Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): A case-control study

Martin J. O'Donnell, Xavier Denis, Lisheng Liu, Hongye Zhang, Siu Lim Chin, Purnima Rao-Melacini, Sumathy Rangarajan, Shofiqul Islam, Prem Pais, Matthew J. McQueen, Charles Mondo, Albertino Damasceno, Patricio Lopez-Jaramillo, Graeme J. Hankey, Antonio L. Dans, Khalid Yusoff, Thomas Truelsen, Hans Christoph Diener, Ralph L Sacco, Danuta RyglewiczAnna Czlonkowska, Christian Weimar, Xingyu Wang, Salim Yusuf

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Abstract

Background The contribution of various risk factors to the burden of stroke worldwide is unknown, particularly in countries of low and middle income. We aimed to establish the association of known and emerging risk factors with stroke and its primary subtypes, assess the contribution of these risk factors to the burden of stroke, and explore the differences between risk factors for stroke and myocardial infarction. Methods We undertook a standardised case-control study in 22 countries worldwide between March 1, 2007, and April 23, 2010. Cases were patients with acute first stroke (within 5 days of symptoms onset and 72 h of hospital admission). Controls had no history of stroke, and were matched with cases for age and sex. All participants completed a structured questionnaire and a physical examination, and most provided blood and urine samples. We calculated odds ratios (ORs) and population-attributable risks (PARs) for the association of all stroke, ischaemic stroke, and intracerebral haemorrhagic stroke with selected risk factors. Findings In the first 3000 cases (n=2337, 78%, with ischaemic stroke; n=663, 22%, with intracerebral haemorrhagic stroke) and 3000 controls, significant risk factors for all stroke were: history of hypertension (OR 2·64, 99% CI 2·26-3·08; PAR 34·6%, 99% CI 30·4-39·1); current smoking (2·09, 1·75-2·51; 18·9%, 15·3-23·1); waist-to-hip ratio (1·65, 1·36-1·99 for highest vs lowest tertile; 26·5%, 18·8-36·0); diet risk score (1·35, 1·11-1·64 for highest vs lowest tertile; 18·8%, 11·2-29·7); regular physical activity (0·69, 0·53-0·90; 28·5%, 14·5-48·5); diabetes mellitus (1·36, 1·10-1·68; 5·0%, 2·6-9·5); alcohol intake (1·51, 1·18-1·92 for more than 30 drinks per month or binge drinking; 3·8%, 0·9-14·4); psychosocial stress (1·30, 1·06- 1·60; 4·6%, 2·1-9·6) and depression (1·35, 1·10-1·66; 5·2%, 2·7-9·8); cardiac causes (2·38, 1·77-3·20; 6·7%, 4·8-9·1); and ratio of apolipoproteins B to A1 (1·89, 1·49-2·40 for highest vs lowest tertile; 24·9%, 15·7-37·1). Collectively, these risk factors accounted for 88·1% (99% CI 82·3-92·2) of the PAR for all stroke. When an alternate definition of hypertension was used (history of hypertension or blood pressure >160/90 mm Hg), the combined PAR was 90·3% (85·3-93·7) for all stroke. These risk factors were all significant for ischaemic stroke, whereas hypertension, smoking, waist-to-hip ratio, diet, and alcohol intake were significant risk factors for intracerebral haemorrhagic stroke. Interpretation Our findings suggest that ten risk factors are associated with 90% of the risk of stroke. Targeted interventions that reduce blood pressure and smoking, and promote physical activity and a healthy diet, could substantially reduce the burden of stroke. Funding Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Canadian Stroke Network, Pfizer Cardiovascular Award, Merck, AstraZeneca, and Boehringer Ingelheim.

Original languageEnglish
Pages (from-to)112-123
Number of pages12
JournalThe Lancet
Volume376
Issue number9735
DOIs
StatePublished - Jun 18 2010

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Case-Control Studies
Stroke
Hypertension
Waist-Hip Ratio
Smoking
Population
Odds Ratio
Alcohols
Diet
Blood Pressure
Binge Drinking
Apolipoproteins B
Physical Examination
Canada

ASJC Scopus subject areas

  • Medicine(all)

Cite this

O'Donnell, M. J., Denis, X., Liu, L., Zhang, H., Chin, S. L., Rao-Melacini, P., ... Yusuf, S. (2010). Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): A case-control study. The Lancet, 376(9735), 112-123. https://doi.org/10.1016/S0140-6736(10)60834-3

Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study) : A case-control study. / O'Donnell, Martin J.; Denis, Xavier; Liu, Lisheng; Zhang, Hongye; Chin, Siu Lim; Rao-Melacini, Purnima; Rangarajan, Sumathy; Islam, Shofiqul; Pais, Prem; McQueen, Matthew J.; Mondo, Charles; Damasceno, Albertino; Lopez-Jaramillo, Patricio; Hankey, Graeme J.; Dans, Antonio L.; Yusoff, Khalid; Truelsen, Thomas; Diener, Hans Christoph; Sacco, Ralph L; Ryglewicz, Danuta; Czlonkowska, Anna; Weimar, Christian; Wang, Xingyu; Yusuf, Salim.

In: The Lancet, Vol. 376, No. 9735, 18.06.2010, p. 112-123.

Research output: Contribution to journalArticle

O'Donnell, MJ, Denis, X, Liu, L, Zhang, H, Chin, SL, Rao-Melacini, P, Rangarajan, S, Islam, S, Pais, P, McQueen, MJ, Mondo, C, Damasceno, A, Lopez-Jaramillo, P, Hankey, GJ, Dans, AL, Yusoff, K, Truelsen, T, Diener, HC, Sacco, RL, Ryglewicz, D, Czlonkowska, A, Weimar, C, Wang, X & Yusuf, S 2010, 'Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): A case-control study', The Lancet, vol. 376, no. 9735, pp. 112-123. https://doi.org/10.1016/S0140-6736(10)60834-3
O'Donnell, Martin J. ; Denis, Xavier ; Liu, Lisheng ; Zhang, Hongye ; Chin, Siu Lim ; Rao-Melacini, Purnima ; Rangarajan, Sumathy ; Islam, Shofiqul ; Pais, Prem ; McQueen, Matthew J. ; Mondo, Charles ; Damasceno, Albertino ; Lopez-Jaramillo, Patricio ; Hankey, Graeme J. ; Dans, Antonio L. ; Yusoff, Khalid ; Truelsen, Thomas ; Diener, Hans Christoph ; Sacco, Ralph L ; Ryglewicz, Danuta ; Czlonkowska, Anna ; Weimar, Christian ; Wang, Xingyu ; Yusuf, Salim. / Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study) : A case-control study. In: The Lancet. 2010 ; Vol. 376, No. 9735. pp. 112-123.
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title = "Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): A case-control study",
abstract = "Background The contribution of various risk factors to the burden of stroke worldwide is unknown, particularly in countries of low and middle income. We aimed to establish the association of known and emerging risk factors with stroke and its primary subtypes, assess the contribution of these risk factors to the burden of stroke, and explore the differences between risk factors for stroke and myocardial infarction. Methods We undertook a standardised case-control study in 22 countries worldwide between March 1, 2007, and April 23, 2010. Cases were patients with acute first stroke (within 5 days of symptoms onset and 72 h of hospital admission). Controls had no history of stroke, and were matched with cases for age and sex. All participants completed a structured questionnaire and a physical examination, and most provided blood and urine samples. We calculated odds ratios (ORs) and population-attributable risks (PARs) for the association of all stroke, ischaemic stroke, and intracerebral haemorrhagic stroke with selected risk factors. Findings In the first 3000 cases (n=2337, 78{\%}, with ischaemic stroke; n=663, 22{\%}, with intracerebral haemorrhagic stroke) and 3000 controls, significant risk factors for all stroke were: history of hypertension (OR 2·64, 99{\%} CI 2·26-3·08; PAR 34·6{\%}, 99{\%} CI 30·4-39·1); current smoking (2·09, 1·75-2·51; 18·9{\%}, 15·3-23·1); waist-to-hip ratio (1·65, 1·36-1·99 for highest vs lowest tertile; 26·5{\%}, 18·8-36·0); diet risk score (1·35, 1·11-1·64 for highest vs lowest tertile; 18·8{\%}, 11·2-29·7); regular physical activity (0·69, 0·53-0·90; 28·5{\%}, 14·5-48·5); diabetes mellitus (1·36, 1·10-1·68; 5·0{\%}, 2·6-9·5); alcohol intake (1·51, 1·18-1·92 for more than 30 drinks per month or binge drinking; 3·8{\%}, 0·9-14·4); psychosocial stress (1·30, 1·06- 1·60; 4·6{\%}, 2·1-9·6) and depression (1·35, 1·10-1·66; 5·2{\%}, 2·7-9·8); cardiac causes (2·38, 1·77-3·20; 6·7{\%}, 4·8-9·1); and ratio of apolipoproteins B to A1 (1·89, 1·49-2·40 for highest vs lowest tertile; 24·9{\%}, 15·7-37·1). Collectively, these risk factors accounted for 88·1{\%} (99{\%} CI 82·3-92·2) of the PAR for all stroke. When an alternate definition of hypertension was used (history of hypertension or blood pressure >160/90 mm Hg), the combined PAR was 90·3{\%} (85·3-93·7) for all stroke. These risk factors were all significant for ischaemic stroke, whereas hypertension, smoking, waist-to-hip ratio, diet, and alcohol intake were significant risk factors for intracerebral haemorrhagic stroke. Interpretation Our findings suggest that ten risk factors are associated with 90{\%} of the risk of stroke. Targeted interventions that reduce blood pressure and smoking, and promote physical activity and a healthy diet, could substantially reduce the burden of stroke. Funding Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Canadian Stroke Network, Pfizer Cardiovascular Award, Merck, AstraZeneca, and Boehringer Ingelheim.",
author = "O'Donnell, {Martin J.} and Xavier Denis and Lisheng Liu and Hongye Zhang and Chin, {Siu Lim} and Purnima Rao-Melacini and Sumathy Rangarajan and Shofiqul Islam and Prem Pais and McQueen, {Matthew J.} and Charles Mondo and Albertino Damasceno and Patricio Lopez-Jaramillo and Hankey, {Graeme J.} and Dans, {Antonio L.} and Khalid Yusoff and Thomas Truelsen and Diener, {Hans Christoph} and Sacco, {Ralph L} and Danuta Ryglewicz and Anna Czlonkowska and Christian Weimar and Xingyu Wang and Salim Yusuf",
year = "2010",
month = "6",
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doi = "10.1016/S0140-6736(10)60834-3",
language = "English",
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pages = "112--123",
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TY - JOUR

