Abstract 2535: Urban Versus Rural Differences In Stroke Risk: The CDC Wonder Estimates Of Mortality, And REasons For Geographic And Racial Differences In Stroke (REGARDS) Estimates Of Incidence And Survival After Stroke

Introduction: Rural-urban disparities in stroke are poorly understood and incompletely characterized. US stroke incidence, mortality, and survival after stroke have not, to our knowledge, been previously reported by urban-rural status. Methods: Data for US residents over age 45 from the CDC WONDER system were used to describe the age-adjusted stroke mortality rates between 1999 and 2007 for each county in the US, stratified by rurality. Stroke was defined by ICD-10 codes 60-69. Rurality was defined at the county level using the National Center for Health Statistics 6-level classification scheme. Data from the REGARDS Study, a longitudinal cohort study of 30,239 black and white participants aged 45+ from 48 states, were used to estimate the age and sex adjusted hazard ratio for incident stroke, and to assess survival after stroke, using the same urban/rural classification scheme. Results: Between 1999 and 2007, stroke mortality (per 100,000) for those aged 45+ was higher in rural counties for both whites and blacks, with a 20% difference in whites (156.6 for rural versus 131.0 for central metropolitan) and a 32% difference in blacks (237.4 versus 179.6). Among 27,740 REGARDS participants who were stroke-free at baseline with follow-up data, 614 adjudicated stroke events occurred over a mean 4.9 years of follow-up. For whites, incident stroke risk did not change with higher urbanization (HR reported in table ). There was a consistently lower risk of incident stroke with higher urbanization for blacks although this difference did not reach statistical significance (see table ). Follow-up was available on 609 of the stroke events. Risk of death after stroke appeared consistently (although generally non-significantly) lower with greater urbanization (see table ) for both blacks and whites. Discussion: Greater urbanization appears to be associated with lower stroke mortality for both whites and blacks, although differences may be larger for blacks. This difference in mortality may be due to both decreased incidence and survival following stroke for blacks; however, higher mortality for rural whites appears to be only due to decreased survival. Reasons for differences in incidence and survival following stroke may be related to control of vascular risk factors and access to care although further study is required.

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Abstract P287: Sex Differences in Stroke Incidence: The REGARDS Study

Circulation ◽

10.1161/circ.125.suppl_10.ap287 ◽

2012 ◽

Vol 125 (suppl_10) ◽

Author(s):

Virginia J Howard ◽

Suzanne E Judd ◽

Abraham J Letter ◽

Dawn O Kleindorfer ◽

Leslie A McClure ◽

...

Keyword(s):

Sex Differences ◽

Stroke Risk ◽

Proportional Hazards ◽

Population Based ◽

Incidence Rates ◽

National Data ◽

Stroke Incidence ◽

The Difference ◽

Regards Study

Background: There are strikingly few national data available to describe sex differences in age-specific stroke incidence. Methods: REGARDS is a national, population-based, longitudinal study of black and white participants aged > 45 years old, with oversampling of blacks and residents of the stroke belt. Between 2003 and 2007, 30,239 participants were enrolled and examined; follow-up is every 6 months by telephone for self- or proxy-reported stroke, with retrieval and adjudication of medical records by physicians. This analysis included 27,756 participants with follow up data who had no physician-diagnosed stroke at baseline. Stroke incidence rates were calculated as the number of stroke events divided by the person-years at risk with 95% confidence limits. Proportional hazards models were used to assess the race-specific association of sex with stroke risk by age strata (<65, 65–74, and 75+) after adjustment for socioeconomic factors, and Framingham stroke risk factors. Results: There were 613 incident strokes events over 135,551 person-years of follow-up. Stroke incidence rates increased with age (from 237/100,000 to 1003/100,000), and were higher in men than women in both blacks and whites (left panel of figure). After multivariable adjustment, men had higher risk than women at younger ages (<75) but for the 65–75 age group, the difference is larger for blacks than whites (right panel of figure). Discussion: These national data confirm the patterns in male/female stroke risk observed in the Greater Cincinnati/Northern Kentucky Stroke Study, with smaller sex differences at older ages, and for men, larger excess risk in whites than blacks.

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Abstract 183: Depressive Symptoms and Incident Stroke in Black and White Participants in the REGARDS Study

Stroke ◽

10.1161/str.43.suppl_1.a183 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Audrey L Austin ◽

Michael G Crowe ◽

Martha R Crowther ◽

Virginia J Howard ◽

Abraham J Letter ◽

...

