Cardiovascular Disease and Risk Factors in Asiacirc.ahajournals.org/content/circulationaha/118/25/2702...portant issues for CVD prevention in Asia. An extensive article search for

Cardiovascular Disease and Risk Factors in AsiaA Selected Review

Hirotsugu Ueshima, MD; Akira Sekikawa, MD; Katsuyuki Miura, MD;Tanvir Chowdhury Turin, MBBS; Naoyuki Takashima, MD; Yoshikuni Kita, PhD;

Makoto Watanabe, MD; Aya Kadota, MD; Nagako Okuda, MD; Takashi Kadowaki, MD;Yasuyuki Nakamura, MD; Tomonori Okamura, MD

Cardiovascular disease (CVD) prevention in Asia is animportant issue for world health, because half of the

world’s population lives in Asia. Asian countries and regionssuch as Japan, the Republic of Korea, the People’s Republicof China, Hong Kong, Taiwan, and the Kingdom of Thailandhave greater mortality and morbidity from stroke than fromcoronary heart disease (CHD), whereas the opposite is true inWestern countries.1 The reasons why this specific situation isobserved in countries with rapid and early-phase westerniza-tion, such as Japan and South Korea, are very interesting.

The Seven Countries Study conducted by Keys et al2 in1957 found that Japanese populations had lower fat intake,lower serum total cholesterol, and lower CHD than popula-tions in the United States and Scandinavia, in spite of highersmoking rates. The serum total cholesterol level in Japan hasincreased rapidly since World War II in accordance with anincrease in dietary fat intake from 10% of total energy intakeper capita per day to 25%.1,2 Despite this increase, thespecific characteristic of lower CHD incidence and mortalitythan that in Western countries has persisted.3,4 WhetherJapanese people and certain other Asian populations havedifferent risk factors for CHD than Western populations hasbeen a subject of discussion for quite some time.

In this article, we discuss the existence of higher strokerates and lower CHD rates in Asian countries than in Westerncountries and the respective risk factors for this on the basisof extensive reviews of cohort studies. We also discusswhether these risk factors differ from those of Westerncountries. Along with this, we examine the relationshipbetween serum total cholesterol and total stroke and itssubtypes. We also address the emerging problems and im-portant issues for CVD prevention in Asia.

An extensive article search for this review was performedwith a primary focus on cohort studies and researchers’names by country in Asia. For mortality data, statistics wereobtained from the World Health Organization.5

Mortality and Morbidity of Stroke and CHD

MortalityThe available data from the World Health Organization onage-adjusted mortality for men and women combined fromcerebrovascular disease (stroke) and CHD are shown inFigure 1.5 The left panel of Figure 1 shows age-adjustedstroke mortality for some selected Asian countries and someWestern countries, Australia, and New Zealand in 2002 forcomparison. In general, stroke mortality in Asian countriesexcept Japan and Singapore is higher than in Westerncountries; however, it is worth mentioning that Japan had thehighest stroke mortality in the world in 1965. It rapidlydecreased by �80% during the period from 1965 to 1990.1

The present stroke mortality rate in Japan is similar to that inWestern countries. Interestingly, stroke mortality trends inChina and South Korea now show similar characteristics tothe Japanese trend observed in the past. The recent age-adjusted stroke mortality rate in China is reported to bedecreasing in urban areas, whereas in rural areas, mortality isstill increasing or is stable.6 In South Korea, age-adjustedstroke mortality is also decreasing but remains at a higherlevel. Other Asian countries, including Middle Easterncountries, Central Asian countries, and South Asian coun-tries except Singapore, have higher stroke mortality thanWestern countries. Therefore, it can be concluded thatAsian countries in general have higher stroke mortalitythan Western countries.