T1 - Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study)

T2 - A case-control study

AU - O'Donnell, Martin J.

AU - Denis, Xavier

AU - Liu, Lisheng

AU - Zhang, Hongye

AU - Chin, Siu Lim

AU - Rao-Melacini, Purnima

AU - Rangarajan, Sumathy

AU - Islam, Shofiqul

AU - Pais, Prem

AU - McQueen, Matthew J.

AU - Mondo, Charles

AU - Damasceno, Albertino

AU - Lopez-Jaramillo, Patricio

AU - Hankey, Graeme J.

AU - Dans, Antonio L.

AU - Yusoff, Khalid

AU - Truelsen, Thomas

AU - Diener, Hans Christoph

AU - Sacco, Ralph L

AU - Ryglewicz, Danuta

AU - Czlonkowska, Anna

AU - Weimar, Christian

AU - Wang, Xingyu

AU - Yusuf, Salim

PY - 2010/6/18

Y1 - 2010/6/18

N2 - Background The contribution of various risk factors to the burden of stroke worldwide is unknown, particularly in countries of low and middle income. We aimed to establish the association of known and emerging risk factors with stroke and its primary subtypes, assess the contribution of these risk factors to the burden of stroke, and explore the differences between risk factors for stroke and myocardial infarction. Methods We undertook a standardised case-control study in 22 countries worldwide between March 1, 2007, and April 23, 2010. Cases were patients with acute first stroke (within 5 days of symptoms onset and 72 h of hospital admission). Controls had no history of stroke, and were matched with cases for age and sex. All participants completed a structured questionnaire and a physical examination, and most provided blood and urine samples. We calculated odds ratios (ORs) and population-attributable risks (PARs) for the association of all stroke, ischaemic stroke, and intracerebral haemorrhagic stroke with selected risk factors. Findings In the first 3000 cases (n=2337, 78%, with ischaemic stroke; n=663, 22%, with intracerebral haemorrhagic stroke) and 3000 controls, significant risk factors for all stroke were: history of hypertension (OR 2·64, 99% CI 2·26-3·08; PAR 34·6%, 99% CI 30·4-39·1); current smoking (2·09, 1·75-2·51; 18·9%, 15·3-23·1); waist-to-hip ratio (1·65, 1·36-1·99 for highest vs lowest tertile; 26·5%, 18·8-36·0); diet risk score (1·35, 1·11-1·64 for highest vs lowest tertile; 18·8%, 11·2-29·7); regular physical activity (0·69, 0·53-0·90; 28·5%, 14·5-48·5); diabetes mellitus (1·36, 1·10-1·68; 5·0%, 2·6-9·5); alcohol intake (1·51, 1·18-1·92 for more than 30 drinks per month or binge drinking; 3·8%, 0·9-14·4); psychosocial stress (1·30, 1·06- 1·60; 4·6%, 2·1-9·6) and depression (1·35, 1·10-1·66; 5·2%, 2·7-9·8); cardiac causes (2·38, 1·77-3·20; 6·7%, 4·8-9·1); and ratio of apolipoproteins B to A1 (1·89, 1·49-2·40 for highest vs lowest tertile; 24·9%, 15·7-37·1). Collectively, these risk factors accounted for 88·1% (99% CI 82·3-92·2) of the PAR for all stroke. When an alternate definition of hypertension was used (history of hypertension or blood pressure >160/90 mm Hg), the combined PAR was 90·3% (85·3-93·7) for all stroke. These risk factors were all significant for ischaemic stroke, whereas hypertension, smoking, waist-to-hip ratio, diet, and alcohol intake were significant risk factors for intracerebral haemorrhagic stroke. Interpretation Our findings suggest that ten risk factors are associated with 90% of the risk of stroke. Targeted interventions that reduce blood pressure and smoking, and promote physical activity and a healthy diet, could substantially reduce the burden of stroke. Funding Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Canadian Stroke Network, Pfizer Cardiovascular Award, Merck, AstraZeneca, and Boehringer Ingelheim.

