NC JUSTUS WARREN HEART DISEASE AND STROKE PREVENTION TASK FORCE MEETING JANUARY 15,

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1 SAMUEL TCHWENKO, MD, MPH Epidemiology, Evaluation and Surveillance Unit Manager Community and Clinical Connections for Prevention and Health Branch Chronic Disease & Injury Section; Division of Public Health NC Department of Health & Human Services NC JUSTUS WARREN HEART DISEASE AND STROKE PREVENTION TASK FORCE MEETING JANUARY 15,

2 INTRODUCTION MORTALITY MORBIDITY ECONOMIC IMPACT RISK FACTORS DISPARITIES/INEQUITY 2

3 I00-I78 I00-I09, I11, I13, I20-I51 Hypertensive Essential Renal (primary) Disease Hypertension (I12) (I10) Other peripheral vascular diseases (I73) Rheumatic fever with heart involvement (I01) Secondary Rheumatic chorea (I02) Acute pericarditis (I30) Rheumatic mitral valve diseases (I05) Hypertension Pulmonary embolism (I26) Rheumatic aortic valve diseases (I06) Pulmonary valve disorders (I37) (I15) Rheumatic tricuspid valve diseases (I07) Endocarditis, valve unspecified (I38) I60-I69 Multiple valve diseases (I08) Acute myocarditis (I40) Other rheumatic heart diseases (I09) Cardiomyopathy (I42) Subarachnoid haemorrhage (I60) Hypertensive heart disease (I11) Atrio-ventricular and left Intra-cerebral haemorrhage (I61) Hypertensive heart and renal disease (I13) bundle-branch block (I44) Other non-traumatic intracranial haemorrhage (I62) Other pulmonary heart diseases (I27) Other conduction disorders (I45) Cerebral infarction (I63) Other diseases of pulmonary vessels (I28) Cardiac arrest (I46) Stroke, not specified as haemorrage of infarction (I64) Other diseases of pericardium (I31) Paroxysmal tachycardia (I47) Other cerebrovascular diseases (I67) Acute and sub-acute endocarditis (I33) Atrial fibrillation and flutter (I48) Non-rheumatic mitral valve disorders (I34) Other cardiac arrhythmias (I49) Non-rheumatic aortic valve disorders (I35) Complications and ill-defined descriptions Non-rheumatic tricuspid valve disorders (I36) of heart disease (I51) I20-I25 Angina pectoris (I20) Acute myocardial infarction (I21) Subsequent myocardial infarction (I22) Other acute ischaemic heart diseases (I24) Chronic ischaemic heart disease (I25) Q20-Q28 Cardiac chambers and connections (Q20) Cardiac septa (Q21) Pulmonary and tricuspid valves (Q22) Aortic and mitral valves (Q23) Other congenital malformations of heart (Q24) I50 Heart failure(i50) Atherosclerosis (I70) Diseases of the capillaries (I78) Other aneurysm (I72) Other disorders of arteries Arterial and arterioles embolism (I77) and thrombosis (I74) 3

4 U.S. Heart Disease Death Rates and Ranking by State State Age Adjusted Death Rate US Rank Age Adjusted Death Rate US Rank Age Adjusted Death Rate US Rank Age Adjusted Death Rate US Rank Age Adjusted Death Rate 95% Confidence Interval US Rank Indiana South Carolina Pennsylvania Maryland New Jersey Illinois Texas Delaware North Carolina Iowa Wyoming Virginia Rhode Island Wisconsin Kansas Heart Disease: ICD-10 codes I00-I09, I11, I13, I20-I51. Rates per 100,000 population, age-adjusted to the 2000 U.S. standard population. Data Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File, CDC WONDER Online Database. Accessed 08/

5 State U.S. Stroke Death Rates and Ranking by State Age Adjusted Death Rate US Rank Age Adjusted Death Rate US Rank Age Adjusted Death Rate US Rank Age Adjusted Death Rate US Rank Age Adjusted Death Rate 95% Confidence Interval Arkansas Alabama Mississippi Oklahoma Tennessee South Carolina West Virginia Georgia Louisiana North Carolina Indiana Texas Kentucky Missouri North Dakota US Rank Stroke: ICD-10 codes I60-I69. Rates per 100,000 population, age-adjusted to the 2000 U.S. standard population. Data Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File, CDC WONDER Online Database. Accessed 05/

