ORIGINAL RESEARCH ARTICLE
Prevalence, Incidence, and Mortality of Stroke
in China
Results from a Nationwide Population-Based Survey of 480 687 Adults
ORIGINAL
RESEARCH
BACKGROUND: China bears the biggest stroke burden in the (65/100 000
world. However, little is known about the current prevalence, person-years)
incidence, and mortality of stroke at the national level, and the (P<0.002).
trend in the past 30 years.
CONCLUSIONS:
METHODS: In 2013, a nationally representative door-to-door Stroke burden in China
survey was conducted in 155 urban and rural centers in 31 has increased over the
provinces in China, totaling 480 687 adults aged ≥20 years. All past 30 years, and
stroke survivors were considered remains particularly
as prevalent stroke cases at the prevalent time (August 31, high in rural areas.
2013). First- ever strokes that occurred during 1 year preceding There is a north-to-
the survey point- prevalent time were considered as incident south gradient in
cases. According to computed tomography/MRI/autopsy findings, stroke in China, with
strokes were categorized into ischemic stroke, intracerebral the greatest stroke
Downloaded from http://ahajournals.org by on June 28,
hemorrhage, subarachnoid hemorrhage, and stroke of burden observed in the
undetermined type. northern and central
regions.
RESULTS: Of 480 687 participants, 7672 were diagnosed with a
prevalent stroke (1596.0/100 000 people) and 1643 with
incident strokes (345.1/100000 person-years). The age-
standardized prevalence, incidence, and mortality rates were
1114.8/100 000 people, 246.8 and 114.8/100 000 person-years,
respectively. Pathological type of stroke was documented by
computed tomography/MRI brain scanning in 90% of prevalent
and 83% of incident stroke cases. Among incident and prevalent
strokes, ischemic stroke constituted 69.6% and 77.8%,
intracerebral
hemorrhage 23.8% and 15.8%, subarachnoid hemorrhage 4.4%
and 4.4%, and undetermined type 2.1% and 2.0%, respectively.
Age-specific stroke prevalence in men aged ≥40 years was
significantly greater than the prevalence in women (P<0.001).
The most prevalent risk factors among stroke survivors were
hypertension (88%), smoking (48%), and alcohol use (44%). Stroke
prevalence estimates in 2013 were statistically greater than
those reported in China 3 decades ago, especially among rural
residents (P=0.017). The highest annual incidence and mortality
of stroke was
in Northeast (365 and 159/100000 person-years), then
Central areas (326 and 154/100 000 person-years), and the
lowest incidence was in Southwest China (154/100 000
person-years), and the lowest mortality was in South China
Circulation. 2017;135:759–771. DOI: February 21, 75
10.1161/CIRCULATIONAHA.116.025250 2017 9
,Wenzhi Wang, MD Bin Jiang, MD
Haixin Sun, MD, PhD Xiaojuan Ru, PhD Dongling Sun, PhD
Linhong Wang, MD Limin Wang, MD Yong Jiang, MD Yichong Li,
PhD
Yilong Wang, MD, PhD Zhenghong Chen, PhD Shengping Wu,
MD Yazhuo Zhang, MD David Wang, DO Yongjun Wang, MD
Valery L. Feigin, MD, PhD for the NESS-China
Investigators
Correspondence to: Wenzhi Wang, MD, Beijing Neurosurgical Institute, Capital Medical
University, 6 TiantanXili, Dongcheng District, Beijing, 100050, China. E-mail
or Yongjun Wang, MD, Beijing Tiantan Hospital, Capital Medical
University, 6 TiantanXili, Dongcheng District, Beijing, 100050, China. E-mail
or Valery L. Feigin, MD, PhD, National Institute for Stroke and Applied Neurosciences,
Auckland University of Technology, Auckland, New Zealand. E-mail valery.feigin@
aut.ac.nz
Sources of Funding, see page 768
Key Words: demographics
■incidence ■ mortality
■prevalence ■ stroke ■ surveys and questionnaires
© 2017 American Heart Association, Inc.
