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Low medication adherence may explain part of the high prevalence of apparent treatment-resistant hypertension (aTRH). The authors assessed medication adherence and aTRH among 4026 participants taking ≥ 3 classes of antihypertensive medication in the population-based Reasons for Geographic and Racial Differences in Stroke (REGARDS) trial using the 4-item Morisky Medication Adherence Scale (MMAS). Low adherence was defined as an MMAS score ≥ 2. Overall, 66% of participants taking ≥ 3 classes of antihypertensive medication had aTRH. Perfect adherence on the MMAS was reported by 67.8% and 70.9% of participants with and without aTRH, respectively. Low adherence was present among 8.1% of participants with aTRH and 5.0% of those without aTRH (P

Although most North American physicians are aware that black patients have lower levels of plasma renin on average, seldom are the reasons given sufficient consideration. Weder et al. found that black study participants excreted a water load more slowly than white participants, and suggested that this may have a selective advantage for human beings surviving in hot arid climates. An important reason why blood pressure is not well controlled in African-Americans is the failure of physicians to recognize that patients of African origin are more likely to have specific causes of low-renin hypertension that require specific therapies. This probably accounts for the observation by Howard et al. that black patients in the stroke belt are more likely to be aware of and more likely to be treated for hypertension, more likely to be treated more intensively, but less likely to be controlled. This could explain why African-Americans have twice the risk of stroke, that is more likely to be due to hypertensive small vessel disease. There are important lessons to be learned from sub-Saharan Africa. Rayner and colleagues found in the Khoi San (indigenous people of Southern Africa, thought to be candidates for the original homo sapiens) that 20% have a polymorphism of the renal tubular epithelial sodium channel (a variant of Liddle’s syndrome, sometimes called pseudohyperaldosteronism, that causes hypertension and potassium depletion). Though this ability to retain salt and water may have been adaptive to survival in the Kalahari Desert, it causes severe hypertension when salt and water are abundant. Genetic polymorphisms of the renal epithelial sodium channel account for 6% of hypertension in South African blacks, and 5% of hypertension in blacks (mainly of Caribbean origin) in London, UK. In a study of hypertensive veterans in the US, of whom 57% were Caucasian, the prevalence of probable Liddle’s syndrome was 6%. Liddle’s

Purpose Recent evidence suggests early-life factors correlate with atrial fibrillation (AF). We hypothesized that AF-related mortality, similar to stroke mortality, is elevated for individuals born in the southeastern United States. Methods We estimated 3-year (1999-2001) average AF-related mortality rates by using U.S. vital statistics for 55- to 89-year-old white (136,573 AF-related deaths) and black subjects (8,288 AF-related deaths). We estimated age- and sex-adjusted odds of AF-related (contributing cause) mortality associated with birth state, and birth within the U.S. stroke belt (SB), stratified by race. SB results were replicated with the use of 1989-1991 data. Results Among black subjects, four contiguous birth states were associated with statistically significant odds ratios ≥ 1.25 compared with the national average AF-related mortality. The four highest-risk birth states for blacks also predicted elevated AF-related mortality among white subjects, but patterns were attenuated. The odds ratio for AF-related mortality associated with SB birth was 1.19 (confidence interval 1.13-1.25) for black and 1.09 (CI 1.07-1.12) for white subjects when we adjusted for SB adult residence. Conclusions Place of birth predicted AF-related mortality, after we adjusted for place of adult residence. The association of AF-related mortality and SB birth parallels that of other cardiovascular diseases and may likewise indicate an importance of early life factors in the development of AF.

We hypothesized that patterns of elevated stroke mortality among those born in the US Stroke Belt (SB) states also prevailed for mortality related to all-cause dementia or Alzheimer Disease (AD). Cause specific mortality (contributing cause of death, including underlying cause cases) rates in 2000 for US-born African-Americans and whites aged 65–89 were calculated by linking national mortality records with population data based on race, sex, age, and birth state or state of residence in 2000. Birth in a SB state (North Carolina, South Carolina, Georgia, Tennessee, Arkansas, Mississippi, or Alabama) was cross-classified against SB residence at the 2000 Census. Compared to those who were not born in the SB, odds of all cause dementia mortality were significantly elevated by 29% for African-Americans and 19% for whites born in the SB. These patterns prevailed among individuals who no longer lived in the SB at death. Patterns were similar for AD-related mortality. Some non-SB states were also associated with significant elevations in dementia-related mortality. Dementia mortality rates follow geographic patterns similar to stroke mortality, with elevated rates among those born in the SB. This suggests important roles for geographically patterned childhood exposures in establishing cognitive reserve.

Background The American "stroke belt" has contributed to the study of stroke. However, U.S. geographic patterns of diabetes have not been as specifically characterized. Purpose This study identifies a geographically coherent region of the U.S. where the prevalence of diagnosed diabetes is especially high, called the "diabetes belt." Methods In 2010, data from the 2007 and 2008 Behavioral Risk Factor Surveillance System were combined with county-level diagnosed diabetes prevalence estimates. Counties in close proximity with an estimated prevalence of diagnosed diabetes ≥11.0% were considered to define the diabetes belt. Prevalence of risk factors in the diabetes belt was compared to that in the rest of the U.S. The fraction of the excess risk associated with living in the diabetes belt associated with selected risk factors, both modifiable (sedentary lifestyle, obesity) and nonmodifiable (age, gender, race/ethnicity, education), was calculated. Results A diabetes belt consisting of 644 counties in 15 mostly southern states was identified. People in the diabetes belt were more likely to be non-Hispanic African-American, lead a sedentary lifestyle, and be obese than in the rest of the U.S. Thirty percent of the excess risk was associated with modifiable risk factors, and 37% with nonmodifiable factors. Conclusions Nearly one third of the difference in diabetes prevalence between the diabetes belt and the rest of the U.S. is associated with sedentary lifestyle and obesity. Culturally appropriate interventions aimed at decreasing obesity and sedentary lifestyle in counties within the diabetes belt should be considered.

Stroke mortality rates and prevalence of several chronic diseases are higher in Southern populations and blacks in the US. This study examined the relationships of race (black, white) and region (Stroke Belt, Stroke Buckle, other) with selected nutrient intakes among black and white American men (n = 9229). The Block 98 FFQ assessed dietary intakes and multivariable linear regression analysis was used to examine whether race and region were associated with intakes of fiber, saturated fat, trans fat, sodium, potassium, magnesium, calcium, and cholesterol. Race and region were significant predictors of most nutrient intakes. Black men consumed 1.00% lower energy from saturated fat compared with white men [multivariable-adjusted β: 1.00% (95% CI = −0.88, −1.13)]. A significant interaction between race and region was detected for trans fat (P < 0.0001), where intake was significantly lower among black men compared with white men only in the Stroke Belt [multivariable-adjusted β: −0.21 (95% CI = −0.11, −0.31)]. Among black men, intakes of sodium, potassium, magnesium, and calcium were lower, whereas cholesterol was higher, compared with white men (P < 0.05 for all). Comparing regions, men in the Stroke Buckle had the lowest intakes of fiber, potassium, magnesium, and calcium compared with those in the Stroke Belt and other regions; men in both the Stroke Buckle and Stroke Belt had higher intakes of cholesterol compared with those in other regions (P < 0.005 for all). Given these observed differences in dietary intakes, more research is needed to understand if and how they play a role in the health disparities and chronic disease risks observed among racial groups and regions in the US.

