmbemblism and hemrrhage, but little extracranial disease r athersclertic heart disease (Japan); (2) ppulatins with bth elevated bld pressures and lipids wuld have high rates f bth intracranial and extracranial disease as well as athersclertic heart disease (U. S. Negres); and (3) ppulatins with elevated lipids wuld tend t have extracranial disease and high rates f athersclertic heart disease (U. S. whites). Elevated bld sugar prbably wuld als affect the incidence, type and distributin f disease. This hypthesis suggests that the prevalence f bth hypertensin and elevated lipids shuld be greater in the high rate areas f the sutheastern United States because f the increased death rates frm bth strke and arterisclertic heart disease amng whites. Negres shuld have a higher rati f intracranial t extracranial disease as cmpared t whites and als, perhaps, shuld wmen as cmpared t men. Treatment f bth hypertensin and elevated lipids shuld result in the reductin f the incidence f bth strke and arterisclertic heart disease, while treatment f hypertensin alne shuld have a greater effect n strke, and lipids alne n arterisclertic heart disease. Further studies f these relatinships shuld include: (1) cmplete ascertainment f all strke cases in these areas in rder t determine the true incidence f strke as well as the cmparisn f incidence amng Negres and whites; (2) the determinatin f risk factrs assciated Strkt. Vl. I, March-April 7970

12 CEREBROVASCULAR DISEASE MORBIDITY STUDY TABLE 11 Distributin f Other Diseases Listed in Hspital Chart Strke Cases by Area (Ages 45-69) Area Seattle Buffal Nrth Carlina Gergia Suth Carlina I ral strke COM* ,320 Hypertensin DIMOMS ASHD Diab«t« At least ne ,190 Excludes deaths certified by medical examiner (five), cases discharged alive frm hspital but subsequently fund dead in mrtality study (40), and strke n past histry nly Dwnladed frm by n Nvember 16, 2018 with the high incidence f strke in the high strke incidence and mrtality areas; (3) measurement f pssible envirnmental and familial factrs that are assciated with hypertensin in rder t develp prcedures fr primary preventin f elevated bld pressure; (4) better clinical and pathphysilgical crrelatins in rder t determine the type f strke disease, the typgraphical distributin f disease and interrelatinships with the risk factrs. Fr example, a cmparisn f the distributin f significant vascular disease (intracranial and extracranial) amng individuals with strke in different ppulatins wuld be wrthwhile as well as a cmparisn f this distributin in relatin t selected risk factrs such as diabetes, hypertensin and elevated lipids; and (5) clinical trials t measure the effectiveness f reducing the levels f bld pressure and serum lipids n the incidence f strke and heart disease in the cmmunity. References 1. Brhani N: Changes and gegraphic distributin f mrtality frm cerebrvascular diseases. Amer J Pub Health 55: (May) Kuller L, et al: Natinwide cerebrvascular disease mrtality study (I) : Methds and analysis f death certificates. Amer J Epidem 90: (Dec) Kuller L, et al: Natinwide cerebrvascular disease mrtality study (II): Cmparisn f clinical recrds and death certificates. Amer J Epidem 90: (Dec) Kuller L, et al: Natinwide cerebrvascular disease mrtality study (III): Accuracy f the clinical diagnsis f cerebrvascular disease. Amer J Epidem 90: (Dec) Kuller L, et al: Natinwide cerebrvascular disease mrtality study (IV) : Cmparisn f the different clinical types f cerebrvascular disease. Amer J Epidem 90: (Dec) The Framingham Study; an epidemilgical investigatin f cardivascular disease. Mngraph, Sectin 6, Table 7-9, Kurland L, Chi N, Sayre G: Current status f the epidemilgy f cerebrvascular diseases. In Fields WS, Spencer WA (ed) : Strke rehabilitatin: Basic cncepts and research trends. St. Luis, W. H. Green, Inc., chap 1, 3-22, Pell S, D'Alnz C: Cerebrvascular disease in an emplyed ppulatin. Paper presented at Epidemilgical Research Sciety Meeting, Chapel Hill, NC, May 3, Eisenberg H, Mrrisn J, Sullivan P, Fte F: Cerebrvascular accidents. Incidence and survival rates in a defined ppulatin, Middlesex Cunty, Cnnecticut. JAMA 189: (Sept 21) US Bureau f the Census. US Census f Ppulatin 1960: Selected area reprts, State Ecnmic Areas Finl Reprt PC (3)-lA, US Gvernment Printing Office, Washingtn, DC, Kannel W: An epidemilgical study f cerebrvascular disease: Transactins f the fifth cnference. Princetn, NJ, 53-59, 1966 Slrkm, Vl. I, March-April