6 US Stroke Death Rates by County, Adults Ages 35+, Stroke Buckle state* Traditional Stroke Belt state** (in addition to Buckle states) Stroke mortality 10% or more higher than national average*** This map was created using the Interactive Atlas of Heart Disease and Stroke, a website developed by the Centers for Disease Control and Prevention, Division for Heart Disease and Stroke Prevention. *Howard G, Anderson R, Johnson NJ, Sorlie P, Russell G, Howard VJ. Evaluation of social status as a contributing factor to the stroke belt region of the United States. Stroke May;28(5): **Howard VJ, Cushman M, Pulley L, Gomez CR, Go RC, Prineas RJ, Graham A, Moy CS, Howard G. The reasons for geographic and racial differences in stroke study: objectives and design. Neuroepidemiology 2005;25(3): Epub 2005 Jun ***Based on National Heart, Lung and Blood Institute criteria cited in: Lanska DJ, Kuller LH. The geography of stroke mortality in the United States and the concept of a stroke belt. Stroke Jul;26(7):

7 Age-Adjusted Death Rate Heart Disease Death Rates, NC vs. US, North Carolina 0 '79 '81 '83 '85 '87 '89 '91 '93 '95 '97 '99 '01 '03 '05 '07 '09 Year United States Heart Disease: : ICD-10 codes I00-I09, I11, I13, I20-I51; : ICD-9 codes , 402, 404, multiplied by comparability ratio of Rates per 100,000 population, age-adjusted to the 2000 U.S. standard population. Data Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File, and CDC WONDER Online Database,

8 Age-adjusted Death Rate Stroke Death Rates N.C. vs. U.S., Health People Target 2020 (33.8) North Carolina United States Health People 2010 Target (50.0) '79 '81 '83 '85 '87 '89 '91 '93 '95 '97 '99 '01 '03 '05 '07 '09 Year Stroke: : ICD-10 codes I60-I69; : ICD-9 codes , multiplied by comparability ratio of Rates per 100,000 population, age-adjusted to the 2000 U.S. standard population. Data Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File, and CDC WONDER Online Database. Accessed 05/

9 Contribution of prevention to decline in CVD mortality About 44% of the reduction in national coronary heart disease mortality that occurred between 1980 and 2000, is attributed to changes in risk factors. Positive contributions: reduction in total cholesterol, systolic blood pressure, smoking and physical inactivity Negative contributions: Increase in diabetes and obesity 47% attributed to treatment Ford ES, Ajani UA, Croft JB, Critchley JA, Labarthe DR, et al. (2007) Explaining the decrease in US deaths from coronary disease, N Engl J Med 356: Detailed technical appendix of model available. 9

10 Percent Premature Major Cardiovascular Disease Deaths, N.C. vs. U.S North Carolina United States 10 '79 '81 '83 '85 '87 '89 '91 '93 '95 '97 '99 '01 '03 '05 '07 '09 Year Premature= Less than 65 years of age. Major Cardiovascular Disease: : ICD-10 codes I00-I78; : ICD-9 codes , Data Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File, and CDC WONDER Online Database,

11 Leading Causes of Death, N.C., 2012 Rank Cause Number % 1 CANCER 18, HEART DISEASE 17, CHRONIC LOWER RESPIRATORY DISEASES 4, STROKE 4, All other unintentional injuries* 2, ALZHEIMER'S DISEASE 2, DIABETES MELLITUS 2, Influenza and pneumonia 1, NEPHRITIS, NEPHROTIC SYNDROME AND NEPHROSIS 1, Unintentional Motor vehicle injuries 1, All other causes (Residual) 23, Total Deaths -- All Causes 81, *Excludes motor vehicle injuries, suicide and homicide. Data Source: North Carolina Division of Public Health, State Center for Health Statistics. NC Vital Statistics Volume 2 Leading Causes of Death Accessed 01/