Keyword(s):

Risk Factors ◽

Risk Factor ◽

Depressive Symptoms ◽

Racial Differences ◽

Stroke Risk ◽

Depression Scale ◽

Stroke Incidence ◽

Blacks And Whites ◽

The Impact

Background and Purpose: Research suggests that depression may contribute to stroke risk independent of other known risk factors. Most studies examining the impact of depression on stroke have been conducted with predominantly white cohorts, though blacks are known to have higher stroke incidence than whites. The purpose of this study was to examine depressive symptoms as a risk factor for incident stroke in blacks and whites, and determine whether depressive symptomatology was differentially predictive of stroke among blacks and whites. Methods: The REasons for Geographic and Racial Differences in Stroke (REGARDS), is a national, population-based longitudinal study designed to examine risk factors associated with black-white and regional disparities in stroke incidence. Among 30,239 participants (42% black) accrued from 2003-2007, excluding those lacking follow-up or data on depressive symptoms, 27,557 were stroke-free at baseline. As of the January 2011 data closure, over an average follow-up of 4.6 years, 548 incident stroke cases were verified by study physicians based on medical records review. The association between baseline depressive symptoms (assessed via the Center for Epidemiological Studies Depression scale, 4-item version) and incident stroke was analyzed with Cox proportional hazards models adjusted for demographic factors (age, race, and sex), stroke risk factors (hypertension, diabetes, smoking, atrial fibrillation, and history of heart disease), and social factors (education, income, and social network). Results: For the total sample, depressive symptoms were predictive of incident stroke. The association between depressive symptoms and stroke did not differ significantly based on race (Wald X 2 = 2.38, p = .1229). However, race-stratified analyses indicated that the association between depressive symptoms and stroke was stronger among whites and non-significant among blacks. Conclusions: Depressive symptoms were an independent risk factor for incident stroke among a national sample of blacks and whites. These findings suggest that assessment of depressive symptoms may warrant inclusion in stroke risk scales. The potential for a stronger association in whites than blacks requires further study.

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The Association of Atrial Fibrillation and Ischemic Stroke in Patients on Hemodialysis: A Competing Risk Analysis

Canadian Journal of Kidney Health and Disease ◽

10.1177/2054358119878719 ◽

2019 ◽

Vol 6 ◽

pp. 205435811987871 ◽

Cited By ~ 4

Author(s):

Mark Findlay ◽

Rachael MacIsaac ◽

Mary Joan MacLeod ◽

Wendy Metcalfe ◽

Manish M. Sood ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Stroke Risk ◽

Competing Risk ◽

Discharge Data ◽

Stroke Incidence ◽

Risk Of Death ◽

Hazards Model ◽

The Relationship

Background: Stroke is common in patients with end-stage renal disease (ESRD) treated with hemodialysis (HD) and associated with high mortality rate. In the general population, atrial fibrillation (AF) is a major risk factor for stroke and therapeutic anticoagulation is associated with risk reduction, whereas in ESRD the relationship is less clear. Objective: The purpose of this study is to demonstrate the influence of AF on stroke rates and probability in those on HD following competing risk analyses. Design: A national record linkage cohort study. Setting: All renal and stroke units in Scotland, UK. Patients: All patients with ESRD receiving HD within Scotland from 2005 to 2013 (follow-up to 2015). Measurements: Demographic, clinical, and laboratory data were linked between the Scottish Renal Registry, Scottish Stroke Care Audit, and hospital discharge data. Stroke was defined as a fatal or nonfatal event and mortality derived from national records. Methods: Associations for stroke were determined using competing risk models: the cause-specific hazards model and the Fine and Gray subdistribution hazards model accounting for the competing risk of death in models of all stroke, ischemic stroke, and first-ever stroke. Results: Of 5502 patients treated with HD with 12 348.6-year follow-up, 363 (6.6%) experienced stroke. The stroke incidence rate was 26.7 per 1000 patient-years. Multivariable regression on the cause-specific hazard for stroke demonstrated age, hazard ratio (HR) (95% confidence interval [CI]) = 1.04 (1.03-1.05); AF, HR (95% CI) = 1.88 (1.25-2.83); prior stroke, HR (95% CI) = 2.29 (1.48-3.54), and diabetes, HR (95% CI) = 1.92 (1.45-2.53); serum phosphate, HR (95% CI) = 2.15 (1.56-2.99); lower body weight, HR (95% CI) = 0.99 (0.98-1.00); lower hemoglobin, HR (95% CI) = 0.88 (0.77-0.99); and systolic blood pressure (BP), HR (95% CI) = 1.01 (1.00-1.02), to be associated with an increased stroke rate. In contrast, the subdistribution HRs obtained following Fine and Gray regression demonstrated that AF, weight, and hemoglobin were not associated with stroke risk. In both models, AF was significantly associated with nonstroke death. Limitations: Our analyses derive from retrospective data sets and thus can only describe association not causation. Data on anticoagulant use are not available. Conclusions: The incidence of stroke in HD patients is high. The competing risk of “prestroke” mortality affects the relationship between AF and risk of future stroke. Trial designs for interventions to reduce stroke risk in HD patients, such as anticoagulation for AF, should take account of competing risks affecting associations between risk factors and outcomes.

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Abstract P28: Awareness and Management of CVD Risk Factors and Area-Level Mortality Regions in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.4.suppl_1.ap28 ◽

2011 ◽

Vol 4 (suppl_1) ◽

Author(s):

Monika M Safford ◽

Gaurav Parmar ◽

Todd M Brown ◽

Martha Hovater ◽

David Roth ◽

...

Keyword(s):

Risk Factors ◽

Racial Differences ◽

Community Dwelling ◽

Stroke Mortality ◽

Cvd Risk Factors ◽

Cvd Risk ◽

National Cohort ◽

Urban Rural ◽

Regards Study ◽

And Control

Background: Federally designated Health Professional Shortage Areas (HPSA) receive extra resources, but recent reports suggest that HPSAs may not consistently identify areas of need. We examined an alternative approach to designating areas of need based on county-level ischemic heart disease (IHD) and stroke mortality rates. Methods: We examined participants in the REGARDS Study, a national cohort of 30,239 US community-dwelling adults (42% African Americans) aged ≥45 recruited 2003-7. “Need” was defined by awareness, treatment or control of hypertension (n=21,118), diabetes (6,355) or hyperlipidemia (21,096). Awareness and treatment were self-reported, and control was defined as BP <140/90 mmHg (<130/80 for diabetes or chronic kidney disease) for hypertension; fasting blood sugar <140 mg/dL (<200 if non-fasting) for diabetes; and LDL cholesterol <130 mg/dL for hyperlipidemia. Each county was categorized into race-specific tertiles of IHD and, separately, stroke mortality, using 1999-2006 CDC data (based on death certificates). Sociodemographics, health behaviors, physical functioning and insurance status were included in separate multivariable models describing the relationships between IHD and stroke mortality and each element of need. Results: Participants resided in 1821 US counties, 578 in the lowest IHD mortality tertile (597 for stroke), 628 in the medium (586), and 627 in the highest (638). Awareness and treatment of CVD risk factors were similar for residents in counties across IHD and stroke mortality tertiles, but control tended to be lower in counties in the highest mortality tertiles (Table). Conclusions: Research is needed to elucidate why some CVD risk factor control is worse in areas of high CVD mortality despite similar levels of awareness or treatment of disease between high and low mortality areas. High stroke and IHD mortality may be one way to designate areas of need for resource allocation… Table. Adjusted * OR (95% CI) for Residence in a County in the Highest vs. Lowest (ref) IHD and Stroke Mortality Tertiles, ** for Awareness, Treatment, and Control of Hypertension, Diabetes and Hyperlipidemia. Outcome Hypertension Diabetes Hyperlipidemia IHD Stroke IHD Stroke IHD Stroke Awareness 1.14 (0.97,1.35) 1.07 (0.90,1.28) 1.02 (0.78,1.34) 0.98 (0.73,1.31) 1.05 (0.94,1.17) 0.98 (0.87,1.10) Treatment 1.10 (0.85,1.43) 0.80 (0.61,1.04) 1.21 (0.96,1.52) 1.12 (0.88,1.42) 1.06 (0.94,1.20) 1.02 (0.90,1.15) Control 1.00 (0.89,1.12) 0.88 (0.78,0.99) 0.79 (0.64,0.96) 0.82 (0.64,1.05) 0.83 (0.70,0.98) 0.95 (0.80,1.14) * Adjusted for age, race, gender, education, income, urban/rural residence, alcohol/tobacco use, medication adherence, exercise, BMI, and functional status. ** Race-specific tertiles.