13 Dwnladed frm by n Nvember 16, Baker A, Resch J: Hypertensin in relatinship t cerebrathersclersis. Minn Med 47: (Oct) Baker A, Flra G, Resch J, Lewensn R: Gegraphic pathlgy f athersclersis: Review f the literature with sme persnal bservatins n cerebral athersclersis. J Chrnic Dis 20: , Jhnsn K, Yan K, Kat H: Cerebral vascular disease in Hirshima, Japan. J Chrnic Dis 20: (July) Katsukl S, Hirta Y: Recent trends in incidence f cerebral hemrrhage and infarctin in Japan. Jap Heart 7: (Jan) Grdn T: Further mrtality experience amng Japanese Americans. Public Health Rep 82: (Nv) Kuller L, Seltser R: Cerebrvascular disease mrtality in Maryland. Amer J Epid 86: (Sept) Cardivascular Disease I960, Data n natinal and state mrtality experience, US Dept HEW, Public Health Service Crnary heart disease in adults. United States , Vital and health statistics, Natinal Center fr Health Statistics, Series II,, McDnugh JR, Hmes C, Stulb S, Garrisn G: Crnary heart disease amng Negres and whites in Evans Cunty, Gergia. J Chrnic Dis 18:4-468 (May) Baker A, lannne A: Cerebrvascular disease I. The large arteries f the circle f Willis. Neurlgy 9: (May) Baker A, lannne A: Cerebrvasculr disease II. The smaller Intracerebral arteries. Neurlgy 9: (June) Baker A, lannne A: Cerebrvascular disease III. The intracerebral arteriles. Neurlgy 9: (July) Russell R: Pathgenesls f primary intracerebral hemrrhage. Cerebral vasculr disease. Sixth Cnference, , Grune & Strattn, NY, Baker A, Kinnard J, lannne A: Cerebrvascular disease VIII. Rle f nutritinal factrs. Neurlgy 1 1 : (May) Addendum AREA 1 FLORIDA HOSPITALS Abbey Hspital Cedars f Lebann Cmmunity Hspital Dctrs Hspital Jacksn Memrial Hspital James Archer Smith Hialeah Hspital Kendall Hspital 98 KULLER, ANDERSON, PETERSON, ET AL. Mercy Hspital Heart Institute Mt. Sinai Hspital Nrth General Nrth Shre Hspital Nrth West Hspital Ostepathic General Hspital Pan American Hspital Saint Francis Suth U.S. Air Frce Hspital Veterans Administratin Hspital Victria Hspital Parkway General (Frmerly Clverleaf) AREA 2 COLORADO HOSPITALS American Medical Center Bethesda Hspital Clrad Psychpathic Hspital General Hspital Fitzsimmns General Hspital General Rse Memrial Hspital Frt Lgan Health Center Lutheran Hspital and Medical Center Mercy Natinal Jewish Hspital Prter's Memrial Hspital St. Luke's Hspital Swedish Medical Center Presbyterian Medical Center University f Clrad, Clrad General Hspital Valley View Cm. Gate's Mutual Benefit Club Mt. Airy Hspital Rcky Mt. Ostepathic St. Jseph's Hspital St. Anthny Beth Israel Graig Rehabilitatin Veterans Administratin Hspital St. Francis Hspital Memrial Hspital AREA 3 KANSAS HOSPITALS Arkansas City Hspital Dechair Hspital Geary Cunty Hspital Greenwd Hspital Newman Memrial Newtn Memrial Onaga Cm. Hspital St. Francis Hspital St. Jseph Hspital St. Mary Hspital-Empria-Lyn Strk; Vl. I, March-April 1970

14 CEREBROVASCULAR DISEASE MORBIDITY STUDY Dwnladed frm by n Nvember 16, 2018 St. Mary Hspital, Manhattan-Riley Strmnt-Vail Hspital Susan B. Allen Memrial Wesley Hspital Veterans Administratin Sedan City Hspital Mrris C. Hspital Memrial Manhattan Irwin Army A.T.S.F., Tpeka, Genn C. Hspital University Medical Center Haistead Hspital Clay C. Hspital Veterans Hspital, Tpeka AREA 5 SEATTLE, WASHINGTON HOSPITALS Dctr's Hspital Grup Health Kirkland Maynard Medical Dental Hspital Nrthgate General Overtake Memrial Prvidence Hspital Rvertn *St. Francis Cabrini Seattle General Stimsn Cbb Hspital Swedish U.S. Public Health Valley General Veterans Administratin Virginia Masn AREA 6 NEW YORK HOSPITALS Buffal Clumbus Millard Fillmre Sisters f Charity Veterans Administratin Deacness Lafayette General Emergency E. J. Meyer Memrial St. Francis Xavier and St. Francis Cabrini are the same Hspital. Rswell Park Buffal General Ken mre Mercy DeGraff Memrial St. Francis Mercy AREA 7 NORTH CAROLINA HOSPITALS Cherry Hspital Cape Fear Eastern, Nrth Carlina 4th Tactical Hspital Wayne Cunty Memrial Wilsn Memrial Walker Memrial AREA 8 GEORGIA HOSPITALS Candler General Hspital Memrial Medical Center Oglethrpe St. Jseph Hspital U.S. Public Health AREA 9 SOUTH CAROLINA HOSPITALS Orangeburg Reg. Hspital St. Eugene Hspital Gergetwn Cunty Memrial Whitten Village Intensive Medical Cllege Hspital Rper Hspital Suth Carlina Baptist Veterans Administratin Hspital Suth Carlina State Hspital McLed Infirmary Tumey Hspital Byerly Hspital Bamberg Cunty Memrial Hspital Ocean View Memrial Hspital Cleman Aimar Wilsn Clinic Hspital Finger Clinic Hspital Marin Cunty Memrial Williamsburg Cunty Memrial Lris Cmmunity Hspital Mullins Hspital Kerchaw Cunty Memrial Aiken Cunty Hspital Clletn Cunty Hspital Lee Cunty Memrial Strke, Vl. I, March-April