12 Percent Percentage of Deaths Caused by CVD, N.C., (n=23,150) 36.3 (n=17,579) (n=4,760) (n =23,294) (n=18,520) (n=4,446) (n=25,552) (n=19,838) (n=5,329) (n=25,726) (n=19,649) (n=5,692) * 1990** 1996** 2000** 2010*** Total CVD Stroke Heart Disease (n=23,232) 21.7 (n=17,090) 5.4 (n=4,281) 1996=Establishment of Justus-Warren Task Force *Total CVD estimate is the sum of deaths from diseases of the heart, hypertension, cerebrovascular diseases, and atherosclerosis. **Total CVD estimate is the sum of deaths from diseases of the heart, cerebrovascular diseases, and atherosclerosis. ***Total CVD Deaths includes deaths from ICD-10 codes I00-I99 Data Source: North Carolina Division of Public Health, State Center for Health Statistics. Leading Causes of Death in North Carolina. SCHS Online Database,

13 MORBIDITY Over 655,000 adult North Carolinians (8.9% of the adult population) have a history of either heart attack, angina or stroke Cardiovascular disease is the leading cause of hospitalization in North Carolina 158,196 CVD hospital discharges (about 16.5% of all discharges) in ,599 stroke 104,458 heart disease Heart disease and Stroke are among the top ten leading causes of disability in noninstitutionalized US adults. 13

14 Total Hospital Charges in 2011 Dollars Cardiovascular Disease Hospital Charges, N.C., $6,000,000,000 $5,000,000,000 $4,000,000,000 Total Males Females $3,000,000,000 $2,000,000,000 $1,000,000,000 $0 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 Total Cardiovascular Disease, excluding congenital malformations: ICD-9-CM codes ; Principal diagnosis only. Data Source: North Carolina Division of Public Health, State Center for Health Statistics. North Carolina Inpatient Hospital Discharges, Produced by: State Center for Health Statistics, 06/08/2012. Charges adjusted to 2011 dollars using the Bureau of Labor Statistics Consumer Price Index tables for Medical Care for years , U.S. city average, not seasonally adjusted. Year

15 Hospitalization Charges for Selected Cardiovascular Disease Conditions and Risk Factors, N.C., 2011 DIAGNOSTIC CATEGORY TOTAL CHARGES CASES CHARGE PER CASE HEART DISEASE 4 BILLION 105,219 $38,785 STROKE $864 MILLION 29,265 $29,558 CORONARY HEART DISEASE $2 BILLION 36,891 $52,915 HEART FAILURE $754 MILLION 28,297 $26,662 DIABETES MELLITUS $412 MILLION 18,873 $21,849 ESSENTIAL HYPERTENSION $45 MILLION 3,085 $14,634 *ICD-9 codes: Heart Disease ( , , 402, 404, , & ), Stroke ( ), Coronary Heart Disease ( ), Heart Failure (428), Diabetes Mellitus (250), Essential Hypertension (401). Data Source: North Carolina Division of Public Health, State Center for Health Statistics. Inpatient Hospital Utilization and Charges by Principal Diagnosis (excluding newborns & discharges from out of state hospitals). Data produced on request by NC State Center for Health Statistics, 05/22/

16 Medicaid Costs for Selected Cardiovascular Disease Conditions and Risk Factors, N.C., 2011 DIAGNOSTIC CATEGORY TOTAL CHARGES BENEFICIARIES CHARGE PER CASE HEART DISEASE $231 MILLION 104,566 $2,213 STROKE $177 MILLION 38,808 $4,571 CORONARY HEART DISEASE $71 MILLION 36,548 $1,943 CONGESTIVE HEART FAILURE $75 MILLION 27,771 $2,701 DIABETES MELLITUS $171 MILLION 113,608 $1,508 ESSENTIAL HYPERTENSION $175 MILLION 160,196 $1,093 *ICD-9 codes: Heart Disease ( , , 402, 404, , & ), Stroke ( ), Coronary Heart Disease ( ), Heart Failure (428), Diabetes Mellitus (250), Essential Hypertension (401). Data Source: North Carolina Division of Public Health, State Center for Health Statistics. Medicaid Costs by Principal Diagnosis. 16 Data produced on request by NC State Center for Health Statistics, 05/22/2013.