For age-adjusted CHD mortality, it is of interest that EastAsian countries have lower mortality than other Asian coun-tries, except Thailand. As observed in the Seven CountriesStudy,2 East Asian countries still have lower CHD mortalitythan what is seen in Mediterranean countries.1,2 A largecohort study in China also confirmed that age-adjusted strokemortality was 3 times higher than CHD mortality.3 Therefore,it is a specific characteristic that East Asian countries have

From the Department of Health Science (H.U., A.S., K.M., T.C.T., N.T., Y.K., M.W., A.K., N.O., T.K., Y.N., T.O.), Shiga University of MedicalScience, Tsukinowa-cho Seta, Otsu, Shiga, Japan; Department of Epidemiology (A.S.), Graduate School of Pubic Health, University of Pittsburgh,Pittsburgh, Pa; Department of Preventive Cardiology (M.W., T.O.), National Cardiovascular Center, Suita, Osaka, Japan; and CardiovascularEpidemiology (Y.N.), Kyoto Women’s University, Kyoto, Japan.

The online-only Data Supplement is available with this article at http://circ.ahajournals.org/cgi/content/full/118/25/2702/DC1.Correspondence to Hirotsugu Ueshima, MD, Department of Health Science, Shiga University of Medical Science, Tsukinowa-cho Seta, Otsu, Japan

520-2192. E-mail [email protected](Circulation. 2008;118:2702-2709.)© 2008 American Heart Association, Inc.

Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIRCULATIONAHA.108.790048

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higher stroke mortality but lower CHD mortality than West-ern countries. Other Asian countries have higher CHD andstroke mortality than East Asian countries or Western coun-tries. Central Asian countries that belonged to the past SovietUnion have both the highest age-adjusted stroke mortalityrates and the highest age-adjusted CHD mortality rates of allAsian countries, followed by other Middle East Asian andSouth Asian countries (Figure 1).

Incidence of Stroke and Myocardial InfarctionData on age-adjusted incidence of stroke and myocardialinfarction for men and women 35 to 64 years of age in 1985to 1987 are available from the World Health OrganizationMultinational Monitoring of Trends and Determinants inCardiovascular Disease (MONICA) Project.7,8 Results from aJapanese registration database with the same diagnosticcriteria are compared with the MONICA results in Figures 2and 3. The Japanese data were surveyed during the period1989 to 1993.1 Stroke incidence rates of 6 Japanese popula-tions and 1 Chinese population are scattered in the middlelevels (Figure 2), whereas the incidence of acute myocardialinfarction in China and in 6 Japanese populations was farlower than that of the Western populations (Figure 3). InSouth Korea, it was also observed that stroke incidence washigher than myocardial infarction.9 Thus, East Asian coun-tries, including Japan, have a lower incidence of and mortal-ity from CHD than stroke.

When trends in mortality and incidence of CHD comparedwith stroke are addressed, the diagnostic method used and

improved case findings may have an influence on the statis-tics obtained in less developed countries. However, even ifthis is the case, the specific characteristics in East Asiancountries hold true.

Subtype of StrokeStroke mortality and incidence are higher in East Asian countriesthan in Western countries. In addition, the incidence of hemor-rhagic stroke in East Asian countries is relatively higher than inWestern countries. The ratio of cerebral infarction to cerebralhemorrhage is approximately 2:1 to 3:1 in East Asian countries,whereas it is 5:1 to 10:1 in Western countries (Data SupplementTable I); however, this feature has become less prominent inrecent years because of the decline in hemorrhagic strokeincidence and mortality.1,10 In addition, lacunar stroke is thedominant type of ischemic stroke in Japan,11–13 whereas inWestern countries, large thromboembolic stroke prevails.14,15

Lacunar stroke decreased by �50% in Japan from 1961 to 2000in the Hisayama study16 as a result of blood pressure reductionsand a decreased smoking rate.