BACKGROUND There are few available data on the epidemiology of prehypertension (preHTN).To determine racial, clinical, and demographic differences in the prevalence of preHTN and its cross-sectional association with vascular risk factors. METHODS Cross-sectional analysis of 5,553 prehypertensives, 20,351 hypertensive's, and 4,246 nonhypertensive participants (age ≥45), from a population-based national cohort study (REasons for Geographic And Racial Differences in Stroke (REGARDS) total population 30,239, of whom 30,150 had adequate blood pressure (BP) measurements) enrolled from January 2003-October 2007 with oversampling from the southeastern stroke belt, and black individuals. Baseline data were collected using a combination of telephone interview and in-home evaluation. preHTN was defined according to The Seventh Report of the Joint national Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guidelines. RESULTS The prevalence of preHTN was associated with age and black race (62.9% in blacks compared to 54.1 % in whites). A higher prevalence of preHTN was observed in obese individuals, self-reported heart disease; and, those with elevated high-sensitivity C reactive protein (hsCRP), diabetes, and microalbuminuria compared to those without these factors. Heavy alcohol consumption in white participants was associated with increased odds of preHTN (odds ratio (OR) = 1 . 3 2) but was even greater in black participants (OR =2.27). CONCLUSION The prevalence of preHTN increased by age and African-American race. In addition, a higher prevalence of preHTN was observed with elevated hsCRP, diabetes, microalbuminuria, and those with heavy alcohol consumption compared to those without these factors.

Background: Omega-3 fatty acids from fish have been shown to have favorable effects on platelet aggregation, blood pressure, lipid profile, endothelial function, and ischemic stroke risk, but there are limited data on racial and geographic differences in fish consumption. Methods: Reasons for Geographic and Racial Differences in Stroke (REGARDS) is a national cohort study that recruited 30,239 participants age ≥45 years with oversampling from the southeastern Stroke Belt and Buckle and African Americans (AAs). Centralized phone interviewers obtained medical histories and in-home examiners measured weight and height. Dietary data for this cross-sectional analysis were collected using the self-administered Block98 Food Frequency Questionnaire (FFQ). Adequate intake of nonfried fish was defined as consumption of ≥2 servings per week based on American Heart Association guidelines. After excluding the top and bottom 1% of total energy intake and individuals who did not answer 85% or more of questions on the FFQ, the analysis included 21,675 participants. Results: Only 5,022 (23%) participants consumed ≥2 servings per week of nonfried fish. In multivariable analysis, factors associated with inadequate intake of nonfried fish included living in the Stroke Belt (vs non-Belt) (odds ratio [OR] 0.83, 95% confidence interval [CI] 0.77–0.90) and living in the Stroke Buckle (vs non-Belt) (OR 0.89, 95% CI 0.81–0.98); factors associated with ≥2 servings per week of fried fish included being AA (vs white) (OR 3.59, 95% CI 3.19–4.04), living in the Stroke Belt (vs non-Belt) (OR 1.32, 95% CI 1.17–1.50), and living in the Stroke Buckle (vs non-Belt) (OR 1.17, 95% CI 1.00–1.36). Conclusions: Differential consumption of fish may contribute to the racial and geographic disparities in stroke.

Resistant hypertension is a major opportunity for prevention of cardiovascular disease. Despite widespread dissemination of consensus guidelines, most patients are uncontrolled with approaches that assume that all patients are the same. Causes of resistant hypertension include 1) non-compliance 2) consumption of substances that aggravate hypertension (such as salt, alcohol, nonsteroidal anti-inflammatory drugs, licorice, decongestants) and 3) secondary hypertension. Selecting the appropriate therapy for a patient depends on finding the cause of the hypertension. Once rare causes have been eliminated (such as pheochromocytoma, licorice, adult coarctation of the aorta), the cause will usually be found by intelligent interpretation (in the light of medications then being taken) of plasma renin and aldosterone. If stimulated renin is low and the aldosterone is high, the problem is primary aldosteronism, and the best treatment is usually aldosterone antagonists (spironolactone or eplerenone; high-dose amiloride for men where eplerenone is not available). If the renin is high, with secondary hyperaldosteronism, the best treatment is angiotensin receptor blockers or aliskiren. If the renin and aldosterone are both low the problem is over-activity of renal sodium channels and the treatment is amiloride. This approach is particularly important in patients of African origin, who are more likely to have low-renin hypertension. © 2010 Bentham Science Publishers Ltd.

Background: Understanding how the timing of exposure to the US Stroke Belt (SB) influences stroke risk may illuminate mechanisms underlying the SB phenomenon and factors influencing population stroke rates. Methods: Stroke mortality rates for United States–born black and white people aged 30–80 years were calculated for 1980, 1990, and 2000 for strata defined by birth state, state of adult residence, race, sex, and birth year. Four SB exposure categories were defined: born in a SB state (North Carolina, South Carolina, Georgia, Tennessee, Arkansas, Mississippi, or Alabama) and lived in the SB at adulthood; non-SB born but SB adult residence; SB-born but adult residence outside the SB; and did not live in the SB at birth or in adulthood (reference group). We estimated age-, sex-, and race-adjusted odds ratios for stroke mortality associated with timing of SB exposure. Results: Elevated stroke mortality was associated with both SB birth and, independently, SB adult residence, with the highest risk among those who lived in the SB at birth and adulthood. Compared to those living outside the SB at birth and adulthood, odds ratios for SB residence at birth and adulthood for black subjects were 1.55 (95% confidence interval 1.28, 1.88) in 1980, 1.47 (1.31, 1.65) in 1990, and 1.34 (1.22, 1.48) in 2000. Comparable odds ratios for white subjects were 1.45 (95% confidence interval 1.33, 1.58), 1.29 (1.21, 1.37), and 1.34 (1.25, 1.44). Patterns were similar for every race, sex, and age subgroup examined. Conclusion: Stroke Belt birth and adult residence appear to make independent contributions to stroke mortality risk.

Background: Among African-Americans, and in southern US states, the rates of stroke are high but the reported prevalences of atrial fibrillation (AF) are low. We hypothesized that the reported ethnic and regional distributions of AF are affected by the sensitivity of the methods that were used to detect AF in previous reports.Methods: A total of 18 833 black and white participants from the US national REasons For Geographic And Racial Differences In Stroke (REGARDS) study were included in this analysis. Levels of sensitivity to detect AF, from least to most sensitive, were created for combinations of self-report (SR) and ECG methods, as follows: (1) SR plus ECG, (2) ECG alone, (3) SR alone, and (4) SR or ECG. Geographic regions were dichotomized as Stroke Belt (the southern US states) and non-Stroke Belt. Logistic regression analysis estimated the odd ratios of AF associated with the Stroke Belt and black ethnicity for each diagnostic combination.Results: Residence in the Stroke Belt was significantly associated with AF when diagnosed by SR plus ECG (multivariable-adjusted OR, 0.66; 95% CI, 0.47 to 0.92), but not when diagnosed with SR or ECG (OR, 0.95; 95% CI, 0.85 to 1.06). Similarly, for the 4 methods used to detect AF, the strength of the association between black ethnicity and AF progressively decreased with increasing test sensitivity (ORs: 0.20, 0.40, 0.70, 0.71, respectively).Conclusions: The association of AF with residence in the Stroke Belt and black ethnicity was inversely related to the sensitivity of the method used to detect AF: as test sensitivity increased, the association became attenuated. This may partially explain the lower reported prevalence of AF in populations and regions with higher stroke rates.

Background and Purpose— The purpose of this study was to examine whether there are disparities in use of stroke secondary prevention services because disparities in stroke outcomes have been found among older adults, women, racial minorities, and within Stroke Belt states. Methods— Using the nationally-representative 2005 Behavior Risk Factor Surveillance System, we examined self-reported use of 11 stroke secondary prevention services queried in the survey. We used multivariable logistic regression to examine the association between service use and age, sex, race, and Stroke Belt state residence, controlling for other socio-demographic and health care access characteristics. Results— Among 11 862 adults with a history of stroke, 16% were 80 or older, 54% were women, 13% were non-Hispanic black, and 23% lived within a Stroke Belt state. Overall service use varied: 31% reported poststroke outpatient rehabilitation, 57% regular exercise, 66% smoking cessation counseling, and 91% current use of antihypertensive medications. Age 80 or older was not associated with lower use of any of the 11 services. Women were less likely to report poststroke outpatient rehabilitation and regular exercise when compared with men (probability values ≤0.005); there were no sex-based differences in use of the 9 other services. Blacks were less likely to report pneumococcal vaccination when compared with whites, but were more likely to report poststroke outpatient rehabilitation (probability values ≤0.005); there were no race-based differences in use of the 9 other services. Stroke Belt state residence was not associated with lower use of any of the 11 services. Conclusions— Use of many stroke secondary prevention services was suboptimal. We did not find consistent age, sex, racial, or Stroke Belt state residence disparities in care.