17 RISK FACTORS Worldwide, nine risk factors account for more than 90% of the risk of initial heart attacks and strokes (INTERHEART & INTERSTROKE studies): 1. Hypertension 2. Current smoking 3. Obesity 4. Unhealthy diet 5. Physical inactivity 6. Diabetes 7. Alcohol intake 8. Psychosocial factors (psychological stress, financial stress, major adverse life events, locus of control, depression) 9. Abnormal lipids (e.g. cholesterol) O'Donnell MJ, Xavier D, Liu L, et al. Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): A case-control study. Lancet. 2010;376(9735): doi: /S (10) Yusuf S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet 2004; 364:

18 High blood pressure RISK FACTORS Primary or contributing cause for 45% of all CVD deaths If completely eliminated from the population, there will be 34.6% fewer cases of stroke and 17.9% fewer cases of myocardial infarction Responsible for about 45% of all strokes occurring in hypertensive individuals IOM (Institute of Medicine) A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension. 18

19 Percent CVD Modifiable Risk Factors, N.C., Fruit, vegetables, or beans (less than 5+ servings a day) Overweight & Obese Did not meet aerobic PA recommendations* High Cholesterol Hypertension Current Smoker Diabetes Adults=18+; *PA = Physical activity Data Source: North Carolina Behavioral Risk Factor Surveillance System Online: Accessed 05/

20 DISPARITIES/NON-MODIFIABLE RISK FACTORS Race/Ethnicity: African Americans are more likely to suffer overall and premature mortality and morbidity from CVD compared to Whites Gender: Men are more like to have or die from CVD and at an earlier age (<55 years) than women Age: Risk of CVD increases with age irrespective of the presence of potentially modifiable risk factors Geographical location: The eastern part of NC has a greater burden of CVD (especially stroke) 20

21 Age-adjusted Death Rate Major Cardiovascular Disease Death Rates by Race and Gender, N.C., African-American Males African-American Females White Males White Females '79 '81 '83 '85 '87 '89 '91 '93 '95 '97 '99 '01 '03 '05 '07 '09 Year Major Cardiovascular Disease: : ICD-10 codes I00-I78; : ICD-9 codes , multiplied by comparability ratio of Rates per 100,000 population, age-adjusted to the 2000 U.S. standard population. Data Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File, and CDC WONDER Online Database,

22 Percent CVD Modifiable Risk Factors by Race and Ethnicity, N.C., 2011 White Black American Indian Hispanic Overweight & High Cholesterol Hypertension Physical Inactivity* Current Smoker Diabetes Obese Adults=18+ *Physical Inactivity=Respondent answered No to During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise? Data Source: North Carolina Division of Public Health, State Center for Health Statistics. North Carolina Behavioral Risk Factor Surveillance System, Extracted by: Heart Disease and Stroke Branch: 10/16/2012.

23 Stroke Death Rates by County of Residence, N.C., Death Rate Unreliable Rate (<20 Deaths) Unreliable Rate (<50 Deaths) Stroke Buckle County* N.C. overall: 46.0 Eastern NC County not included as part of the Stroke Buckle* Non-Eastern NC County included as part of the Stroke Buckle * *Howard G, Evans GW, Pearce K, Howard VJ, Bell RA, Mayer EJ, Burke GL. Is the Stroke Belt Disappearing?: An Analysis of Racial, Temporal, and Age Effects. Stroke. 1995;26(7): ; Howard G, Anderson R, Johnson NJ, Sorlie P, Russell G, Howard VJ. Evaluation of social status as a contributing factor to the stroke belt region of the United States. Stroke May;28(5): Stroke: ICD-10 codes I60-I69. Rates per 100,000 population, age-adjusted to the 2000 U.S. standard population. Data Source: North Carolina Division of Public Health, State Center for Health Statistics. Volume 2: Leading Causes of Death in 23 North Carolina 2011, SCHS Online Database. Accessed 02/2013.