Risk Factors for Stroke and CHDSimilar to the well-established traditional risk factors forstroke1,17 and CHD1,2,4,18 in Western countries, hypertension,smoking, and diabetes mellitus (DM) are the main risk factorsfor stroke in Asia.1,17 A large-scale meta-analysis project, theAsia Pacific Cohort Studies Collaboration (APCSC), whichincludes 44 separate cohorts (from mainland China, HongKong, Taiwan, Japan, South Korea, Singapore, Thailand,

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Figure 1. Age-standardized death rates per 100 000 for stroke (left) and CHD (right) across countries in different regions of Asia in2002. Data from the World Health Organization, Department of Measurement and Health Information. Patterns on the bars representdifferent regions: Middle Eastern countries ( ), Central Asian countries (p), South Asian countries ( ), Southeast Asian countries (o),East Asian countries (1), and non-Asian countries (open bars). UAE indicates United Arab Emirates; USA, United States of America;and UK, United Kingdom.

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New Zealand, and Australia) and data from �650 000 indi-viduals, showed that hypertension,19 smoking,20 and DM21

were major risk factors for fatal and nonfatal stroke. How-ever, the APCSC found that the slope of the relationshipbetween blood pressure and fatal and nonfatal stroke wassteeper in Asian countries than in Australia and New Zea-land.19 In addition, the slope of the relationship betweensystolic blood pressure and hemorrhagic stroke was steeperthan that of the relationship between systolic blood pressureand ischemic stroke.19

Serum total cholesterol is a risk factor for CHD in Asiancountries.22,23 It has been clearly shown in Asian cohort studiesthat serum total cholesterol level is positively related to CHDmorbidity and mortality.22,23 Serum total cholesterol was not arisk factor for total stroke,17,24 although it was a weak risk factorfor cerebral infarction,22,25 and low cholesterol was a weak riskfactor for cerebral hemorrhage,24–27 especially in hypertensiveindividuals,24,25 on the basis of observational cohort studies. Onthe other hand, a large, individual-based meta-analysis28 showedthat cholesterol-lowering therapy with statins could prevent totalstroke or ischemic stroke without increasing the rate of hemor-

rhagic stroke. This discrepancy should be studied further toclarify the reasons for it.

In Japan, lacunar stroke is more prevalent than large-arteryatherothrombotic ischemic stroke.11–13 The main risk factorsfor lacunar stroke are hypertension, smoking, and DM,13,14

although the Hisayama study showed that serum total cho-lesterol was also a risk factor for lacunar stroke.13 Large-artery atherothrombotic ischemic stroke may be related toserum total cholesterol; however, this remains to be investi-gated. There are no reports clearly showing a positiverelationship between serum total cholesterol and athero-thrombotic stroke in China and Korea. On the basis ofobservational cohort studies, it is understood that serum totalcholesterol is not a risk factor for total stroke and is even lessimportant for ischemic stroke in East Asian countries.

Smoking is a major risk factor for stroke (total, ischemic,and subarachnoid strokes) and CHD even in Asian coun-tries1,4,17,20,29,30 where CHD is generally lower than in West-ern countries, except Singapore.31 Smoking is not as clearly arisk factor for cerebral hemorrhage20,29 as for subarachnoidhemorrhage and ischemic stroke.30,32,33

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Figure 2. Age-adjusted (35 to 64 years old) stroke incidence from a MONICA study in 1985 to 1987 and a Japanese study (d ) in 1980to 1993. The diagnostic criteria of the MONICA study were used for the Japanese study. Male stroke incidence (left) for the 6 Japanesepopulations and 1 Chinese population (in Beijing, China) showed that rates were intermediate for these populations and much lowerthan that of Finland. The female Beijing population was in the higher group (right). The world standard population was used for the cal-culation of age-adjusted rates for 35- to 64-year-olds. Reprinted with permission from the Japan Atherosclerosis Society.1 FIN-KUOindicates Kuopio Province, Finland; FIN-NKA, North Karelia, Finland; RUS-NOI, Novosibirsk Intervention, Russia; LTU-KAU, Kaunas,Lithuania; FIN-TUL, Turku/Loimaa, Finland; YUG-NOS, Novi Sad, Yugoslavia; JPN-HOKKAIDO, Hokkaido, Japan; JPN-SHIGA, Shiga,Japan; CHN-BEI, Beijing, China; SWE-NSW, Northern Sweden, Sweden; RUS-MOC, Moscow Control, Russia; JPN-AKITA, Akita,Japan; RUS-MOI, Moscow Intervention, Russia; JPN-OKINAWA, Okinawa, Japan; DEN-GLO, Glostrup, Denmark; JPN-NAGANO,Nagano, Japan; GER-KMS, Karl-Marx-Stadt County, Germany; GER-HAC, Halle County, Germany; POL-WAR, Warsaw, Poland; JPN-OSAKA, Osaka, Japan; SWE-GOT, Gothenburg, Sweden; GER-RDM, Rest of DDR (East Germany)-MONICA; GER-RHN, Rhein-NeckarRegion, Germany; and ITA-FRI, Friuli, Italy.