Stroke is the third leading cause of death in the United States, accounting for 1 of every 16 deaths in 2004 1. Residents of the Southeastern United States (“stroke belt”) have approximately 50% higher rates of stroke mortality than the remainder of the United States 2–4. These geographic differences have existed since at least 1940 2, with excess deaths demonstrated for men, women, whites and African-Americans 4. The cause of the excess stroke mortality in the stroke belt is unknown 5, 6. Differences in stroke incidence may contribute to the excess mortality, but little national data on regional differences in incidence are available to address this hypothesis. For white men and women, data from the first National Health and Nutrition Examination Survey (NHANES I) suggested that stroke incidence was higher in the Southeast than the Northeast, but the pattern was inconsistent between the Southeast and other regions 7. In addition, while the stroke belt is at least as pronounced for blacks as for whites 8–10 and the incidence of stroke was higher among blacks 11–13 in some studies, in NHANES I regional differences in stroke incidence among African-Americans were not as striking as those among whites 7. Lower rates of stroke hospitalization in the stroke belt could also explain underlying differences in mortality; however among Medicare recipients, those in Southeastern states were more likely to be hospitalized for stroke than in other regions 14. Another potential cause of the stroke belt is differences in case fatality by region; however little information is available to support this hypothesis 15. Similarly, differential case fatality according to race has not been clearly demonstrated 12, 13, 16. Hence, the available data suggest that geographic and racial variations in stroke mortality relate to differences in incidence, not case fatality. If this is the case, then disparities in stroke risk factors may underlie observed differences in stroke mortality. The Framingham Heart Study investigators identified nine risk factors for stroke: age, sex, systolic blood pressure, antihypertensive therapy, diabetes, current smoking, prior cardiovascular disease, atrial fibrillation, and left ventricular hypertrophy 17. The Framingham Stroke Risk Score (FSRS), developed and validated in a primarily white population, predicts the 10-year probability of stroke based on these nine risk factors. To address the role of stroke risk factors on regional and racial differences in stroke mortality, we studied geographic and racial differences in the FSRS in a national cohort.

Background Heart failure (HF) and cognitive impairment are both common in older adults. However, the association between the two has not been well studied. Methods and Results We explored the relationship between very probable HF, determined by self-reported symptoms, and cognitive impairment, defined as four or fewer correct on the Six-item Screener, in 14,089 participants of the Reasons for Geographic and Racial Differences in Stroke cohort. We determined the effect of adding demographic, socioeconomic status (SES), health behavior, and comorbidity covariates. In the univariate model, participants with very probable HF were 1.51 (95% confidence interval: 1.15–1.96) times more likely to have cognitive impairment than those without HF. As covariates were added to the model, the relationship between HF and cognitive impairment was attenuated and lost statistical significance after adjustment for depression. Demographic variables, Stroke Belt location (1.28 [1.11–1.48]), SES factors, prior stroke (1.43 [1.18–1.73]), and depression (1.66 [1.38–2.01]) remained significant in the multivariable model. Higher hemoglobin was associated (0.95 [0.9–1.00]) with modestly reduced odds of cognitive impairment. Conclusions The relationship between cognitive impairment and HF can be accounted for by multiple demographic and SES factors, and by comorbidities, some of which are modifiable. Persons with HF and cognitive impairment should be screened for anemia and depression.

Understanding the reasons for overweight and obesity is critical to addressing the obesity epidemic. Often the decision to lose weight is based as much on one's self-perception of being overweight as on inherent health benefits.Examine the relationships between self-reported health and demographic factors and measured health risk status and the misperception of actual weight status.Cross-sectional study of factors associated with self-perceived overweight status in participants who self-selected to participate in stroke risk factor screenings. Participants were asked, "Are you overweight?" before their body mass index (BMI) was determined from measured weight and self-reported height. Demographics including, sex, race, education, and location; and health status variables including level of exercise and history of high blood pressure and cholesterol were collected.Mean BMI for the group was 30 kg/m(2). Most women (53.1%) perceived themselves to be overweight, whereas most men (59.6%) perceived themselves not to be overweight. Factors related to misperception of weight status varied by actual BMI category. Among individuals with normal BMI, sedentary individuals had 63% higher odds of misperceiving themselves as overweight. Sedentary individuals with obese BMI were at 55% reduced odds of misperceiving themselves as normal weight.Active obese and overweight individuals may be more likely to incorrectly perceive themselves as normal weight, and thus misperceive their risk for stroke. Thus, it is not enough to only counsel individuals to be active. Physicians and other health professionals need to counsel their clients to both be active and to attain and maintain a healthy weight.

Background and Purpose— Most Stroke Belt studies define exposure based on residence at stroke onset. We assessed whether residence in the Stroke Belt during childhood confers extra stroke risk in adulthood, even among people who left the region. Methods— Stroke-free Health and Retirement Study participants (n=18 070) followed up (average, 8.4 years) for first stroke (1452 events) were classified as living in 1 of 7 Stroke Belt states in childhood or at study enrollment (average age, 63 years). We used Cox proportional-hazards models to compare stroke risk for people who had never lived in the Stroke Belt with those who had lived there at both ages, in childhood only, or in adulthood only. Results— Compared with never having lived in the Stroke Belt, the hazard ratio for Stroke Belt residence in both childhood and adulthood was 1.23 (95% CI, 1.06, 1.43) and for Stroke Belt residence in childhood only was 1.25 (95% CI, 1.02, 1.55). Stroke Belt residence at enrollment but not during childhood was not significantly related to stroke risk (hazard ratio=1.01; 95% CI, 0.70, 1.46), but the small sample in this group resulted in wide CIs. Results changed little after risk factor adjustment, including comprehensive adult socioeconomic measures. Subgroup analyses found similar patterns by sex and birth cohort. In contrast, blacks who had lived in the Stroke Belt in childhood only did not appear to have significantly elevated stroke risk compared with blacks who had never lived in the Stroke Belt. Conclusions— The excess stroke risk for people who had lived in Stroke Belt states during childhood implicates early life exposures in the etiology of the Stroke Belt.

Introduction Cardiovascular disease is the leading cause of death in the United States, and mortality rates are higher among African Americans than among people of other races/ethnicities. We aimed to understand how African American adults and adolescents conceptualize cardiovascular health and perceive related barriers and facilitators. Methods This qualitative study was conducted as formative research for a larger study, Heart Healthy Lenoir, which aimed to reduce cardiovascular disease disparities among African Americans in eastern North Carolina, part of the widely-known "stroke belt" that runs through the southeastern United States. Using photovoice, a community-based participatory research method, we conducted eight 90-minute photovoice sessions with 6 adults and 9 adolescents in Lenoir County, North Carolina. Topics for each discussion were selected by participants and reflected themes related to cardiovascular health promotion. All sessions were transcribed and coded using a data-driven, inductive approach. Results Participants conceptualized cardiovascular health to have mental, spiritual, and social health dimensions. Given these broad domains, participants acknowledged many ecological barriers to cardiovascular health; however, they also emphasized the importance of personal responsibility. Facilitators for cardiovascular health included using social health (eg, family/community relationships) and spiritual health dimensions (eg, understanding one's body and purpose) to improve health behaviors. Conclusion The perspectives of African American adults and adolescents elicited through this formative research provided a strong foundation for Heart Healthy Lenoir's ongoing engagement of community members in Lenoir County and development and implementation of its intervention to prevent cardiovascular disease.