24 Stroke Hospital Discharge Rates by County of Residence, N.C., Hospital Discharge Rate Stroke Buckle County* N.C. overall: Eastern NC County not included as part of the Stroke Buckle* Non-Eastern NC County included as part of the Stroke Buckle * *Howard G, Evans GW, Pearce K, Howard VJ, Bell RA, Mayer EJ, Burke GL. Is the Stroke Belt Disappearing?: An Analysis of Racial, Temporal, and Age Effects. Stroke. 1995;26(7): ; Howard G, Anderson R, Johnson NJ, Sorlie P, Russell G, Howard VJ. Evaluation of social status as a contributing factor to the stroke belt region of the United States. Stroke May;28(5): Stroke: ICD-9-CM codes ; Principal diagnosis only; N.C. residents only. Discharge rates per 100,000 population age-adjusted to the U.S standard population. Data Source: North Carolina Division of Public Health, State Center for Health Statistics. North Carolina Inpatient 24 Hospital Discharges, Data produced on request by NC State Center for Health Statistics, 06/08/2012.

25 Heart Disease Death Rates by County of Residence, N.C., Death Rate N.C. overall: Heart Disease: ICD-10 codes I00-I09, I11, I13, I20-I51. Rates per 100,000 population, age-adjusted to the 2000 U.S. standard population. N.C. Data Source: North Carolina Division of Public Health, State Center for Health Statistics. Volume 2: Leading Causes of Death in North Carolina 2010, U.S. Data Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File, CDC WONDER Online Database,

26 Heart Disease Hospital Discharge Rates by County of Residence, N.C., Hospital Discharge Rate N.C. overall: Heart Disease: ICD-9-CM codes: , , 402, 404, , ; Principal diagnosis only; N.C. residents only. Discharge rates per 100,000 population age-adjusted to the U.S standard population. Data Source: North Carolina Division of Public Health, State Center for Health Statistics. North Carolina Inpatient Hospital Discharges, Produced by: State Center for Health Statistics, 06/08/2012.

27 Clues to Underlying Causes of Racial and Geographic Disparities in Stroke Mortality The Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study Designed with the primary aim of documenting and finding possible explanations for geographic (Stroke belt and buckle vs. rest of the US) and racial/ethnic (African-American vs. White) differences in stroke 1 Full list of publications from the REGARDS study could be found at: 1. Howard VJ, Cushman M, Pulley L, Gomez C, Go R, Prineas RJ, Graham A, Moy CS, Howard G. The REasons for Geographic And Racial Differences in Stroke (REGARDS) Study: Objectives and design. Neuroepidemiology 2005;25:

28 Clues to Underlying Causes of Racial and Geographic Disparities in Stroke Mortality Racial Disparities Geography (some of the excess stroke mortality traditionally attributed to race is due to geography) 1 Variation in traditional risk factors such as hypertension, systolic blood pressure, diabetes, smoking and left ventricular hypertrophy and socioeconomic factors 2,3 Incidence of strokes 4 Blood pressure control 5 Prevalence, awareness and control of dyslipidemia 6 Prophylactic aspirin therapy 7 Awareness and treatment of Atrial Fibrillation 8 Fish consumption 9 Nutrient intake 10 Overall diet profile 11 Impact of elevated blood pressure 12 28