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Burden of Risk Factors for CVD inAsian Populations

Blood Pressure and the Prevalenceof HypertensionBlood pressure is higher and hypertension is more prevalentin East Asia than in South Asia.34 High-quality standardiza-tion for blood pressure measurement is needed for thecomparison of blood pressure levels and for comparison ofthe prevalence of hypertension across countries and popula-tions.35,36 The International Study of Macro- and Micro-Nutrients and Blood Pressure (INTERMAP)36 and severalother studies37–41 found that blood pressure levels and hyper-tension prevalence in the northern part of China were higherthan in the southern part of China. The difference in bloodpressure between the northern and southern populations isexplained in part by the difference in salt consumption.37–41

The relationship between salt consumption and blood pressure inindividuals has been reported from Japan,35,36 China,37–41 andKorea.42

Trends in blood pressure levels reported by the JapaneseNational Nutrition and Health Survey showed that bloodpressure was highest in 1965 and declined substantiallyduring the years 1965 to 1990 for men and women in all agegroups; for instance, an approximately 16-mm Hg decline insystolic blood pressure was recorded in men 60 to 69 yearsold.1 Concomitantly, stroke mortality declined greatly by�80% in Japan from 1965 to 1990.1 Notably, salt consumption

in the northern part of Japan was 26 to 27 g/d, estimated by24-hour urine collection, in the 1950s43 and is now �13 g/d.Current, well-standardized epidemiological studies have shownthat Japanese populations have similar levels of blood pressureas Americans.35,36,44 The International Cooperative Study ofElectrolyte Excretion and Blood Pressure (INTERSALT) andthe INTERMAP study show that salt consumption in northernChinese populations is greater than in Japanese populations.35,36

The Korean population also has a higher salt consumption thanthe Japanese population.35,42 Therefore, high salt consumptionand high blood pressure continue in East Asian countries,although substantial reductions in both have been observed inJapan.1

The APCSC reported that the population-attributable fractionof hypertension for CVD is as high as 60% in Asian countries.45

In addition, the total number of individuals with hypertension inChina and India is expected to increase to �500 million by2025.46 However, awareness of hypertension in Asia is �50%in China and India46 (although not so in Japan), and theserates of awareness are far lower than in Western countries. Inaddition, the treatment rate is lower in Asia, especially inlow-income countries.46 Therefore, we must increase aware-ness of hypertension and implement all possible policies toreduce and prevent it. However, there are several barriers tothis goal, including drug cost, the need for a primaryhealthcare system to identify high-risk individuals, and policybarriers that prevent implementation of programs to lowerblood pressure.46

Figure 3. Age-adjusted (35 to 64 years old) incidence of acute myocardial infarction from a MONICA study in 1985 to 1987 and a Japanesestudy in ( ) 1989 to 1993. The incidence rates of 6 Japanese populations and a single Chinese population were far lower than those ofselected Western countries. The world standard population was used for the calculation of age-adjusted rates for 35- to 64-year-olds.Reprinted with permission from the Japan Atherosclerosis Society.1 UNK-BEL indicates Belfast, United Kingdom; CAN-HAL, Halifax County,Canada; ICE-ICE, Iceland; USA-STA, Stanford (California), United States; CZE-CZE, Czech Republic; NEZ-AUC, Auckland, New Zealand;AUS-PER, Perth, Australia; BEL-GHE, Ghent, Belgium; GER-EGE, East Germany; SWI-TIC, Ticino, Switzerland; FRA-LIL, Lille, France; SWI-VAF, Vaud/Fribourg, Switzerland; SPA-CAT, Catalonia, Spain; JPN-SHIGA, Shiga, Japan; other abbreviations as in Figure 2.