OBJECTIVE To evaluate the impact of comorbid depressive symptoms and/or stress on adverse cardiovascular (CV) outcomes in individuals with diabetes compared with those without diabetes. RESEARCH DESIGN AND METHODS Investigators examined the relationship between baseline depressive symptoms and/or stress in adults with and without diabetes and physician-adjudicated incident CV outcomes including stroke, myocardial infarction/acute coronary heart disease, and CV death over a median follow-up of 5.95 years in the national REGARDS cohort study. RESULTS Subjects included 22,003 adults (4,090 with diabetes) (mean age 64 years, 58% female, 42% black, and 56% living in the southeastern “Stroke Belt”). Elevated stress and/or depressive symptoms were more common in subjects with diabetes (36.8% vs. 29.5%; P < 0.001). In fully adjusted models, reporting either elevated stress or depressive symptoms was associated with a significantly increased incidence of stroke (HR 1.57 [95% CI 1.05, 2.33] vs. 1.01 [0.79, 1.30]) and CV death (1.53 [1.08, 2.17] vs. 1.12 [0.90, 1.38]) in subjects with diabetes but not in those without diabetes. The combination of both elevated stress and depressive symptoms in subjects with diabetes was associated with a higher incidence of CV death (2.15 [1.33, 3.47]) than either behavioral comorbidity alone (1.53 [1.08, 2.17]) and higher than in those with both elevated stress and depressive symptoms but without diabetes (1.27 [0.86, 1.88]). CONCLUSIONS Comorbid stress and/or depressive symptoms are common in individuals with diabetes and together are associated with progressively increased risks for adverse CV outcomes.

Over the past several decades, much of the developed world has experienced a sustained reduction in age-standardized stroke mortality and morbidity rates.1 For many of these countries, these improvements have translated into declines in absolute stroke mortality and morbidity as well. For example, stroke had been the third-leading cause of death in the United States for >70 years until 2008, when it became the fourth leading cause of death.2,3 Just 5 years later, stroke became the fifth leading cause of death4—a drop that reflected the >60% decline in the age-adjusted mortality rate from stroke over just the past few decades.5,6 For most other developed countries, the recent experience and outlook for stroke has been similar.1,7 Over the past 20 years, high-income countries as a group have experienced a 13% decline (95% confidence interval, 6–18%) in the age-standardized incidence rate, a 37% decline (95% confidence interval 19–39%) in the age-standardized mortality rate, and a 21% decline (95% confidence interval, 10–27%) in the age-standardized disease burden from ischemic stroke as measured in disability-adjusted life year (DALY) loss rates.8,9 (DALYs are a summary measure of disease burden that combines the impact of years of healthy life lost caused by premature death with the effect of long-term disability on quality of life over time.) For hemorrhagic stroke, there have been similar improvements in these indicators over the same period.8,10 However, the global outlook for the total disease burden from stroke is a bit more humbling. In 2013, an estimated 6.4 million deaths (11.8% of all deaths) were caused by stroke, and stroke remained the third-leading cause of years-of-potential-life lost worldwide (Table 1).1,8,11,12 Between 1990 and 2010, the absolute incidence of …

Disparities in atrial fibrillation (AF)-related stroke and mortality persist, especially racial disparities, within the US "Stroke Belt." This study identified barriers to optimal stroke prevention to develop a framework for clinician education. A comprehensive educational needs assessment was developed focusing on clinicians within the Stroke Belt. The mixed qualitative-quantitative approach included regional surveys and one-on-one clinician interviews. Identified contributors to disparities included implicit racial biases, lack of awareness of racial disparities in AF stroke risk, and lack of effective multicultural awareness and training. Additional barriers affecting disparities included patient medical mistrust and clinician-patient communication challenges. General barriers included lack of consistency in assessing stroke and anticoagulant-related bleeding risk, underuse of standardized risk assessment tools, discomfort with novel anticoagulants, and patient education deficiencies. Effective cultural competency training is one strategy to reduce disparities in AF-related stroke and mortality by improving implicit clinician bias, addressing medical mistrust, and improving clinician-patient communication.

Background and purpose: It has long been recommended that patients at risk of cardiovascular events limit their intake of dietary cholesterol to Methods: A longitudinal cohort study of 30,239 community-dwelling black and white individuals aged 45+ years, recruited between January 2003 and October 2007 from the 48 contiguous states. The study oversampled black participants (44%), and residents of the southeastern “stroke belt” (56%). We analyzed total mortality and atherosclerotic events (ischemic stroke, myocardial infarction and revascularization) after 4.9 (SD 1.7) years of followup. Hazard ratios were computed for egg consumption and cholesterol consumption by quartiles, adjusted for race, age, sex, income, education, region, dyslipidemia, exercise, hypertension, diabetes, smoking, atrial fibrillation and caloric intake. Results: As shown in the table, there was a dose-related increase in all-cause mortality and atherosclerotic events with both cholesterol intake and egg consumption. Conclusions: Recommendations to limit the intake of cholesterol remain good advice for patients at risk of cardiovascular events. As one large egg yolk contains more than the daily recommended intake of cholesterol, egg yolk consumption should also be limited.

Background: There are regional variations in adult stroke mortality and hospitalization rates in the US, with higher rates in the Southeastern part of the country (the ‘stroke belt’). At least one study found children in stroke belt states also have higher stroke-related mortality; whether they have higher hospitalization rates is unknown. We compared ischemic stroke hospitalization rates for adults and children in stroke belt and non-stroke belt states. Methods: Ischemic stroke discharges (ICD-9-CM 433, 434, 436) were identified for calendar years 2006 and 2009 in the Kids’ Inpatient Database (N=1,434; age 0-20y) and years 2007 and 2009 in the Nationwide Inpatient Sample (N=221,351; age ≥21y). Age-specific population estimates were obtained from US Census data. Hospitalization rates per 100,000 person-years (PY) were calculated in 5-year age increments and by region. Mixed Poisson regression was used to determine the hospitalization rate ratio between stroke belt and non-stroke belt states within age groups; logistic models estimated odds ratios for in-hospital mortality. Results: Hospitalization rates were higher for adults residing in the stroke belt, but were similar for children (1.2 and 1.4 per 100,000 PY; figure). Although adult hospitalization rates were 32%-52% higher in the stroke belt, after adjustment for age, race, and sex, there was no difference in childhood stroke hospitalizations based on stroke belt residence (rate ratio=0.89, 95% CI 0.70-1.12). In-hospital mortality did not differ by region for any age group. Conclusions: Consistent with prior studies, adults in the stroke belt had higher hospitalization rates than those in non-stroke belt states; however, there was no difference for children. Because higher stroke mortality has been reported for adults and children in the stroke belt, the lack of difference in hospitalization rates and in-hospital mortality may suggest a higher late case-fatality rate for children in the stroke belt.

Introduction: The excess stroke mortality among African Americans and Southerners is well known. Because a higher proportion of the population living in the ‘Stroke Belt’ is African American, then a portion of the estimated excess risk of stroke death traditionally associated with African-American race may be attributable to geography (i.e., race and geography are ‘confounded’). In this paper we estimate the proportion of the excess stroke mortality among African Americans that is attributable to geography. Methods: The numbers of stroke deaths at the county level are available from the vital statistics system of the US. A total of 1,143 counties with a population of at least 500 whites and 500 African Americans were selected for these analyses. The black-to-white stroke mortality ratio was estimated with and without adjustment for county of residence for those aged 45–64 and for those aged 65 and over. The difference in the stroke mortality ratio before versus after adjustment for county provides an estimate of the proportion of the excess stroke mortality inappropriately attributed to race (that is in fact attributable to geographic region). Results: For ages 45–64, the black-to-white stroke mortality ratio was reduced from 3.41 to 3.04 for men, and from 2.82 to 2.60 for women, suggesting that between 10 and 15% of the excess mortality traditionally attributed to race is rather due to geography. Over the age of 65, the black-to-white stroke mortality ratio was reduced from 1.31 to 1.27 for men, and from 1.097 to 1.095 for women, suggesting that between 2 and 13% of the excess mortality attributed to black race is actually attributable to geography. The reductions of all the four age strata gender groups were highly significant. Discussion: These results suggest that a significant, although relatively small, proportion of the excess mortality traditionally attributed to race is rather a factor of geography.