29 Clues to Underlying Causes of Racial and Geographic Disparities in Stroke Mortality Racial Disparities - References 1. Yang D, Howard G, Coffey CS, Roseman J. The confounding of race and geography: how much of the excess stroke mortality among African Americans is explained by geography? Neuroepidemiology 2004:23: Howard G, Cushman M, Kissela BM, Kleindorfer DO, McClure LA, Safford MM, Rhodes JD, Soliman EZ, Moy CS, Judd SE, Howard VJ. Traditional risk factors as the underlying cause of racial disparities in stroke: lessons from the half full (empty?) glass. Stroke 2011 Dec;42(12): Cushman M, Cantrell RA, McClure LA, Howard G, Prineas RJ, Moy CS, Temple EM, Howard VJ. Estimated 10-year stroke risk by region and race in the United States: Geographic and racial differences in stroke risk. Annals of Neurol 2008; 64: Howard VJ, Kleindorfer DO, Judd SE, McClure LA, Safford MM, Rhodes JD, Cushman M, Moy CS, Soliman EZ, Kissela BM, Howard G. Disparities in stroke incidence contributing to disparities in stroke mortality. Ann Neurol 2011;69: Howard G, Prineas R, Moy C, Cushman M, Kellum M, Temple E, Graham A, Howard V. Racial and geographical differences in awareness, treatment and control of hypertension. The REasons for Geographic And Racial Differences in Stroke (REGARDS) Study. Stroke 2006;37: Zweifler RM, McClure LA, Howard VJ, Cushman M, Hovater M, Safford MM, Howard G, Goff D Jr. Racial and geographic differences in prevalence, awareness, treatment and control of dyslipidemia: The Reasons for Geographic And Racial Differences in Stroke (REGARDS) Study. Neuroepid 2011 Aug 5;37(1): Glasser SP, Cushman M, Prineas R, Kleindorfer D, Prince V, You Z, Howard VJ, Howard G. Does differential prophylactic aspirin use contribute to racial and geographic disparities in stroke and coronary heart disease (CHD)? Preventive Medicine 2008;47: Meschia JF, Merril P, Soliman EZ, Howard VJ, Barrett KM, Zakai NA, Kleindorfer D, Safford M, Howard G. Racial disparities in awareness and treatment of atrial fibrillation: The Reasons for Geographic and Racial Differences in Stroke (REGARDS) study. Stroke 2010;41: Nahab F, Le A, Judd S, Frankel MR, Ard J, Newby PK, Howard VJ. Racial and geographic differences in fish consumption: The REGARDS study. Neurology 2011:75: Newby PK, Noel SE, Grant R, Judd S, Shikany JM, Ard J. Race and region are associated with nutrient intakes among black and white men in the United States. J Nutr 2011;141: Judd SE, Gutierrez O, Kissela BM, Howard G, Locher J, Howard VJ, Newby PK, Shikany JM. Southern Diet Pattern Increases Risk Of Stroke While Plant-based Pattern Decreases Risk Of Stroke in the REGARDS Study. Stroke 2013;44:A Howard, G., Lackland, D. T., Kleindorfer, D. O., Kissela, B. M., Moy, C. S., Judd, S. E., et al.. (2013). Racial differences in the impact of elevated systolic blood pressure on stroke risk. JAMA Intern Med, 173(1), presented at the 2013 Jan 14. doi: /2013.jamainternmed

30 Clues to underlying causes of Racial and Geographic Disparities in Stroke Mortality Geographic Disparities Age and duration of stay in the Stroke Belt 1,2 Variations in prevalence of diabetes 3 Fish consumption 4 Nutrient intake 5 Overall diet profile 6 Evaluation of strokes at Primary Stroke Centers 7 1. Howard VJ, McCLure LA, Glymour M, Cunningham SA, Kleindorfer, Crowe M, Bradley VG, Peace F, Howard G, Lackland DT. The effect of duration and age at exposure to the stroke belt on incident stroke in adulthood. Neurology, 2013 in press. 2. Howard VJ, Woolson RF, Egan BM, Nicholas JS, Adams RJ, Howard G, Lackland DT. Prevalence of hypertension in a US cohort by duration and age at exposure to the stroke belt. J of Am Soc Hypertens 2010;4: Voeks J, McClure, Go R, Prineas R, Cushman M, Kissela B, Roseman J. Regional differences in diabetes as a possible contributor to the geographic disparity in stroke mortality: The REasons for Geographic and Racial Differences in Stroke Study. Stroke 2008;39: Nahab F, Le A, Judd S, Frankel MR, Ard J, Newby PK, Howard VJ. Racial and geographic differences in fish consumption: The REGARDS study. Neurology 2011:75: Newby PK, Noel SE, Grant R, Judd S, Shikany JM, Ard J. Race and region are associated with nutrient intakes among black and white men in the United States. J Nutr 2011;141: Judd SE, Gutierrez O, Kissela BM, Howard G, Locher J, Howard VJ, Newby PK, Shikany JM. Southern Diet Pattern Increases Risk Of Stroke While Plant-based Pattern Decreases Risk Of Stroke in the REGARDS Study. Stroke 2013;44:A Mullen, M. T., Judd, S., Howard, V. J., Kasner, S. E., Branas, C. C., Albright, K. C., et al.. (2013). Disparities in evaluation at certified primary stroke centers: reasons for geographic and racial differences in stroke. Stroke, 44(7), presented at the 2013 Jul. 30 doi: /strokeaha

31 THANK YOU 31