AB - Background The contribution of various risk factors to the burden of stroke worldwide is unknown, particularly in countries of low and middle income. We aimed to establish the association of known and emerging risk factors with stroke and its primary subtypes, assess the contribution of these risk factors to the burden of stroke, and explore the differences between risk factors for stroke and myocardial infarction. Methods We undertook a standardised case-control study in 22 countries worldwide between March 1, 2007, and April 23, 2010. Cases were patients with acute first stroke (within 5 days of symptoms onset and 72 h of hospital admission). Controls had no history of stroke, and were matched with cases for age and sex. All participants completed a structured questionnaire and a physical examination, and most provided blood and urine samples. We calculated odds ratios (ORs) and population-attributable risks (PARs) for the association of all stroke, ischaemic stroke, and intracerebral haemorrhagic stroke with selected risk factors. Findings In the first 3000 cases (n=2337, 78%, with ischaemic stroke; n=663, 22%, with intracerebral haemorrhagic stroke) and 3000 controls, significant risk factors for all stroke were: history of hypertension (OR 2·64, 99% CI 2·26-3·08; PAR 34·6%, 99% CI 30·4-39·1); current smoking (2·09, 1·75-2·51; 18·9%, 15·3-23·1); waist-to-hip ratio (1·65, 1·36-1·99 for highest vs lowest tertile; 26·5%, 18·8-36·0); diet risk score (1·35, 1·11-1·64 for highest vs lowest tertile; 18·8%, 11·2-29·7); regular physical activity (0·69, 0·53-0·90; 28·5%, 14·5-48·5); diabetes mellitus (1·36, 1·10-1·68; 5·0%, 2·6-9·5); alcohol intake (1·51, 1·18-1·92 for more than 30 drinks per month or binge drinking; 3·8%, 0·9-14·4); psychosocial stress (1·30, 1·06- 1·60; 4·6%, 2·1-9·6) and depression (1·35, 1·10-1·66; 5·2%, 2·7-9·8); cardiac causes (2·38, 1·77-3·20; 6·7%, 4·8-9·1); and ratio of apolipoproteins B to A1 (1·89, 1·49-2·40 for highest vs lowest tertile; 24·9%, 15·7-37·1). Collectively, these risk factors accounted for 88·1% (99% CI 82·3-92·2) of the PAR for all stroke. When an alternate definition of hypertension was used (history of hypertension or blood pressure >160/90 mm Hg), the combined PAR was 90·3% (85·3-93·7) for all stroke. These risk factors were all significant for ischaemic stroke, whereas hypertension, smoking, waist-to-hip ratio, diet, and alcohol intake were significant risk factors for intracerebral haemorrhagic stroke. Interpretation Our findings suggest that ten risk factors are associated with 90% of the risk of stroke. Targeted interventions that reduce blood pressure and smoking, and promote physical activity and a healthy diet, could substantially reduce the burden of stroke. Funding Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Canadian Stroke Network, Pfizer Cardiovascular Award, Merck, AstraZeneca, and Boehringer Ingelheim.

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