Purpose: To provide a descriptive analysis of the stroke features in a population of patients from a large urban hospital within the ‘stroke belt’, with the intention of stimulating interest in creating similar comprehensive databases across the country; the differential population features that may contribute to the increased incidence of ischemic and hemorrhagic stroke within the ‘stroke belt’ can thus be better studied and understood. Background: Strokes account for approximately 5–10% of all deaths in the western world. Within a geographically nondescript region in the Southern United States known as the ‘stroke belt’, however, the incidence of stroke is 1.5–2 times greater than in other regions of the country. Despite the relatively high incidence of stroke within the ‘stroke belt’, very little information is available regarding the differential population features that distinguish stroke patients within this region from those in other parts of the country. Design/Methods: During the period September 1, 1995 to August 31, 1998, data for 506 patients meeting criteria for stroke as outlined in the National Survey of Stroke were entered into the ‘Adult Brain Attack Database’ at the Medical College of Virginia Hospitals of Virginia Commonwealth University. The data were analyzed using descriptive statistics. Results: Of the 506 patients entered into the database 281 experienced their first stroke during the data collection period. Of these individuals, 60.5% (n = 170) were female (mean age 60.6). The mean age in men presenting with new stroke (n = 111) was 62.5. African-Americans represented the predominant ethnic group making up 63.3% (n = 178) of all first stroke patients. The three most common risk factors among deceased ischemic stroke patients (3.2%; n = 9) included hypertension (58.3%), alcohol abuse (41.6%) and cigarette smoking (33.3%). Among ischemic stroke survivors, the three most common risk factors included hypertension (53.6%), prior neurovascular disease (36.2%) and cigarette smoking (28.0%). Risk factors among hemorrhagic stroke patients included hypertension (42.0%), cigarette smoking (26.3%) and alcohol abuse (21.1%). The most common complication associated with stroke across all subtypes was hypertension with an overall prevalence of 9.3%. The use of antiplatelet and antihypertensive therapy at discharge among stroke patients in whom such data was recorded was 58.8% (179/289) and 48.9% (132/270), respectively. Discussion: Future studies comparing data from the Richmond, Va. stroke database with data from other regions of the country outside the ‘stroke belt’ may allow for differentiation of the population features that contribute to the increased prevalence of stroke within the ‘stroke belt’.

Southeastern part of United States has been called the Stroke Belt due to a much higher incidence of stroke compared to the rest of the country. In this article, I summarize my 2 weeks of observations as a clinical preceptor at the Comprehensive Stroke Center, University of Alabama Hospital, Birmingham, AL. 57 patients were admitted during these 2 weeks, 61% had ischemic strokes, and 23% received intravenous recombinant tissue plasminogen activator (IV rt-PA). Endovascular neuro-interventionalists were performing diagnostic catheter angiography in 14% and emergent revascularization procedures in 7% of consecutive patients. Also, the stroke team enrolled 6 patients into National institute of health (NIH) funded clinical trials (3 Argatroban tPA stroke study (ARTSS), 2 Safety study of external counter pulsation as a treatment for acute ischemic stroke (CUFFS), 1 stenting and aggressive medical management for preventing recurrent stroke in intracranial stenosis (SAMMPRIS). In my opinion, these observations provided me with useful knowledge how to develop a cutting edge, proactive stroke treatment system. In particular, availability 24 × 7 and consistent application of a curative, “finding reasons to treat approach” coupled with state-of the-art technologies and skilled operators could make a huge difference.

The southeastern region of the United States is known as the "stroke belt" because of excess stroke mortality in this region compared to the rest of the country. However, whether a similar geographic variation in heart failure mortality exists is unknown. Using the Center for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research publicly available compressed mortality data files and 2000 United States population as the standard, we estimated age-adjusted heart failure and stroke mortality rates per 100,000 for patients of all ages, men and women, and all races during 1979 through 1998 in the United States and mapped rates at the state level. Age-adjusted heart failure mortality rate for the 6 contiguous southeastern states (Alabama, Arkansas, Mississippi, Oklahoma, Louisiana, and Georgia) was 31.0/100,000, which was 69% higher than the national rate of 18.3/100,000. This geographic disparity was similar in African-Americans (32.9/100,000 in the southeast vs 21.7/100,000 nationally) and whites (30.8/100,000 in the southeast vs 18.1/100,000 nationally). These findings suggest that, in addition to the stroke belt, the southeastern region of the United States may also be burdened by a "heart failure belt." To better understand the causes of excess stroke mortality in the stroke belt, the National Institutes of Health has funded the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study (n = 30,239, >1/2 from the southeastern region), which provides a unique opportunity to study the underlying causes of excess heart failure mortality in the heart failure belt.

Background: African Americans (AAs) living in the “Stroke Belt” region are at elevated risk for cardiovascular diseases (CVDs) including stroke. Our long-term goal is to eliminate this ethnic/regional health disparity by targeting a major modifiable risk factor for stroke, hypertension (HTN). Besides medications, lifestyle interventions are effective in lowering blood pressure (BP), and the “DASH diet has been shown to lower BP, however, in the PREMIER program, DASH with lifestyle modifications was less effective in AAs with regards to BP reduction. We hereby present a PREMIER modified, faith-based, socio-culturally tailored, multi-level HTN control behavioral intervention called HEALS adopted by AA churches. The objective is to determine the efficacy of HEALS on BP and other related outcomes. Methods: Based on Community advisory board (CAB) recommendations, a church selected from a pool of 26 participating churches. Trained church leaders enrolled eligible participants and delivered weekly HEALS sessions for 12 weeks. Target population included church members 25-75 years, with known or newly diagnosed HTN/pre-HTN as per JNC-7 classification. Information was obtained on BP, weight, waist circumference, diets and physical activity. Results: A total of 36 eligible church members were recruited, 32 provided data that was used in this analysis n=32 (89% retention). At baseline, 28 members were known HTN and remaining were newly diagnosed (22%). After the completion of the 12 weeks intervention, the mean reduction in systolic BP (SBP) and diastolic BP (DBP) were 6.72mmHg (p=.0425) and 4 mmHg (p=.0073), respectively. A weight reduction of 1.7 Kg was also significant (p=0.0023). Similarly, diet changes were significant and showed that more than half consumed dark green or other vegetables frequently, while 75% consumed at least one fruit daily or weekly. Lower percentages (44%) reported consumption of 100% fruit juices or cooked beans regularly. Study is currently in its 6-month maintenance phase. Conclusion: Under controlled settings, community-based interventions can be successful in producing desirable outcomes and in maintaining high retention rates. HEALS intervention can be used as a model of efficacious program in church settings.

Background Life's Simple 7 is a new metric based on modifiable health behaviors and factors that the American Heart Association uses to promote improvements to cardiovascular health ( CVH ). We hypothesized that better Life's Simple 7 scores are associated with lower incidence of cognitive impairment. Methods and Results For this prospective cohort study, we included RE asons for Geographic And Racial Differences in Stroke ( REGARDS ) participants aged 45+ who had normal global cognitive status at baseline and no history of stroke (N=17 761). We calculated baseline Life's Simple 7 score (range, 0 to 14) based on smoking, diet, physical activity, body mass index, blood pressure, total cholesterol, and fasting glucose. We identified incident cognitive impairment using a 3‐test measure of verbal learning, memory, and fluency obtained a mean of 4 years after baseline. Relative to the lowest tertile of Life's Simple 7 score (0 to 6 points), odds ratios of incident cognitive impairment were 0.65 (0.52, 0.81) in the middle tertile (7 to 8 points) and 0.63 (0.51, 0.79) in the highest tertile (9 to 14 points). The association was similar in blacks and whites, as well as outside and within the Southeastern stroke belt region of the United States. Conclusions Compared with low CVH , intermediate and high CVH were both associated with substantially lower incidence of cognitive impairment. We did not observe a dose‐response pattern; people with intermediate and high levels of CVH had similar incidence of cognitive impairment. This suggests that even when high CVH is not achieved, intermediate levels of CVH are preferable to low CVH .