Circulation. 2017;135:759–771. DOI: February 21, 75
10.1161/CIRCULATIONAHA.116.025250 2017 9
, Wang et al in China (NESS-China) was to identify the true
stroke bur- den (incidence, prevalence, and
mortality) in men and women of ≥20 years of
Clinical Perspective
What Is New?
high in rural areas, and that there is a north-to-south gradient in stroke in China, with the greatest stroke burden observed in
What Are the Clinical Implications?
care and rehabilitation staff), with priority setting for stroke care (eg, the need for greater resources required for northern an
age across all major regions of
China in 2012 to 2013.
S
troke is the third most common cause of
death in most Western countries, after
coronary heart disease and cancer,1,2 but it
has been the leading cause of death in China
in recent years,3,4constituting almost one-third
of the total number of deaths from stroke
Downloaded from http://ahajournals.org by on June 28,
worldwide.2 By 2013, 27 of 33 provinces in
China had stroke as the leading cause of
death.5 How- ever, previous studies of stroke
epidemiology in China were either not
population based, or of limited scope and
diagnostic accuracy (eg, confined to the age
group between 25 and 74 years, lacked
neuroimaging veri- fication of pathological
type of stroke, suffered from selection bias or
were based on small, not nationally
representative sample sizes), and most of
them were conducted 20 to 30 years ago.6–10
In addition, in the past 2 decades, China has
experienced rapid health transitions and
sociodemographic changes5,11 that have had
an impact on the prevalence of common
stroke risk factors.11 For example, there was a
large increase in the prevalence of
hypertension, smoking, overweight, and
diabetes mellitus, all of which might have
affected stroke burden in China.11–18
Therefore, obtaining more up-to-date and
accurate estimates of stroke burden (as
measured by incidence, prevalence, and
mortality) and its secular trend across China
is crucial for evidence-based and region-
specific plan- ning and evaluation of the
effectiveness of the currently implemented
treatment and prevention strategies. The goal
of this national epidemiological survey of stroke
7 February 21, Circulation. 2017;135:759–771. DOI:
Prevalence, Incidence, and Mortality of Stroke
in China
Results from a Nationwide Population-Based Survey of 480 687 Adults
ORIGINAL
RESEARCH
BACKGROUND: China bears the biggest stroke burden in the (65/100 000
world. However, little is known about the current prevalence, person-years)
incidence, and mortality of stroke at the national level, and the (P<0.002).
trend in the past 30 years.
CONCLUSIONS:
METHODS: In 2013, a nationally representative door-to-door Stroke burden in China
survey was conducted in 155 urban and rural centers in 31 has increased over the
provinces in China, totaling 480 687 adults aged ≥20 years. All past 30 years, and
stroke survivors were considered remains particularly
as prevalent stroke cases at the prevalent time (August 31, high in rural areas.
2013). First- ever strokes that occurred during 1 year preceding There is a north-to-
the survey point- prevalent time were considered as incident south gradient in
cases. According to computed tomography/MRI/autopsy findings, stroke in China, with
strokes were categorized into ischemic stroke, intracerebral the greatest stroke
Downloaded from http://ahajournals.org by on June 28,
hemorrhage, subarachnoid hemorrhage, and stroke of burden observed in the
undetermined type. northern and central
regions.
RESULTS: Of 480 687 participants, 7672 were diagnosed with a
prevalent stroke (1596.0/100 000 people) and 1643 with
incident strokes (345.1/100000 person-years). The age-
standardized prevalence, incidence, and mortality rates were
1114.8/100 000 people, 246.8 and 114.8/100 000 person-years,
respectively. Pathological type of stroke was documented by
computed tomography/MRI brain scanning in 90% of prevalent
and 83% of incident stroke cases. Among incident and prevalent
strokes, ischemic stroke constituted 69.6% and 77.8%,
intracerebral
hemorrhage 23.8% and 15.8%, subarachnoid hemorrhage 4.4%
and 4.4%, and undetermined type 2.1% and 2.0%, respectively.
