Hoang T Phan1, Christopher L Blizzard1, Mathew J Reeves1, Amanda G Thrift1, Dominique Cadilhac1, Jonathan Sturm1, Emma Heeley1, Petr Otahal1, Vemmos Konstantinos1, Craig Anderson1, Priya Parmar1, Rita Krishnamurthi1, Suzanne Barker-Collo1, Valery Feigin1, Yannick Bejot1, Norberto L Cabral1, Antonio Carolei1, Simona Sacco1, Nicolas Chausson1, Stephane Olindo1, Peter Rothwell1, Carolina Silva1, Manuel Correia1, Rui Magalhães1, Peter Appelros1, Janika Kõrv1, Riina Vibo1, Cesar Minelli1, Seana Gall2. 1. From the Menzies Institute for Medical Research Tasmania, University of Tasmania, Hobart, Australia (H.T.P., C.L.B., P.O., S.G.); Department of Health Management and Health Economics, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam (H.T.P.); Department of Epidemiology and Biostatistics, Michigan State University, East Lansing (M.J.R.); Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia (A.G.T., D.C.); Florey Institute Neuroscience and Mental Health, Heidelberg, University of Melbourne, Victoria, Australia (D.C.); Faculty of Health and Medicine, University of Newcastle, New South Wales, Australia (J.S.); George Institute for Global Health, University of Sydney, New South Wales, Australia (E.H., C.A.); Hellenic Cardiovascular Research Society, Athens, Greece (V.K.); National Institute for Stroke and Applied Neurosciences, School of Public Health and Psychosocial Studies, Auckland, New Zealand (P.P., R.K., V.F.); School of Psychology, University of Auckland, New Zealand (S.B.-C.); University of Burgundy, Dijon, France (Y.B.); University Hospital of Dijon, France (Y.B.); Clinica Neurológica de Joinville, Joinville Stroke Registry, University of Joinville Region-Univille, Brazil (N.L.C.); Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'Aquila, Italy (A.C., S.S.); Stroke Unit, Centre Hospitalier Sud Francilien, Corbeil-Essonnes, France (N.C.); Stroke Unit, University Hospital of Bordeaux, France (S.O.); Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, United Kingdom (P.R.); UNIFAI, Instituto de Ciências Biomédicas de Abel Salazar, Universidade do Porto, Portugal (C.S., M.C., R.M.); Department of Neurology, Faculty of Medicine and Health, Örebro University, Sweden (P.A.); Department of Neurology and Neurosurgery, University of Tartu, Estonia (J.K., R.V.); and Departamento de Neurologia, Psicologia e Psiquiatria, Universidade de São Paulo, Ribeirão Preto, Brazil (C.M.). 2. From the Menzies Institute for Medical Research Tasmania, University of Tasmania, Hobart, Australia (H.T.P., C.L.B., P.O., S.G.); Department of Health Management and Health Economics, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam (H.T.P.); Department of Epidemiology and Biostatistics, Michigan State University, East Lansing (M.J.R.); Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia (A.G.T., D.C.); Florey Institute Neuroscience and Mental Health, Heidelberg, University of Melbourne, Victoria, Australia (D.C.); Faculty of Health and Medicine, University of Newcastle, New South Wales, Australia (J.S.); George Institute for Global Health, University of Sydney, New South Wales, Australia (E.H., C.A.); Hellenic Cardiovascular Research Society, Athens, Greece (V.K.); National Institute for Stroke and Applied Neurosciences, School of Public Health and Psychosocial Studies, Auckland, New Zealand (P.P., R.K., V.F.); School of Psychology, University of Auckland, New Zealand (S.B.-C.); University of Burgundy, Dijon, France (Y.B.); University Hospital of Dijon, France (Y.B.); Clinica Neurológica de Joinville, Joinville Stroke Registry, University of Joinville Region-Univille, Brazil (N.L.C.); Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'Aquila, Italy (A.C., S.S.); Stroke Unit, Centre Hospitalier Sud Francilien, Corbeil-Essonnes, France (N.C.); Stroke Unit, University Hospital of Bordeaux, France (S.O.); Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, United Kingdom (P.R.); UNIFAI, Instituto de Ciências Biomédicas de Abel Salazar, Universidade do Porto, Portugal (C.S., M.C., R.M.); Department of Neurology, Faculty of Medicine and Health, Örebro University, Sweden (P.A.); Department of Neurology and Neurosurgery, University of Tartu, Estonia (J.K., R.V.); and Departamento de Neurologia, Psicologia e Psiquiatria, Universidade de São Paulo, Ribeirão Preto, Brazil (C.M.). seana.gall@utas.edu.au.