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High Smoking RateThe smoking rate for men in Asian countries (except Singa-pore, Hong Kong, and India) in 2000 remains high at 40% to60%,1,46–49 although it has declined substantially over the last2 decades (Figure 4).8,50–54 The smoking rate for women in allAsian countries is far lower, at 3% to 15%, than in Westerncountries.1,46–49 It is a specific characteristic in Asia thatwomen smoke and drink much less than men.1,46–49

Because smoking is a potent risk factor not only for CHDbut also for stroke, the population-attributable fraction ofsmoking for CVD is high, at 30%, second only to high bloodpressure.45,49 The impact of smoking on the population-attributable fraction in men is much stronger than in women(13% to 27% versus 2% to 7%, respectively, with regard toheart disease),49 although smoking is strongly related to theexcess of cardiovascular mortality and morbidity in both menand women.49,55 The full impact of smoking on CVD mayappear in the future, because the epidemic of smoking is amore recent phenomenon in China than in other Asiancountries, eg, Japan (Figure 4). In any case, quitting smoking,especially among men, could greatly reduce the prevalence ofCVD in Asia.

Increases in Serum Total CholesterolSerum total cholesterol levels in Asian countries are generallylower than in the United States and other Western countries2

(Figure 5). Among Asian countries, the serum total choles-terol level from 1982 to 1985 was highest in Singapore.Age-adjusted CHD mortality in Singapore was also higherthan in East Asian countries.2,4 The serum total cholesterollevel and age-adjusted mortality due to CHD in Singapore havedecreased in recent years.4 Among most other Asian countries,serum total cholesterol increased from �4.1 mmol/L (160mg/dL) to 4.9 mmol/L (190 mg/dL) for middle-aged men,and these increases are similar to those of the Japanese

population from 1970 to 1980.56,57 These increases in serumtotal cholesterol level in Asian countries are compatible withthe increase in intake of total and saturated fat.1,56–58 Total fatintake in the National Nutrition Survey of Singapore in 1998was 31% of total energy intake, whereas that in Japan in 1998was �26%.1,4 Accordingly, the INTERMAP study in 1996 to1999 showed that the fat energy intake of Chinese popula-tions for men 40 to 59 years of age was 20%, whereas it was

Figure 4. Trends in smoking rate by sexand by selected Asian countries. Thesmoking rate for women in Asian countrieswas lower (�10%) than that for men.Among Asian countries, Singapore had thelowest smoking rate for men and women,with a declining smoking rate for men. Thesmoking rate for men in Japan, Korea,China, and Vietnam remains high (over45%), although declining trends are clear.Data were obtained from previousstudies.48,50–54

Figure 5. Serum total cholesterol levels (Serum T-CHOL) formen among Asian populations in 1980 to 2000 and in theUnited States in 1960 to 1991. Serum total cholesterol in Singa-pore was the highest among the selected Asian populations,followed by Hong Kong and Japan. That of Japanese peopleincreased from 1980 to 2000, and currently, young people inJapan have levels similar to their American counterparts; how-ever, there remains a 20-mg/dL difference in serum total choles-terol levels between elderly Japanese and Americans. The levelsof Taiwanese and Korean populations were intermediatebetween those of the Japanese and Chinese. Chinese andsome Korean populations have lower serum total cholesterollevels than other industrialized Asian populations. Reprinted withpermission from Oxford University Press.4




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24% for the Japanese population, 34% for the US population,and 33% for the United Kingdom population.36 The NationalNutrition Survey in South Korea58 showed that average fatintake per capita per day was 19% of total energy intake,which was lower than that in China and Japan.