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Abstract 52: Contributors to the Rural Excess in Stroke Mortality: The REasons for Geographic and Racial Differences in Stroke (REGARDS) Study

Stroke ◽

10.1161/str.48.suppl_1.52 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

George Howard ◽

Dawn O Kleindorfer ◽

D. L Long ◽

Mary Cushman ◽

Virginia J Howard ◽

...

Keyword(s):

Risk Factors ◽

Risk Factor ◽

Racial Differences ◽

Proportional Hazards ◽

Case Fatality ◽

Stroke Mortality ◽

Rural Regions ◽

Stroke Incidence ◽

Regards Study ◽

The Impact

Introduction: One NIH goal is to investigate the US nationwide rural-urban health disparities; however, few studies provide data to help understand the 30% higher rural stroke mortality. It is unknown if the higher stroke mortality is attributable to a higher incidence of stroke, or to a higher case fatality, in rural regions. Further, the role of risk factors or SES status in higher incidence or case-fatality is unknown. Methods: REGARDS participants stroke-free at baseline (n = 25,090) were stratified by Rural-Urban Commuting Area strata: urban, large rural city/town, or small rural town or isolated region. Participants were followed for incident stroke, and case fatality was defined as death within 30-days of a stroke. Difference in incident stroke was assessed using proportional hazards analysis, and case-fatality by logistic regression, each considered after adjustment for demographic factors, further adjustment for risk factors, and further adjustment for SES. Results: Over an average follow-up of 8.2 years, 1,060 incident strokes occurred, of which 160 died within 30 days. Risk of incident stroke increased with rurality (p = 0.016), with a hazard 1.21-times (95% CI: 1.00 - 1.46) higher in large rural cities/towns, and 1.24-times (95% CI: 1.00 - 1.54) higher in small rural towns or isolated regions (see table). Adjustment for risk factors and SES attenuated the estimated risk by 50%, and the association became non-significant. There was no evidence of a higher case-fatality from stroke in rural regions (p > 0.46). Discussion: The higher stroke mortality in rural regions appears to be attributable to higher stroke incidence, and not to higher case-fatality. Higher stroke incidence in rural regions is partially attributable to a worse risk factor profile and lower SES. Efforts to reduce rural disparity in stroke mortality should focus on preventive strategies, especially those relevant to risk factor development and control, and/or mitigating the impact of lower SES.

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Abstract 19554: Lipoprotein(a) and Risk of Ischemic Stroke in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study

Circulation ◽

10.1161/circ.132.suppl_3.19554 ◽

2015 ◽

Vol 132 (suppl_3) ◽

Author(s):

Kristine S Alexander ◽

Neil A Zakai ◽

Fred Unverzagt ◽

Virginia Wadley ◽

Brett M Kissela ◽

...

Keyword(s):

Ischemic Stroke ◽

Racial Differences ◽

Stroke Risk ◽

Proportional Hazards ◽

Continuous Variable ◽

Cox Proportional Hazards ◽

Stroke Incidence ◽

Lipoprotein A ◽

Cox Proportional Hazards Models ◽

Regards Study

Background: Increased lipoprotein (a) (Lp(a)) is associated with coronary risk, but links with stroke have been less consistent. Blacks have 2-4-fold higher Lp(a) levels than whites, and have higher stroke incidence than whites, but have been under-represented in studies of Lp(a) and stroke to date. Hypothesis: Lp(a) is a risk factor for ischemic stroke, and this risk differs by race. Methods: REGARDS recruited 30,239 black and white U.S. men and women in 2003-7 to study regional and racial differences in stroke mortality. We measured Lp(a) by immunonepholometric assay in 572 cases of incident ischemic stroke and a 1,104-person cohort random sample. The hazard ratio of stroke by baseline Lp(a) was calculated using Cox proportional hazards models, stratified by race. Lp(a) was modeled both as a continuous variable (per sex- and race-specific SD) and in sex- and race-specific quartiles, given known differences in distributions by race and sex. Results: As shown in the Figure, being in the 4 th vs 1 st Lp(a) quartile was associated with ischemic stroke in black but not white participants, adjusted for age and sex (Model 1). The HRs were essentially unchanged with added adjustment for stroke risk factors (Model 2). There was no significant association between Lp(a) as a continuous variable and stroke, though race-specific patterns were similar. There remained no association between Lp(a) and stroke in whites when we used the sex- and race-specific 90 th percentile as a cut-off (HR: 0.91 95% CI: 0.52, 1.60). Discussion: Lp(a) was associated with ischemic stroke risk in black but not white REGARDS participants, this might partly explain the black/white disparity in stroke. Further studies in racially diverse groups are necessary to confirm these findings. Figure 1. Hazard ratios for Lp(a) and stroke in blacks and whites, per quartile (compared with first quartile) and SD.

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Abstract W MP64: Incident Stroke and Alcohol Consumption among Older Adults

Stroke ◽

10.1161/str.46.suppl_1.wmp64 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Solveig A Cunningham ◽

Aleena Mosher ◽

Suzanne E Judd ◽

Lisa M Matz ◽

Edmond K Kabagambe ◽

...

Keyword(s):

Alcohol Consumption ◽

Racial Differences ◽

Medical Records ◽

Stroke Risk ◽

Proportional Hazard ◽

Black And White ◽

Stroke Risk Factors ◽

Regards Study ◽

White Adults

Background: Alcohol consumption may reduce the risk of stroke. While both stroke and alcohol consumption patterns differ by race and sex, it is not known to what extent alcohol consumption contributes to the elevated risk of stroke in some groups, particularly in men and blacks in general. Methods: Risk of stroke was studied in 25,162 black and white adults aged 45+, in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. Information on alcohol consumption was obtained by telephone interview at baseline. Participants are contacted every 6 months by telephone for self- or proxy-reported stroke; medical records are retrieved and adjudicated by physicians Proportional hazard models, adjusted for demographic, socioeconomic, and stroke risk factors , were used. Results: Participants’ mean age was 64.7 years; 40% were black and 56% were women with 867 stroke events and a median follow-up time of 7.6 years. Compared to current drinkers, non-drinkers had 36% higher hazards of incident stroke which was significantly higher consistent across all race-sex groups except black men. Risks were particularly high among past drinkers (50% higher than among current drinkers), as would be expected since many may have stopped drinking due to health problems. However, risks were also elevated among lifetime abstainers. Differences in stroke risks were explained by demographic and socioeconomic differences between drinkers and non-drinkers. Among those who are current drinkers, those who consumed <1 drink per week had significantly lower hazards of stroke than moderate drinkers, and these protective factors remained marginally significant after accounting for demographic, socioeconomic, behavioral and health characteristics. Conclusions: Results suggest that individuals who do not currently consume alcohol may experience higher risks of stroke, which may be due in part due to socio-demographic and other characteristics associated with consuming alcohol.

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The Carpentier-Edwards Classic and Physio Mitral Annuloplasty Rings: A Randomized Trial

The Heart Surgery Forum ◽

10.1532/hsf.419 ◽

2006 ◽

Vol 8 (5) ◽

pp. 389 ◽

Cited By ~ 9

Author(s):

Ghada M. M. Shahin ◽

Geert J. M. G. van der Heijden ◽

Michiel L. Bots ◽

Maarten-Jan Cramer ◽

Wybren Jaarsma ◽

...

Keyword(s):

Left Ventricular Function ◽

Ventricular Function ◽

Absolute Risk ◽

Statistical Significance ◽

Nyha Class ◽

Left Ventricular ◽

Mitral Annuloplasty ◽

Risk Of Death ◽

Late Failure

Objective: To evaluate clinical and echocardiographic outcomes for the semi-flexible Carpentier-Edwards Physio and the rigid Classic mitral annuloplasty ring. Methods: Ninety-six patients were randomized for either a Classic (n = 53) or a Physio (n = 43) ring from October 1995 through July 1997. Mean follow-up was 5.1 years (range .1-6.6). We included standard patient characteristics at baseline and during follow-up. Analyses were adjusted for age and gender, and for factors that differed across groups at baseline. In 2002, echocardiography was performed in 74% of the survivors. Results: We found a 16% difference in mortality: 14% in the Physio group (n = 6) and 30% in the Classic group (n = 16) (adjusted P = .41). Life table analysis shows that the absolute risk of death after 30 months is lower in the Physio group. Intra-operative repair failure occurred in 3 patients (6%) of the Classic group, and in 4 (9%) of the Physio group, resulting in mitral valve replacement. Late failure occurred in 1 patient (2%) in the Classic group, and in 4 (9%) in the Physio group. At follow-up, left ventricular function did not differ across groups (ejection fraction 45% and 48% (adjusted P = .65)). The combined NYHA class III-IV had improved for the Classic group in 42% and for the Physio group in 34%. Conclusion: Although the 16% difference in mortality did not reach statistical significance, it is considered clinically important. No differences in morbidity, valve function, and left ventricular function were found. Further research to explain the difference in mortality is required.

