From the Center for Stroke Research, Department of Neurology, Henry Ford
Hospital & Health Sciences Center (Detroit Campus of Case Western
University), Detroit, Mich (D.T.); The Computing Center, Bar-ilan University,
Ramat Gan, Israel (S.Y.); and the Department of Epidemiology and Preventive
Medicine, Sackler School of Medicine, Tel-Aviv University and Neufeld Cardiac
Research Institute, Sheba Medical Center, Tel-Hashomer, Israel (U.G.). Dr
Tanne is now at the Department of Neurology, Sheba Medical Center,
Tel-Hashomer, Israel.
Correspondence to U. Goldbourt, PhD, Section of Epidemiology, Neufeld Cardiac Research Institute, Sheba Medical Center, Tel-Hashomer 52621, Israel. E-mail goldbu1{at}ccsg.tau.ac.il
Background—Multinational
comparisons demonstrate marked ethnic and regional variation in stroke
mortality and risk-factor distribution. We assessed the role of
ethnicity and estimated the cumulative effect of multiple risk factors
on long-term ischemic stroke mortality.
Methods and Results—Civil servants and municipal employees
in Israel (n=9734 men; age,
Conclusions—Assessment of multiple risk factors provides useful
quantitative prediction of long-term ischemic stroke mortality
risk. Regional-ethnic variations are consistent with a
hypothesis that other, undetermined inherent genetic or sociocultural
factors act to increase ischemic stroke mortality rates in
immigrants to Israel from the Mideast and northern Africa over that
predicted by conventional risk factors.
© 1998 American Heart Association, Inc.
Clinical Investigation and Reports
Risk Profile and Prediction of Long-Term Ischemic Stroke Mortality
A 21-Year Follow-up in the Israeli Ischemic Heart Disease (IIHD) Project
42 years), chosen by stratified sampling
in 6 prespecified areas of birth (those born in Israel and those who
were immigrants from 5 other regional-ethnic strata), were included in
the Israeli Ischemic Heart Disease (IIHD) Project. Over a
21-year follow-up period, age-adjusted mortality rates per 10 000
person-years attributed to ischemic stroke (n=282;
International Classification of Diseases [ICD]-9 codes 433 to 438)
were higher among immigrants to Israel from northern Africa and the
Mideast (17.1 to 19.0), than from 3 parts of Europe (11.3 to 12.4).
Crude rates per 1000 subjects observed in those born in Asia or Africa
(29.4 to 31.2) exceeded rates predicted by risk-factor profiles (21.4
to 24.9). Adjusted hazard ratios were 3.00 for age (per 10 years), 2.15
for left ventricular hypertrophy, 1.69 for
systolic blood pressure (BP, per 20 mm Hg), 1.86 for
diabetes mellitus, 1.83 for peripheral vascular disease,
1.79 for smoking (>20 cigarettes per day), 1.51 for coronary
heart disease, 1.16 for percent cholesterol contained in
the HDL fraction (%HDL, per 5% decrease), and 1.88 for
diastolic BP (per 12 mm Hg; assessed in an
alternative model). Accounting for regression dilution bias and
assessed from repeat measurements, we found that hazard ratio estimates
associated with diastolic BP, systolic BP, and
percent HDL (per increments described) increased to 3.22, 2.23, and
1.23, respectively. Ischemic stroke mortality rates were
30-fold greater among subjects at the highest versus the lowest
quintile of predicted probability according to risk-factor profiles
(81.2 versus 2.6 per 1000 subjects).
Key Words: cerebrovascular disorders • risk factors • epidemiology • mortality
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