Prevalence of Glucose Intolerance and DMGlucose intolerance and DM are risk factors for CHD andstroke in Asia, as in Western countries.17 However, Asianpopulations are presently less obese than Western popula-tions; the body mass index is approximately 20 to 24 kg/m2 inAsian but is 26 to 29 kg/m2 in the West.36,58 Because bodymass index is increasing in most Asian countries, the preva-lence of glucose intolerance and DM may increase further.APCSC results show that the hazard ratios of DM forischemic stroke and CHD are similar (�2) for both Asian andWestern countries.21

The prevalence of DM has been increasing throughoutAsia, and the speed of increase is much faster than in Westerncountries. The World Health Organization estimated that of171 million individuals with DM worldwide, �80 millionlived in Asia in 2000.59 The World Health Organizationprojects these numbers will double by the year 2030, with thegreatest increase in Asia. Therefore, we should carefullymonitor obesity trends in Asia that cause DM, metabolicsyndrome, or risk factor clustering for CVD.60

Migrant Studies on CVD, DM, and Atherosclerosisin Asian PopulationsMigrant studies of Asian populations to Western countriesgenerally show increases in CHD, type 2 DM, and athero-sclerosis. Migrant studies of Japanese in the United States, eg,the Honolulu Heart Program, show that Japanese Americanshave higher CHD rates than Japanese people living inJapan,61 whereas stroke rates in Japanese Americans arelower than in the Japanese in Japan and in whites.62 Likewise,migrant studies of Asian Indians show an increase in CHDamong those living in Western countries. Migrant Asianpopulations, including Chinese, Indians, and Japanese, have ahigher prevalence of type 2 DM not only when comparedwith their counterparts in their home countries but alsocompared with whites living in countries where Asians havemigrated.

A recent multiethnic study of 6700 men and women in theUnited States showed that the presence of coronary arterycalcification predicts future CHD similarly in whites andChinese Americans,63 although the latter have lower preva-lence and slower progression of coronary artery calcification.Among men in a post–World War II birth cohort, JapaneseAmericans and whites had a similarly high prevalence ofcoronary artery calcification that was significantly higherthan that in Japanese people living in Japan.64

ConclusionsIn Asian countries, stroke is more prominent than CHD. Thisis most likely due to a higher prevalence of hypertension anda lower level of serum total cholesterol in Asian countries.The population-attributable fraction of hypertension for CVDis as high as 60% in Asian countries. High blood pressure

accompanies high salt intake in East Asia, whereas low serumtotal cholesterol accompanies lower fat intake. Reduction insalt consumption in East Asian countries, including Japan, isimportant for the reduction of CVD, especially stroke. Pre-vention of smoking is also an important strategy for reducingCVD in most Asian countries, especially for men. Thepopulation-attributable fraction of smoking for CVD is�30%. Recent westernization in Asian countries has in-creased fat consumption, which has been followed by anincrease in serum total cholesterol. This may have caused theincrease in CHD in Asian countries. The prevalence ofobesity is also increasing, and this may also increase theprevalence of DM, glucose intolerance, and the metabolicsyndrome. Management of these traditional risk factors forCVD is important for the prevention of CVD in Asian andWestern countries.

AcknowledgmentsWe would like to express our appreciation to Takako Mihara andChiaki Masuda for their clerical assistance.

Sources of FundingThis research was supported by grants A 13307016 from theJapanese Ministry of Education, Culture, Sports, Science, andTechnology and R01 HL68200 and HL071561 from the NationalInstitutes of Health.

DisclosuresNone.

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KEY WORDS: myocardial infarction � epidemiology � cerebrovascular disorders� stroke � risk factors




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Hirotsugu Ueshima, Akira Sekikawa, Katsuyuki Miura, Tanvir Chowdhury Turin, NaoyukiCardiovascular Disease and Risk Factors in Asia: A Selected Review

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1

SUPPLEMENT MATERIAL Online Supplement Table １ Age-adjusted incidence of ischemic and hemorrhagic stroke and its ratio for selected East Asian, Western and Latin American countries Region Survey year Age Incidence (per 100,000)

Ischemic stroke Hemorrhagic

stroke Ratio*

Asian countries Japan Takashima, Shiga1 1989-93 Men 35+ 189.9 58.0 3.3

Women 35+ 94.1 47.5 2.0

Takashima, Shiga2 1989-2000 Men and women, all ages

1131 (number) 352 (number) 3.2

Hisayama Study3 1988-2000, follow-up Men, all ages 357 /1000 P-Y 130 /1000 P-Y 2.7 Women, all ages 260 /1000 P-Y 70 /1000 P-Y 3.7 Akita4 1999-2000 Men, all ages 143 60 2.4 Women, all ages 112 49 2.3 Okinawa5 1988-1991 Men, all ages 75 54 1.4 Women, all ages 38 31 1.2 Yao6 1992-2002 Men, all ages 65 (proportion) 26 (proportion) 2.5 Women, all ages 44 (proportion) 29 (proportion) 1.5 Oyabe7 1988-1998 Men, 35-79 31.3 7.4 4.2 Women, 35-79 10 4.8 2.1

2

Shibata8 1977-1992, follow-up Men, 40+ 3.0 /1000 P-Y 0.7 /1000 P-Y 4.6

Women, 40+ 2.18 /1000 P-Y 1.06 /1000 P-Y 2.1

Korea Korean Medical Insurance9 1990-2002, follow-up Men, 35-59 164 /100000 P-Y 68.4 /100000 P-Y 2.4 China Seven urban centers10 1987-1990, follow-up Men and women, 35+ 221 (number) 203 (number) 1.1 Sino-MONICA11 1984-2004 in 1990 Men, 25-74 93.2 54.7 1.7 Women, 25-74 75.7 45.2 1.7 in 2000 Men, 25-74 176.6 39.4 4.5 Women, 25-74 111.8 28.9 3.9

China Multicenter Collaborative Study12

1991-2000 Men and women, 25+ 49.3 (proportion) 23.9 (proportion) 2.1

Three large cities13 1991-2000 Men and women, 35+ Beijing 90.8 38.1 2.4 Shanghai 40.7 27.1 1.5 Changsha 62.8 77.1 0.8

3

Western countries USA Framingham study14 1965-85, follow-up Men 45-68 66.1 /1000 P-Y 13.8 /1000 P-Y 4.8 Honolulu Heart Program14 1965-85, follow-up Men 45-68 44.3 /1000 P-Y 14.9 /1000 P-Y 3.0 Minnesota Metropolitan Area15

1990 Men 30-74 100 10 10.0

1990 Women 30-74 90 10 9.0 Greater Cincinnati/Northern Kentucky Stroke Study16 1993-94 Black, all ages 226 42 5.4 1999 Black, all ages 219 44 5.0 1993-94 White, all ages 156 20 7.8 1999 White, all ages 181 24 7.5 UK Oxfordshire Community

Stroke Project17 1981-86 Men, all ages 273 29 9.4

Scottish Borders Stroke Study18

1998-2000 Men and women, all ages

197 (Crude) 24 (Crude) 8.2

France Dijon19 Midyear 1984,

follow-up Men and women, 45-84

183 26 7.0

Umbria19 Midyear 1988, follow-up

Men and women, 45-84

294 40 7.4

4

Aosta19 Midyear 1989, follow-up

Men and women, 45-84

287 60 4.8

Denmark Frederiksberg19 Midyear 1989,


339 33 10.3

Sweden Söderhamn19 Midyear 1990,


349 49 7.1

Germany Erlangen Stroke Project20 1994-1996 Men, all ages 119 (Crude) 18 (Crude) 6.6 Women, all ages 154 (Crude) 29 (Crude) 5.3 Australia Perth19 Midyear 1989,


262 26 10.1

Melbourne21 1996-97 Men and women, all ages

58 9 6.4

Latin America Chile22 2000-2002 Men, all ages 63 24.4 2.6 Women, all ages 52 16.1 3.2The rate for Minnesota was estimated from figures taken from the paper. P-Y: Person-year * Ratio is ischemic stroke to hemorrhagic stroke.

5

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