Racial differences have been observed in stroke-related knowledge and knowledge of specific stroke risk factors and stroke prevention practices. Using data from 134 male stroke survivors, racial differences in overall knowledge, risk factor knowledge, and stroke prevention practices were examined using the Stroke Knowledge Test. Knowledge that diabetes doubles ones risk of stroke was present in 48% of the participants, while knowledge of aspirin in the prevention of stroke by stopping blood clot formation was reported in 83% of the participants. Findings indicate participants were knowledgeable that obesity increased risk of stroke (71%) and high blood pressure was the most important stroke risk factor (70%). Participants indicated knowledge that diet, exercise, and controlling blood pressure and cholesterol reduces risk of stroke (86%). In regression models, there were no significant race differences in overall stroke knowledge or the odds of knowledge of information related to stroke risk factors and stroke prevention practices after adjusting for age, education, and marital status. Although stroke-related knowledge did not differ by race, stroke survivors exhibited gaps in stroke knowledge particularly of knowledge of common risk factors. These factors should be considered in approaches to improve stroke-related knowledge in all stroke survivors.

Background: Significant racial and ethnic disparities in stroke incidence, severity, morbidity and mortality have been consistently reported, but there are limited reports on racial/ethnic differences in post-stroke rehabilitation utilization and long term functional outcomes. Objective: To examine racial and ethnic differences in post-stroke rehabilitation utilization and functional outcomes. Methods: We examined one year follow-up data collected as part of the STEP-South Carolina Project that was designed to measure clinical, treatment, and functional outcomes in post-stroke patients. We used univariate and multivariate regression analyses adjusted for stroke severity to examine racial-ethnic differences in rehabilitation utilization (occupational therapy, physical therapy, speech therapy) and functional outcomes using a 20 question measure of activities of daily living (ADL) & instrumental activities of daily living (IADL) performance, life participation and driving. Results: Data from 162 stroke survivors (106 White, 56 Black) were collected at one year follow-up. As shown in the table, no significant differences were found between Blacks and Whites for rehabilitation utilization. In multivariate comparisons controlling for NIHSS, Blacks were less likely to report independence in overall functional performance outcomes as well as specific measures of toileting, walking, transportation, laundry and shopping. In addition, fewer Blacks reported driving at one year post-discharge. Conclusions: Fewer Blacks exhibited ADL and IADL independence at one year post-stroke after controlling for stroke severity, despite the fact that there were no racial-ethnic differences in rehabilitation utilization. Future studies are needed to further understand the reason for this disparity in recovery

Andalusia in southern Spain, one of the largest regions in the European Union, has made a profound economic and social transformation that has led to establishment of a modern universal public health care system. However, due to its high stroke mortality rates, Andalusia is still known as the “Spanish Stroke Belt”. To fight these figures, successive initiatives culminated in the launch of the Andalusian Plan for Stroke Care, to be developed during the period of 2011 to 2014. In addition, involved professionals have hypothesized that clinical and experimental research may contribute to improving stroke care in our community. To that end, one of the leading institutes of biomedical research in Andalusia, the Institute of Biomedicine of Seville (IBiS), has selected stroke as a flagship project in the region. Moreover, Seville, the capital of Andalusia, is now conducting a fusion process of its two largest hospitals, with the potential to generate a stroke alliance that will make it one of the main stroke hospitals in Europe (>2000 cases per year). It is anticipated that this will be an excellent platform to facilitate acute-phase clinical trials and speed the translation process from basic research in IBiS laboratories to the clinical setting. Furthermore, the recently created Andalusian Neurovascular Group is ready to develop prospective, collaborative, multicenter research projects that will evaluate interventions in areas of stroke care uncertainty. If we succeed in forging a link between research and health care quality, we may succeed in lowering the incidence of stroke and related mortality in the region in a short period of time.

Although black men and women residing in the US experience the highest rates of mortality from both stroke and coronary heart disease (CHD)1 (1), underlying reasons for these statistics remain uncertain. Although differential traditional risk factors, access to care, and sociodemographic and psychosocial variability between race/ethnic groups might undoubtedly account for some of the observed differences, other factors might be at play. For example, whereas both ischemic stroke and CHD often share atherosclerosis as a core pathogenic element, evidence suggests that in general blacks tend to have less atherosclerotic burden measured by coronary calcium score or angiography than whites (2). Additionally, autopsy results from blacks and whites who succumb to sudden cardiac death indicate that blacks have a higher preponderance of stable plaque than whites (3). Thus, from a pathological perspective, race/ethnic differences in cardiovascular risk require further elucidation. The REGARDS (Reasons for Geographic and Racial Differences in Stroke) study was instituted to examine causes for the excess stroke mortality among US blacks and people living in the stroke belt (4). Previous publications from the study examined individual traditional risk factors for stroke and CHD. Differences between blacks and whites and by region were demonstrated—including differences in the prevalence of blood pressure and antihypertensive use, diabetes, smoking, and left ventricular hypertrophy. The estimated predicted probability of stroke, reflecting a combination of risk factors, showed clear differences by race and sex: blacks had higher 10-year stroke risk than whites (11.3% vs 9.7%, P < 0.0001), largely driven by differences in diabetes and possibly hypertension in the 2 groups (4). The same studies, however, have not explained the differences in stroke by region. Whereas the prevalence of antihypertensive use was higher among both blacks and whites residing in the stroke belt (4), there was a trend toward better treatment and …

A high burden of hypertension-related cardiovascular disease remains an unfortunate hallmark In the southeastern United States (also known as the Stroke Belt). A convergence of factors related to aging, systolic blood pressure (BP), and hypertension control rates indicate that the Southeast burden will remain and probably increase well into the next century unless strategic initiatives are undertaken soon. More specifically, systolic BP, which is a major independent risk factor, increases as a function of age, whereas diastolic BP reaches a plateau. Given a selective immigration of elderly residents from other areas of the country, the Southeast is "aging" more rapidly. Thus, Isolated systolic hypertension (ISH), which carries a very high relative risk, is likely to increase at a faster rate In the Southeast than in other areas of the U.S. Moreover, control rates for systolic BP are poorer than for diastolic BP. Hypertension control rates are also lower In elderly people than in younger patients with hypertension. In the absence of a paradigm shift in medical practice, control rates will decline as the prevalence of ISH rises In an aging population. The health and economic implications of an inadequate response to this challenge are imposing, particularly for the Southeast. On a positive note, the emerging recognition of systolic B: as a significant risk factor may lead to more appropriate recognition and higher rates of treatment and control. Randomized, controlled clinical trials have clearly established that treatment reduces BP in the elderly patient with ISH and combined systolic-diastolic hypertension. Moreover, treatment dramatically reduces hypertension-related cardiovascular complications among elderly patients with hypertension. In summary, the Southeast will lead the aging of the nation into the next century. The implications of this large demographic shift are likely to worsen rather than reduce the relative burden of cardiovascular disease in the Stroke Belt. Thus, a high priority should be given to the recognition, treatment, and control of systolic hypertension in the Southeast.

After the data collection phase of a clinical trial has been completed, new hypotheses may surface which require additional data before they can be tested. In the Veterans Affairs Cooperative Study on Single Drug Therapy of Hypertension, we investigated the relationship between location of the participating center, race and ability to control blood pressure. The analysis indicated poorer blood pressure control among sites located in the “stroke belt” (southeastern United States), especially among African-Americans. We sought to determine whether the effect was attributable to socioeconomic patternss however, income data were not collected as part of the original study. Therefore, we accessed centralized data bases to obtain zipcode-level income information for the randomized study patients. This approach yielded estimates of income data for 94.3% of the patients and compared favorably to data acquisition rates for variables which were collected prospectively in the study.

See related article, pages 2221–2227. Despite clear documentation that the “Stroke Belt” has existed for more than 60 years, we know remarkably little regarding the underlying causes. The US vital statistics system requiring the mandatory reporting of causes of death has provided nearly all of what we know about geographic disparities in stroke with virtually no data available on geographic disparities in stroke incidence. The vital statistics system allows estimates of stroke mortality rates to be made at the national level as well as for specific regions (eg, state and county level) and for specific race/sex groups. Large cohort studies, including Framingham,1 Atherosclerosis Risk in Communities (ARIC),2 Cardiovascular Health Study (CHS),3 and the Multi-Ethnic Study of Atherosclerosis (MESA),4 provide stroke incidence data; however, these outstanding studies are limited to only a few communities and provide little insight to the geographic variations in incidence. The National Health and Nutrition Examination Survey (NHANES) provides incidence data from a larger number of communities; however, even this study is limited in both the number of communities across the United States (only 81) and a sample size of only approximately 6000 individuals of ages where stroke is more prevalent.5 Although most readers of Stroke are likely aware of the Stroke Belt, they may not be aware of the paucity of data to address the next logical questions such as “Is the Stroke Belt caused by a higher incidence of stroke or a higher case fatality following stroke?” The lack of data describing the geographic disparities in stroke incidence underscores the substantial contribution of the article by Rich et al based on up to 22.5 years of follow up of a national cohort that provides a description of regional variations in stroke incidence.6 This important contribution is among the …

Abstract —A workshop to describe and then seek possible causes for the increased stroke mortality in the southeastern United States briefly considered 30 suspected correlates and discussed in more detail the 10 thought to be most likely. Recent age-adjusted stroke mortality rates in adults from industrialized countries reveal marked geographic differences. Age-adjusted statewide stroke mortality rates also differ, and they are higher in the Southeast than elsewhere in the United States. For five southeastern coastal states in the heart of the “Stroke Belt,” excess stroke mortality has been present at least since 1930. In a 20-year follow-up of 10 000 veterans, the Stroke Belt had a 25% increase in all-cause mortality and congestive heart failure. A potential cause of increased fatal stroke included hypertension, which was more frequent in the Stroke Belt. No consistent patterns of lifestyle differences or of differences in potassium or calcium intake seemed to explain the higher rates of fatal strokes in the Stroke Belt; however, detailed investigations of smaller populations in localized areas seem warranted. Some data suggest a relationship between socioeconomic status and the Stroke Belt effect. Other differences in the Southeast that could explain, at least partially, the Stroke Belt effect include presence of soft water throughout most of the area, decreased antioxidant intake, and differences in the use of medical care and in the response to antihypertensive drugs. On the basis of available information, the three most likely explanations or partial explanations for the Stroke Belt are increased levels of blood pressure, localized differences in socioeconomic status, and toxic environmental factor(s). Two major recommendations were made: (1) to encourage both patient and caregiver to use all currently available means of decreasing morbidity and mortality by controlling blood pressures at or below normal levels and by reducing other risk factors and (2) to seek precise information about relationships of identified possible causes of increased morbidity and mortality in the Stroke Belt.

Abstract —There is continuing uncertainty about whether morbidity and mortality of treated hypertensive patients depends on the drug(s) used to treat or only on the level of blood pressure achieved. This study was undertaken in a sample of special Veterans Administration hypertension clinics to determine which antihypertensive drugs were selected by the involved healthcare providers and how effective they were in achieving normotension. Hypertensive veterans (n=6100) were followed in six VA Hypertension Screening and Treatment Program clinics for 46 months beginning in May 1989. Their average age was 60.7 years; 53% lived in the Stroke Belt; 46% had target organ damage, 36% were black, 23% smoked, and 10% had diabetes mellitus. Antihypertensive regimens were divided into 12 all-inclusive categories. Blood pressures were averaged at the last study visit for all patients on a regimen. The regimens of diuretic or diuretic plus β-blocker gave the lowest average pressures (140.6/82.3 mm Hg) and calcium antagonist the highest (149.0/86.5 mm Hg). ANOVA indicated that differences between seven common regimens and also between the four single drug regimens were highly significant ( P

Background and Purpose We sought to determine whether the “Stroke Belt” has continued to shift and to assess variation in geographic patterns by age, sex, and race. Methods Mortality data for Health Service Areas for 1988 to 1992 were used for analyses of geographic mortality patterns for stroke by race, sex, and age (50, 70, and 90 years). Results In 1988 to 1992, considerable geographic variation in stroke mortality was demonstrated for each sex/race group. In black and white women and men, previously described high mortality in the southeastern United States persisted. Mortality rates were generally higher in the South than in the North and in the East than in the West. Compared with data from 1962 to 1988, there was a continuation of the previously described westward shift of high-rate areas to the Mississippi River valley, a trend more marked at age 50 years than at 70 or 90 years. Although rates in the Pacific region were low overall, a surprising area of high rates was seen in southern California among women at all three ages examined. Conclusions In whites, rapid declines in stroke mortality in the Southeast have left West South Central states with relatively high mortality rates; this trend may continue as younger cohorts age. However, rates in the Southeast also remain high, especially for blacks.

Background and Purpose The southeastern United States has stroke mortality rates above the national average. The causes for this excess mortality are unknown; however, lower socioeconomic status (SES) is a risk factor for stroke, and the lower SES in the Southeast is a potential cause. In this report we assess the proportion of the excess stroke mortality attributable to SES. Methods The more than 400 000 participants in the National Longitudinal Mortality Study were categorized into three regions: the coastal plain region of North Carolina, South Carolina, and Georgia (“stroke buckle”); the remainder of these states plus five other southern states (“stroke belt”); and the remainder of the United States. The stroke mortality rates were calculated with and without adjustment for SES, and the proportion of the excess mortality attributable to SES was estimated. Results In persons between the ages of 35 and 54 years, stroke mortality in the stroke buckle is estimated to be more than twice that of the rest of the nation and 1.7 times greater for ages 55 to 74 years. For persons in the stroke belt, the stroke mortality was 1.3 times greater than that in the rest of the nation for the ages of 35 to 54 and 55 to 74 years. Less than 16% of this excess stroke morality was attributable to SES. Conclusions SES does not appear to be a major contributor to the excess mortality in the southeastern United States. Of additional concern is the stroke buckle region, which was shown to have stroke mortality rates substantially greater than those in the traditionally recognized stroke belt.

Geographic variations in adverse health outcomes have long been recognized in the United States, with specific focus on the southeastern region of the country. Cerebrovascular disease mortality rates have identified the Southeast as the "stroke belt" for decades, though rates are also high for other hypertension-related diseases including ischemic heart disease, diabetes, and end-stage renal disease. The increased cerebrovascular disease mortality in the Southeast has prompted intervention and research efforts. This paper provides a descriptive profile of the hypertensive end-organ diseases in this area to guide research efforts and to gauge changes in health outcomes and risks. In addition to mortality from stroke, this assessment identified excessive risks from diabetes, ischemic heart disease, and end-stage renal disease for some states in the Southeast. Trend variations in health outcomes were also detected.

The higher burden that many diseases pose on racial and ethnic minorities in the United States represents one of the most significant public health problems facing modern society. Stroke is no exception, with dramatic disparities in incidence and outcome among racial and ethnic minorities, rural, and disadvantaged socioeconomic groups. National Institute of Neurological Disorders and Stroke (NINDS) efforts to address health disparities in stroke are guided by a report from the NINDS Strategic Planning Advisory Panel on Health Disparities Research, which recommended ways for the institute to achieve maximal impact with its investments in health disparities research (see http://www.ninds.nih.gov/about\_ninds/plans/NINDS\_health\_disparities\_report.htm). As outlined below, NINDS has implemented recommendations within this report and continues to incorporate the expert panel’s suggestions as new health disparities initiatives are developed and executed. The impact of stroke is higher among racial and ethnic minority groups, with an increased overall incidence and especially at younger ages among blacks, Mexican Americans, and Native populations. Geographic differences also exist with a 20% higher mortality rate in the so-called stroke belt of the …

Geographic variation in stroke rates is well established in the general population, with higher rates in the South than in other areas of the United States. ESRD is a potent risk factor for stroke, but whether regional variations in stroke risk exist among dialysis patients is unknown. Medicare claims from 2000 to 2005 were used to ascertain ischemic stroke events in a large cohort of 265,685 incident dialysis patients. A Poisson generalized linear mixed model was generated to determine factors associated with stroke and to ascertain state-by-state geographic variability in stroke rates by generating observed-to-expected (O/E) adjusted rate ratios for stroke. Older age, female sex, African American race and Hispanic ethnicity, unemployed status, diabetes, hypertension, history of stroke, and permanent atrial fibrillation were positively associated with ischemic stroke, whereas body mass index >30 kg/m2 was inversely associated with stroke (P1.0 were all in the South: North Carolina, Mississippi, and Oklahoma. Regional efforts to increase primary prevention in the “stroke belt” or to better educate dialysis patients on the signs of stroke so that they may promptly seek care may improve stroke care and outcomes in dialysis patients.

Objective To determine the association between race, region and pre-diabetes. Method The study used 2003–2007 United States baseline data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study for this cross-sectional analysis. Participants in this study were 45 years or older at recruitment. Logistic regression was used to assess whether race and region are associated with pre-diabetes independent of demographics, socioeconomic factors and risk factors. Results Twenty-four percent of the study participants (n = 19,889) had pre-diabetes. The odds ratio (95% confidence interval) for having pre-diabetes was 1.28 (1.19–1.36) for blacks relative to whites and 1.18 (1.10–1.26) for people living in the Stroke Belt region relative to the other parts of the United States. The odds of having pre-diabetes for Stroke Belt participants changed minimally after additional adjustment for race (OR = 1.20; 1.13–1.28), age and sex (OR = 1.24; 1.16–1.32), socioeconomic status (OR = 1.22; 1.15–1.31) and risk factors (OR = 1.26; 1.17–1.35). In the adjusted model, being black was independently associated with pre-diabetes (OR = 1.19; 1.10–1.28). Conclusion The prevalence of pre-diabetes was higher for both blacks and whites living in the Stroke Belt relative to living outside the Stroke Belt, and the prevalence of pre-diabetes was higher for blacks independent of region.

Background and Purpose— In 1960s, a stroke belt with high stroke mortality was discovered in the southeast United States. In China, where stroke is the leading cause of death, we aimed to determine whether a focal region of high stroke incidence (stroke belt) exits and, if so, the possible causal and modifiable factors. Methods— We systematically reviewed all studies of stroke incidence in China between 1980 and 2010, and included those which met our criteria for a high-quality study. Criteria for a provincial region of high stroke incidence were ranking in the top one third of all provinces for stroke incidence and ranking of more than one third of prefectural regions within the province in the top two sevenths of all prefectural regions for stroke incidence. We also reviewed regional distribution of major vascular risk factors, socioeconomic status, and demographic profiles in China. Results— Nine eligible studies provided data on the incidence of stroke in 32 of 34 provincial regions of China (with Hong Kong and Macao as exceptions) and 52% of the 347 prefectural regions. Nine provincial regions (Heilongjiang, Tibet, Jilin, Liaoning, Xinjiang, Hebei, Inner Mongolia, Beijing, and Ningxia) met our criteria for a region of high stroke incidence and constitute a stroke belt in north and west China. The incidence of stroke in the stroke belt was 236.2 per 100 000 population compared with 109.7 in regions outside the belt (rate ratio, 2.16; 95% confidence interval, 2.10–2.22). The mean population prevalence of hypertension and overweight (body mass index, >25) was greater in the stroke belt than that in other regions (15.3% versus 10.3%, P P =0.013, respectively). The prevalence of hypertension and overweight also correlated significantly with regional stroke incidence ( R =0.642, P R =0.438, P =0.014, respectively, by Spearman rank correlation). Conclusions— A stroke belt of high stroke incidence exists in 9 provincial regions of north and west China. The stroke belt may be caused, at least in part, by a higher population prevalence of hypertension and excess body weight. Lowering blood pressure and body weight in the stroke belt may reduce the geographic disparity in stroke risk and incidence in China.

Background and Purpose— Evaluation at primary stroke centers (PSCs) has the potential to improve outcomes for patients with stroke. We looked for differences in evaluation at Joint Commission certified PSCs by race, education, income, and geography (urban versus nonurban; Southeastern Stroke Belt versus non-Stroke Belt). Methods— Community-dwelling, black and white participants from the national Reasons for Geographic And Racial Differences in Stroke (REGARDS) prospective population–based cohort were enrolled between January 2003 and October 2007. Participants were contacted at 6-month intervals for suspected stroke events. For suspected stroke events, it was determined whether the evaluating hospital was a certified PSC. Results— Of 1000 suspected strokes, 204 (20.4%) strokes were evaluated at a PSC. A smaller proportion of women than men (17.8% versus 23.0%; P =0.04), those with a previous stroke (15.1% versus 21.6%; P =0.04), those living in the Stroke Belt (14.7% versus 27.3%; P P Conclusions— Disparities in evaluation by PSCs are predominately related to geographic factors but not to race, education, or low income. Despite an increased burden of cerebrovascular disease in the Stroke Belt, subjects there were less likely to be evaluated at certified hospitals.

To the Editor: We read with great interest the recent article published by Judd et al1 in which a study on risk of future stroke recurrence was described. The authors specifically studied different types of baseline ischemic strokes influencing US patients’ future risk of ischemic stroke in a sample from the south eastern sector of the United States, also known as the stroke belt. This study found a graded association between baseline stroke type and future stroke risk, increasing from patients reporting stroke symptoms only, transient ischemic attack, distant stroke, or recent stroke. This information is clinically relevant as it clearly shows that not all previous strokes are the same, and the risk of recurrent stroke increases as severity of stroke increases and also if the stroke is more recent (defined …

Background: Elderly survivors of acute myocardial infarction (AMI) are at elevated risk for hemorrhagic stroke, which has a mortality rate of approximately 50%. Increasing use of warfarin for arterial fibrillation and anti-platelet agents for AMI combined with an increasing aging population may have influenced the risk of post-AMI strokes. We sought to characterize temporal trends in the risk for and mortality from hemorrhagic stroke over 12 years among older AMI survivors of different age, sex, race, revascularization status, and region within the US. Methods: We used 100% of Medicare inpatient claims data to identify all fee-for-service (FFS) patients aged> 64 years who were hospitalized for AMI in 1999-2010. We excluded patients who died during the hospitalization or were transferred. Revascularization procedures were identified during the index admission. We used a Cox proportional-hazards regression model to estimate the risk-adjusted annual changes in one-year hemorrhagic stroke hospitalization after AMI, overall and by subgroups. Changes were adjusted by age, gender, race, medical history and comorbidities. We calculated the 30-day mortality among patients readmitted for hemorrhagic stroke. Stroke belt regions were defined as the states with high stroke hospitalization rates in the southeast United States. Results: Among 2,433,036 AMI hospitalizations and 4,852 hemorrhagic stroke readmissions, the risk-adjusted one-year post-AMI hemorrhagic stroke rate remained stable from 1999 to 2010 (range, 0.2% to 0.3%). No significant trends were found for post-AMI stroke rates across all age-sex-race groups and all treatment groups (Figure). Thirty-day mortality rates for stroke after AMI did not show significant changes (1999, 46.7%, 95% CI 39.9%-53.7%; 2010, 50.7%, 95% CI 45.3%-56.1%; range: 46.5% to 54.6%). No difference was found in post-AMI hemorrhagic stroke rates between the stroke belt and non-stroke belt regions. Conclusions: From 1999 to 2010, the overall hospitalization rates of hemorrhagic stroke after AMI were relatively stable without significant changes across all subgroups. Thirty-day mortality rates remained largely unchanged over time. Stroke risk in the stroke belt was not found significantly higher comparing with non-stroke belt states.

The Eastern North Carolina Stroke Network was formed in 2006 by local partners in 30 counties in what is known as the buckle of the stroke belt, where stroke mortality is alarmingly high. The organization's goal is to improve the continuum of stroke care from community prevention through recovery.