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Enrolling Incident Caregivers and Matched Controls From a Nationwide Epidemiological Study

Innovation in Aging ◽

10.1093/geroni/igaa057.2272 ◽

2020 ◽

Vol 4 (Supplement_1) ◽

pp. 658-658

Author(s):

David Roth ◽

William Haley ◽

Orla Sheehan ◽

J David Rhodes ◽

Virginia Howard

Keyword(s):

Blood Sample ◽

Epidemiological Study ◽

Racial Differences ◽

Family Caregiving ◽

Regards Study

Abstract Participants in the national Reasons for Geographic and Racial Differences in Stroke (REGARDS) study were asked about family caregiving responsibilities at enrollment (2003-2007). Among the 88% of participants who were not caregivers at enrollment, 1,229 reported becoming caregivers before a follow-up interview 12 years later. The Caregiving Transitions Study screened these participants and enrolled 251 as incident caregivers. All reported 5 or more hours of care per week, provided assistance with at least one ADL or IADL, and were caregivers for at least 3 months before a 2nd blood sample was obtained in the REGARDS study. A total of 251 noncaregiving control participants who reported no caregiving responsibilities over this 12-year period were also enrolled. Each control was matched to a caregiver on age (+ 5 years), sex, race, other demographics, and baseline (pre-caregiving) health variables. Descriptive analyses confirm the unique comparability of the samples compared to previous caregiving studies.

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Abstract 88: Social Inequalities in Stroke Mortality, Incidence and Case-fatality in Europe.

Stroke ◽

10.1161/str.47.suppl_1.88 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Marco M Ferrario ◽

Giovanni Veronesi ◽

Kari Kuulasmaa ◽

Martin Bobak ◽

Lloyd E Chambless ◽

...

Keyword(s):

Risk Factors ◽

Social Inequalities ◽

Cox Regression ◽

Case Fatality ◽

Stroke Mortality ◽

Stroke Incidence ◽

Low Education ◽

Mortality Incidence ◽

European Populations

Introduction and aim: There are limited comparative data on social inequalities in stroke morbidity across Europe. We aimed to assess the magnitude of educational class inequalities in stroke mortality, incidence and 1-year case-fatality in European populations. Methods: The MORGAM study comprised 45 cohorts from Finland, Denmark, Sweden, Northern Ireland, Scotland, France, Germany, Italy, Lithuania, Poland and Russia, mostly recruited in mid 1980s-early 90s. Baseline data collection and follow-up (median 12 years) for fatal and non-fatal strokes adhered to MONICA-like procedures. Stroke mortality was defined according to the underlying cause of death (ICD-IX codes 430-438 or ICD-X I60-I69). We derived 3 educational classes from population-, sex- and birth year-specific tertiles of years of schooling. We estimated the age-adjusted difference in event rates, and the age- and risk factor-adjusted hazard ratios (HRs), between the bottom and the top of the educational class distribution from sex- and population-specific Poisson and Cox regression models, respectively. The association between 1-year case-fatality and education was estimated through logistic models adjusted for risk factors. Results: Among the 91,563 CVD-free participants aged 35-74 at baseline, 1037 stroke deaths and 3902 incident strokes occurred during follow-up. Low education accounted for 26 additional stroke deaths per 100,000 person-years in men (95%CI: 9 to 42), and 19 (7 to 32) in women. In both genders, inequalities in fatal stroke rates were larger in the East EU and in the Nordic Countries populations. The age-adjusted pooled HRs of first stroke, fatal or non-fatal, for the least educated men and women were 1.52 (95%CI: 1.29-1.78) and 1.51 (1.25-1.81), respectively, consistently across populations. Adjustment for smoking, blood pressure, HDL-cholesterol and diabetes attenuated the pooled HRs to 1.34 (95%CI: 1.14-1.57) in men and 1.29 (1.07-1.55) in women. A significant association between low education and increased 1-year case-fatality was observed in Northern Sweden only. Conclusions: Social inequalities in stroke incidence are widespread in most European populations, and less than half of the gap is explained by major risk factors.

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