Abstract
BACKGROUND: Women are reported to have greater mortality after stroke than men, but the reasons are uncertain. We examined sex differences in mortality at 1 and 5 years after stroke and identified factors contributing to these differences. METHODS AND RESULTS: Individual participant data for incident strokes were obtained from 13 population-based incidence studies conducted in Europe, Australasia, South America, and the Caribbean between 1987 and 2013. Data on sociodemographics, stroke-related factors, prestroke health, and 1- and 5-year survival were obtained. Poisson modeling was used to estimate the mortality rate ratio (MRR) for women compared with men at 1 year (13 studies) and 5 years (8 studies) after stroke. Study-specific adjusted MRRs were pooled to create a summary estimate using random-effects meta-analysis. Overall, 16 957 participants with first-ever stroke followed up at 1 year and 13 216 followed up to 5 years were included. Crude pooled mortality was greater for women than men at 1 year (MRR 1.35; 95% confidence interval, 1.24-1.47) and 5 years (MRR 1.24; 95% confidence interval, 1.12-1.38). However, these pooled sex differences were reversed after adjustment for confounding factors (1 year MRR, 0.81; 95% confidence interval, 0.72-0.92 and 5-year MRR, 0.76; 95% confidence interval, 0.65-0.89). Confounding factors included age, prestroke functional limitations, stroke severity, and history of atrial fibrillation. CONCLUSIONS: Greater mortality in women is mostly because of age but also stroke severity, atrial fibrillation, and prestroke functional limitations. Lower survival after stroke among the elderly is inevitable, but there may be opportunities for intervention, including better access to evidence-based care for cardiovascular and general health.
BACKGROUND:Women are reported to have greater mortality after stroke than men, but the reasons are uncertain. We examined sex differences in mortality at 1 and 5 years after stroke and identified factors contributing to these differences. METHODS AND RESULTS: Individual participant data for incident strokes were obtained from 13 population-based incidence studies conducted in Europe, Australasia, South America, and the Caribbean between 1987 and 2013. Data on sociodemographics, stroke-related factors, prestroke health, and 1- and 5-year survival were obtained. Poisson modeling was used to estimate the mortality rate ratio (MRR) for women compared with men at 1 year (13 studies) and 5 years (8 studies) after stroke. Study-specific adjusted MRRs were pooled to create a summary estimate using random-effects meta-analysis. Overall, 16 957 participants with first-ever stroke followed up at 1 year and 13 216 followed up to 5 years were included. Crude pooled mortality was greater for women than men at 1 year (MRR 1.35; 95% confidence interval, 1.24-1.47) and 5 years (MRR 1.24; 95% confidence interval, 1.12-1.38). However, these pooled sex differences were reversed after adjustment for confounding factors (1 year MRR, 0.81; 95% confidence interval, 0.72-0.92 and 5-year MRR, 0.76; 95% confidence interval, 0.65-0.89). Confounding factors included age, prestroke functional limitations, stroke severity, and history of atrial fibrillation. CONCLUSIONS: Greater mortality in women is mostly because of age but also stroke severity, atrial fibrillation, and prestroke functional limitations. Lower survival after stroke among the elderly is inevitable, but there may be opportunities for intervention, including better access to evidence-based care for cardiovascular and general health.
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