Age-specific stroke prevalence in men aged ≥40 years was
significantly greater than the prevalence in women (P<0.001).
The most prevalent risk factors among stroke survivors were
hypertension (88%), smoking (48%), and alcohol use (44%). Stroke
prevalence estimates in 2013 were statistically greater than
those reported in China 3 decades ago, especially among rural
residents (P=0.017). The highest annual incidence and mortality
of stroke was
in Northeast (365 and 159/100000 person-years), then
Central areas (326 and 154/100 000 person-years), and the
lowest incidence was in Southwest China (154/100 000
person-years), and the lowest mortality was in South China
Circulation. 2017;135:759–771. DOI: February 21, 75
10.1161/CIRCULATIONAHA.116.025250 2017 9
,Wenzhi Wang, MD Bin Jiang, MD
Haixin Sun, MD, PhD Xiaojuan Ru, PhD Dongling Sun, PhD
Linhong Wang, MD Limin Wang, MD Yong Jiang, MD Yichong Li,
PhD
Yilong Wang, MD, PhD Zhenghong Chen, PhD Shengping Wu,
MD Yazhuo Zhang, MD David Wang, DO Yongjun Wang, MD
Valery L. Feigin, MD, PhD for the NESS-China
Investigators
Correspondence to: Wenzhi Wang, MD, Beijing Neurosurgical Institute, Capital Medical
University, 6 TiantanXili, Dongcheng District, Beijing, 100050, China. E-mail
or Yongjun Wang, MD, Beijing Tiantan Hospital, Capital Medical
University, 6 TiantanXili, Dongcheng District, Beijing, 100050, China. E-mail
or Valery L. Feigin, MD, PhD, National Institute for Stroke and Applied Neurosciences,
Auckland University of Technology, Auckland, New Zealand. E-mail valery.feigin@
aut.ac.nz
Sources of Funding, see page 768
Key Words: demographics
■incidence ■ mortality
■prevalence ■ stroke ■ surveys and questionnaires
© 2017 American Heart Association, Inc.
Circulation. 2017;135:759–771. DOI: February 21, 75
10.1161/CIRCULATIONAHA.116.025250 2017 9
, Wang et al in China (NESS-China) was to identify the true
stroke bur- den (incidence, prevalence, and
mortality) in men and women of ≥20 years of
Clinical Perspective
What Is New?
high in rural areas, and that there is a north-to-south gradient in stroke in China, with the greatest stroke burden observed in
What Are the Clinical Implications?
care and rehabilitation staff), with priority setting for stroke care (eg, the need for greater resources required for northern an
age across all major regions of
China in 2012 to 2013.
S
troke is the third most common cause of
death in most Western countries, after
coronary heart disease and cancer,1,2 but it
has been the leading cause of death in China
in recent years,3,4constituting almost one-third
of the total number of deaths from stroke
Downloaded from http://ahajournals.org by on June 28,
worldwide.2 By 2013, 27 of 33 provinces in
China had stroke as the leading cause of
death.5 How- ever, previous studies of stroke
epidemiology in China were either not
population based, or of limited scope and
diagnostic accuracy (eg, confined to the age
group between 25 and 74 years, lacked
neuroimaging veri- fication of pathological
type of stroke, suffered from selection bias or
were based on small, not nationally
representative sample sizes), and most of
them were conducted 20 to 30 years ago.6–10
In addition, in the past 2 decades, China has
experienced rapid health transitions and
sociodemographic changes5,11 that have had
an impact on the prevalence of common
stroke risk factors.11 For example, there was a
large increase in the prevalence of
hypertension, smoking, overweight, and
diabetes mellitus, all of which might have
affected stroke burden in China.11–18
Therefore, obtaining more up-to-date and
accurate estimates of stroke burden (as
measured by incidence, prevalence, and
mortality) and its secular trend across China
is crucial for evidence-based and region-
specific plan- ning and evaluation of the
effectiveness of the currently implemented
treatment and prevention strategies. The goal
of this national epidemiological survey of stroke
7 February 21, Circulation. 2017;135:759–771. DOI:
