Burden of Stroke in Europe: An Analysis of the Global Burden of Disease Study Findings From 2010 to 2019
Abstract
BACKGROUND:
While most European Regions perform well in global comparisons, large discrepancies within stroke epidemiological parameters exist across Europe. The objective of this analysis was to evaluate the stroke burden across European regions and countries in 2019 and its difference to 2010.
METHODS:
The GBD 2019 analytical tools were used to evaluate regional and country-specific estimates of incidence, prevalence, deaths, and disability-adjusted life years of stroke for the European Region as defined by the World Health Organization, with its 53 member countries (EU-53) and for European Union as defined in 2019, with its 28 member countries (EU-28), between 2010 and 2019. Results were analyzed at a regional, subregional, and country level.
RESULTS:
In EU-53, the absolute number of incident and prevalent strokes increased by 2% (uncertainty interval [UI], 0%–4%), from 1 767 280 to 1 802 559 new cases, and by 4% (UI, 3%–5%) between 2010 and 2019, respectively. In EU-28, the absolute number of prevalent strokes and stroke-related deaths increased by 4% (UI, 2%–5%) and by 6% (UI, 1%–10%), respectively. All-stroke age-standardized mortality rates, however, decreased by 18% (UI, −22% to −14%), from 82 to 67 per 100 000 people in the EU-53, and by 15% (UI, −18% to −11%), from 49.3 to 42.0 per 100 000 people in EU-28. Despite most countries presenting reductions in age-adjusted incidence, prevalence, mortality, and disability-adjusted life year rates, these rates remained 1.4×, 1.2×, 1.6×, and 1.7× higher in EU-53 in comparison to the EU-28.
CONCLUSIONS:
EU-53 showed a 2% increase in incident strokes, while they remained stable in EU-28. Age-standardized rates were consistently lower for all-stroke burden parameters in EU-28 in comparison to EU-53, and huge discrepancies in incidence, prevalence, mortality, and disability-adjusted life-year rates were observed between individual countries.
Graphical Abstract

Although substantial efforts have been made in primary stroke prevention, treatment, and tertiary prevention strategies, stroke remains the second-leading cause of death and the third-leading cause of burden of disease worldwide.1 The GBD (Global Burden of Disease), Injuries, and Risk Factors Study 2019 stroke analysis reported a sharp decrease in age-standardized stroke mortality rates between 1990 and 2019.2 However, despite reductions in age-standardized rates, absolute numbers of incident, prevalent, and mortality cases secondary to strokes have increased by 70%, 85%, and 43% between 1990 and 2019 worldwide.2
In the European Union, stroke is the second most frequent cause of death and the leading cause of adult disability, with 30-year projections of absolute numbers of incidence, prevalence, deaths, and disability-adjusted life years (DALYs) estimating a 27% increase by 2047.3 In 2006, the Helsingborg Declaration on European Stroke Strategies was adopted.4 One of their aims was for all patients with stroke in Europe to have access to a stroke unit by 2015; however, the 2020 Stroke Alliance for Europe Report found that only 30% of stroke patients across Europe currently have access to acute stroke unit care.4–6 They also found high discrepancies in stroke burden exist across Europe, with age-standardized death rates in Bulgaria, Romania, Serbia, Latvia, Lithuania, Croatia, Hungary, and Slovakia 7× higher than in France, Spain, Luxembourg, Austria, and Belgium.6
The European Stroke Organisation and the Stroke Alliance for Europe created the European Stroke Action Plan for the years 2018 to 2030.7,8 Their pursued targets for 2030 are (1) reduction of absolute number of strokes in Europe by 10%, (2)) treatment of at least 90% of patients with stroke in dedicated stroke units as the first level of care, (3) implementation of national plans for stroke management, and (4) implementation of national strategies for multisector public health interventions.7 Implementation of European Stroke Organisation guidelines and 2018 to 2030 European Stroke Action Plan strategies across all European countries could lead to standardization of stroke care across Europe, improving and homogenizing the burden of stroke across different European countries.7–10 However, studies analyzing the burden of stroke throughout Europe, considering both the European Union (European Union as defined in 2019, with its 28 member countries [EU-28]), as well as European Region as defined by the World Health Organization, with its 53 member countries (EU-53) are lacking.
The aim of this study was to compare the burden of stroke during the last 10 years in EU-28 (the 27 member countries of the EU plus the United Kingdom) and in the EU-53, including a regional and country-specific analysis.
METHODS
All data and materials are made publicly available at the GBD website and can be accessed at https://vizhub.healthdata.org/gbd-results/. Finally, no informed consent was required due to the lack of patient-specific data.
Global Burden of Disease 2019
The GBD 2019 study effort has quantified the burden of 369 diseases and injuries in 204 countries and territories worldwide, analyzing data from 3686 vital registration sources, 147 verbal autopsy sources, 368 incidence sources, 117 prevalence sources, 229 excess mortality sources, 7753 risk-factor exposure sources, and 2733 risk factor relative risk sources (see http://ghdx.healthdata.org/ for further details).1,11–15 It is a landmark effort, updated annually, designed to allow for consistent comparison over time starting from 1990 to 2019, by age and sex, sociodemographic index, World Bank country income, and across locations.1,11 It produces standard epidemiological measures such as incidence, prevalence, and death rates, as well as summary measures of health, including DALYs,1,11 reported in compliance with Guidelines for Accurate and Transparent Health Estimates Reporting guidelines.16 All of their results are publically available and can be found using the GBD results tool and GBD compare website.1,10,11
The GBD classifies causes into 4 levels, from the broadest (level 1; eg, noncommunicable diseases), to the most specific (level 4; eg, ischemic stroke [IS]). Stroke is categorized as a level 3 cause, and has 3 level 4 subtypes. Definitions and International Classification of Diseases codes used categorization are described in Table S1.17,18 Vital registration and verbal autopsy data are used as inputs into the Cause of Death Ensemble modeling framework to estimate deaths due to stroke and stroke subtypes.1,2 Cause of Death Ensemble modeling is a flexible modeling tool that utilizes geospatial relationships and information from covariates to produce estimates of death for all locations across the time series (1990–2019). Deaths from vital registration systems coded to impossible or intermediate causes of death or unspecified stroke are reassigned using statistical methods.1,2,19–21 Methods used for assigning cause of death to stroke and stroke subtypes in regions, where neuroimaging is not available have been previously described in detail.1,11–13
Study Design
This study has analyzed the burden of stroke using GBD data for all countries included in EU-53 (World Health Organization definition of Europe), its 3 subregions (Central, Eastern, and Western Europe), the EU-28 (countries included in the European Union in 2019) and all 53 individual countries making up the EU-53 for both 2019 and 2010 (Table S2). Epidemiological estimates for incidence, prevalence, deaths, DALYs, years of life lost and years lived with disability are given for stroke (level 3). Epidemiological estimates for IS, intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) can be found in the Supplemental Materials. Standard life expectancy of the individual countries has been obtained using the lowest observed age-specific rates of mortality among populations in the world >5 million.1,15,19–21 Absolute numbers, age-standardized rates per 100 000 population/y, age-standardized rates by sex, rates for the population under the age of 70 years of age and for the population ≥70 years of age (70+) for incidence, prevalence, death, and DALYs for the years 2010 and 2019 have been presented, as well as the difference between 2010 and 2019, given as percentage. All estimates are given with a 95% uncertainty interval (UI), which are derived from the 25th and 975th ordinals of 1000 draws of the posterior distribution at each step of the burden estimation process.1 An increase in the absolute number or rate from 2010 to 2019 has been defined as a positive change between 2010 and 2019, wherein 0 can be in the limits of the UI interval, but cannot be included inside the UI interval (ie [UI, 0% to +13%] has been considered a significant increase, but [UI, −3% to +13%] would not be considered a significant increase). Similarly, a decrease in the absolute number or rate between 2010 and 2019 is considered as any negative change between 2010 and 2019, in which the UI does not cross the zero line. Negative changes between 2010 and 2019 have been represented throughout the tables with a (−) sign.
RESULTS
Incidence
EU-53
The EU-53 saw a 2% (95% UI, 0%–4%) increase in the total number of incident strokes between 2010 and 2019, with 1 802 560 total incident stroke cases in 2019, 70% of which were attributable to IS (Figure 1A; Table S3). Absolute numbers of IS and SAH increased by 3%, while ICH decreased by 4% (Table S4). Age-adjusted incidence rates, however, decreased by 10% (UI, −12% to −8%) from 132.3 to 118.7 per 100 000 people, with consistent reductions in all-stroke subtypes (Figure 1B). Despite a higher total number of incident strokes in women (1 029 427 versus 773 133 in men, 2019), both sexes presented similar age-adjusted incidence rates (116.9 in women versus 118.8 in men, per 100 000; Figures 1A and 1B). Between 2010 and 2019, all EU-53 countries showed either stability or reduction of age-standardized incidence rates, with the largest reductions observed in Norway, Austria, and Israel (Figure 1C). The lowest age-standardized incidence rate was observed in Switzerland, with 58.9 new cases per 100 000 (Figure 1D). Other countries with incidence rates under 65 included Ireland, France, Luxembourg and the United Kingdom. Overall, however, there were large discrepancies, with multiple countries presenting incidence rates >230 per 100 000, including Turkmenistan, Montenegro, and Bulgaria. Of EU-53 countries, Northern Macedonia presented the highest age-adjusted incidence rate, at 259.3 per 100 000, 4.4× higher than Switzerland (Figure 1D). An 8% (UI, −11% to −5%) reduction in incidence rates was observed in the population 70+, while remaining stable in those <70 (Figure 1E). Finally, when analyzing the EU-53 by subregions, Eastern Europe reported the highest absolute number of incident strokes (629 928), followed by Western and Central Europe, with stable rates between 2010 and 2019 in all subregions (Table S5). Age-standardized incidence rates, however, decreased consistently across all subregions (Figure 1F), expect for those <70 in Eastern and Central Europe, were they remained stable. The highest age-standardized incidence rate was observed in Eastern Europe, which was 2.75× higher than in Western Europe, despite all subregions presenting significant rate reductions over the last 10 years.

EU-28
In contrast to the EU-53, the absolute number of incident strokes in EU-28 remained stable during this period (Figure 1A), with a total of 844 239 incident strokes in 2019 (Table S3). Age-adjusted incidence rates for all strokes decreased by 12% (UI, −14% to −10%) between 2010 and 2019, from 95.39 to 83.9 per 100 000. In 2019, these were 0.71× lower in EU-28 in comparison to the EU-53 (Figure 1C). In EU-28, age-standardized rates for women and men showed an 11% (UI, −14% to −8%) and a 13% (UI, −16% to −11%) reduction for all strokes. In contrast to the EU-53, all strokes in the EU-28 showed a reduction of rates not only for the 70+ population (−11 reduction, UI −14 to −7), but also for the population <70 (−3% reduction, UI −7% to 0%) (Figure 1E). Except Switzerland, countries presenting lowest incidence rates were part of the EU-28. In the EU-28, countries with the highest age-standardized incidence rates were Bulgaria, with 236.24 new cases per 100 000, Romania (184.4), and Latvia (183.6; Figure 2).

Prevalence
EU-53
The total number of prevalent strokes increased by 4% (UI, 3%–5%) from 2010 to 2019, with 14 261 365 total prevalent cases in 2019 (Figure 3A). ISs accounted for 78.9% of prevalent strokes, while ICH accounted for 14.4% and SAH for 10.6%. The largest increase in absolute prevalence numbers was observed for IS (Table S4). Age-adjusted prevalence rates, however, decreased by 6% (UI, −7% to −5%) for all strokes between 2010 and 2019, from 1056 to 989 per 100 000 people, a decrease that was consistent for all-stroke subtypes and for both men and women (Figure 3B, Table S4). Women presented both significantly larger absolute prevalence numbers, but also 1.2 to 1.3× higher age-adjusted prevalence rates for all strokes (1067.6 versus 899.2), IS (831.6 versus 689.6), and for SAH (129.8 versus 97.2). All EU-53 countries showed either stability or reduction of the age-standardized prevalence rates, with the most significant reductions between 2010 and 2019 observed in Denmark, Kyrgyzstan, and Kazakhstan (Figure 3C). Switzerland presented the lowest age-standardized prevalence rate in 2019, with 608 prevalent cases/100 000 people. Other countries with age-standardized prevalence rates <650 were Italy, France, and Ireland. In contrast, Northern Macedonia and Bulgaria had the highest age-adjusted prevalence rates, both over 1600 per 100 000 people (Figure 3D). Stroke prevalent cases in the population 70+ showed an 8% (UI, −10% to −6%) decrease. However, in the population <70, in contrast to incidence rates, they increased by 4% (UI, 2% to 5%) (Figure 3E). Finally, when analyzing the EU-53 by subregions, absolute prevalence numbers increased in Western and Central Europe, while remaining stable in Eastern Europe. Overall, age-standardized prevalence rates decreased for all subgroups (Figure 3F). However, there was a 4% and 5% increase in age-standardized prevalence rates for the population <70 in Eastern and Central Europe. The highest age-standardized prevalence rate was observed in Eastern Europe, which was 1.89× higher than in Western Europe.

EU-28
In the EU-28, absolute prevalence numbers also increased by 4% (UI, 2%–5%) between 2010 to 2019, with 7 350 739 total prevalent cases in 2019 (Figure 3A). IS and SAH absolute prevalent cases increased by 4% (UI, 2%–6%) and 6% (UI, 4%–8%), respectively, while ICH cases decreased by −2% (UI, −3% to 0%) (Table S3). Age-standardized prevalence rates, however, decreased by 6% (UI, −8 to −5), from 848 to 795 per 100 000 (Figure 3B). Although both the EU-53 and the EU-28 showed significant decreases in age-standardized prevalence rates, these were 0.80×, 0.82×, 0.68×, and 0.87× lower for all strokes, IS, ICH, and SAH in the EU-28. Similar to the EU-53, prevalent cases in the population <70 also increased (2%, UI, 0%–4%). Finally, the majority of countries with low prevalence rates were part of the EU-28. In the EU-28, countries with the highest age-standardized incidence rates were Bulgaria, with 1605.2 prevalent cases per 100 000, Romania (1327.7) and Hungary (1236.6; Figure 2).
Age-standardized incidence and prevalence rates for each of the 53 countries included in the EU-53, for both sexes, men, and women can be found in Table S6.
Deaths
EU-53
The total number of all-stroke deaths remained stable between 2010 and 2019 (Figure 4A), with 1 176 328 deaths due to stroke registered in 2019. Of these, 70%, 24.5%, and 5.5% were accounted for by IS, ICH, and SAH, respectively (Table S3). Age-standardized mortality rates saw a significant reduction, decreasing by 18% (95% UI, −22% to −14%) between 2010 and 2019, from 81.5 to 66.8 per 100 000 (Figure 4B). Despite a higher absolute number of deaths in women, age-adjusted mortality rates were 0.87× lower in women than in men (61.9 versus 71.3). In 2019, stroke was the leading cause of death in Montenegro, North Macedonia, and Portugal (Figure S1). Countries presenting the largest reductions in age-adjusted mortality rates between 2010 and 2019 were Luxembourg, Armenia, and Kyrgyzstan (Figure 4C). In 2019, Switzerland, Iceland, and Andorra presented the lowest age-adjusted mortality rate with <25 deaths per 100 000; while Northern Macedonia and Montenegro had the highest rates with >200 deaths per 100 000 people (Figure 4D). Death rates in Montenegro were 12.5× higher than in Switzerland. In this regard, significant discrepancies in stroke deaths attributable to risk factors exist throughout the EU-53 (Figure 5A and 5B). Death rates in the population 70+, similarly to incidence rates, decreased by 11% (UI, −15% to −7%), while remaining stable in those <70 years (Figure 4E). Finally, when looking at the 3 subregions, the absolute number of stroke-related deaths increased by 9% (UI, 6%–12%) in Western Europe, while remaining stable in Eastern and Central Europe. The highest age-adjusted mortality rate, but also the biggest decrease between 2010 and 2019, was observed in Eastern Europe (167–131, 21% decrease [95% UI, −28% to −15%]), followed by Central Europe (116–95, 18% decrease [95% UI, −26 to −9%]) and lastly by Western Europe (37–32, 13% decrease [95% UI, −15% to −10%]) (Figure 4F).


EU-28
In contrast to the EU-53, a 6% (UI, 1%–10%) increase in the number of stroke-related deaths was observed in the EU-28, with a total of 535 742 deaths in 2019, mainly attributable to a 7% increase of deaths caused by IS and SAH (UI, 2%–12% for IS, and 1%–12% for SAH; Figure 4A). Age-adjusted mortality rates, however, decreased by 15% (95% UI, −18% to −11%) from 49 to 42 per 100 000 (Figure 4B), with the greatest reduction observed for ICH mortality (from 13 to 11, −16% decrease [95% UI, −20% to −12%]). Although the age-adjusted mortality rate reduction was smaller for the EU-28 in comparison to EU-53, age-adjusted mortality rates for all strokes, IS, ICH, and SAH were 0.62, 0.61, 0.64, and 0.76 lower in EU-28 than in EU-53, respectively. Reduction of age-adjusted rates was similar in both women and men. In contrast to the EU-53, mortality rates in the population <70 in EU-28 also showed a 9% reduction (UI, −16% to −3%) between 2010 and 2019 (Figure 4E). In the EU-28, the country with the lowest age-standardized mortality rate was France, with 24.54 deaths per 100 000, while the country with the highest rate, 7.8× higher than France, was Bulgaria, with 191.54 deaths per 100 000 (Figure 2). Although there is also a significant discrepancy in stroke deaths attributable to risk factors, its distribution is more consistent than in EU-53 (Figure 5B), with Bulgaria and Romania passing 250 deaths per 100 000 attributable to risk factors. In the majority of countries, however, this rate was under 100. The rate of stroke deaths attributable to risk factors for 2010 can be found in Figures S2 and S3. Finally, heat maps of the contribution of risk factors to stroke deaths for the EU-53 and EU-28, for both 2010 and 2019 can be found in Figures S4 and S5.
Disability-Adjusted Life Years
EU-53
The total number of DALYs decreased by 7% (UI, −12% to −3%), from 22 043 161 to 20 501 446 in 2019, of which 62.3%, 29%, and 8.1% were accounted by IS, ICH, and SAH, respectively (Figure 6A; Table S3). Of all age-adjusted rates evaluated in EU-53, DALYs showed the largest reduction, with a 19% decrease between 2010 and 2019 (Figure 6B). IS was the stroke subtype with the largest reduction (−23%, UI, −19 to −16%). Despite higher absolute numbers of stroke DALYs in women, age-adjusted rates were 0.79×, 0.88×, 0.63×, and 0.86 lower in women than men, for all strokes, IS, ICH, and SAH, respectively. Countries with the largest decrease in age-standardized DALYs between 2010 and 2019 were the Republic of Moldova and Kyrgyzstan, followed by Luxembourg and Armenia (Figure 6C). In 2019, Switzerland presented the lowest DALY rates, at 372 per 100 000 people. Other countries with rates <450, were Iceland and Andorra. In contrast, Northern Macedonia, Uzbekistan, and Turkmenistan presented rates of over 3500 DALYs/100 000 people (Figure 6D). Stroke was the leading cause of death and DALYs in Montenegro, North Macedonia, and Portugal (Figure S1). Regarding EU-53 subregions, the absolute number of DALYs remained stable in Central and Eastern Europe, while it decreased by 15% (UI, −22 to −7) in Eastern Europe. Despite larger reductions observed in Eastern and Central Europe age-adjusted DALY rates, significant discrepancies exist between regions, with rates being 4.5× higher in Eastern Europe in comparison to Western Europe (Figure 6F). Interestingly, despite Eastern Europe presenting the highest incidence, prevalence, death, and DALY age-standardized rates of the 3 European subregions, Central Europe presented the highest stroke-prevalence rate in the population 70+.

EU-28
In comparison, the total number of DALYs in the EU-28 remained stable, with 8 155 623 DALYs attributable to stroke in 2019 (Figure 6A). Here, too, age-standardized DALYs showed the biggest reduction in EU-28 of all evaluated parameters (16% decrease; 95% UI, −19% to −12%) (Figure 6B). Although the age-adjusted DALY rate reduction was smaller for EU-28 in comparison to EU-53, age-adjusted DALYs for all strokes, IS, ICH, and SAH were 0.58, 0.57, 0.55, and 0.74 lower in EU-28 than in EU-53, respectively. Reduction of age-adjusted rates was similar in both women and men, with women having an age-adjusted DALY rate 0.90×, 0.87×, and 0.63× lower than men for all strokes, IS, and ICH in 2019, respectively. In the EU-28, the country with the lowest age-standardized DALY rates was France, with 453.6 DALYs per 100 000, while the country with the highest rate, 7.5× higher than France, was Bulgaria, with 3390.2 DALYs per 100 000 (Figure 2).
Age-standardized death and DALY rates for each of the 53 countries included in the EU-53, for both sexes, men and women can be found in Table S7.
DISCUSSION
This study reflects significant geographic variations in the burden of stroke across EU-53, EU-28, Western, Central, and Eastern Europe, as well as between individual countries. While similar general trends were observed across EU-53 and EU-28, there were considerable discrepancies between individual countries. Comparison of age-adjusted mortality and DALYs rates in countries with the lowest versus highest stroke burden showed some countries presenting rates up to 12× higher. These differences were more evident across countries in EU-53 than in EU-28. However, relevant discrepancies were also observed across EU-28 countries, with Bulgaria, Hungary, Latvia, Lithuania, Romania, and Slovakia presenting the highest incidence and prevalence rates. Interestingly, while Bulgaria, Latvia, and Romania presented equiparable death and DALY rates, Hungary, Lithuania, and Slovakia had closer death and DALY rates to the rest of the EU-28 countries (Figure 2).
Absolute numbers of first-ever-in-a-lifetime-strokes and stroke prevalence increased throughout Europe, with the highest increase observed in Western Europe and EU-28. These findings may be explained by the long life expectancy in these countries, alongside a rising incidence of age-related diseases. Additionally, Europe’s population is continuously growing, with an estimated 930 million people living in EU-53 in 2019, >35 million in 2010 (a 3.7% increase).22 Most of these 53 countries saw a population increase during this time (Figure S6), with Tajikistan, Luxembourg, and Kyrgyzstan presenting the largest population growth (24%, 21%, and 18%, respectively) from 2010 to 2019.22 On the contrary, 18 countries presented a population decline, with Latvia and Lithuania experiencing the largest reductions (−10% and −11%, respectively). During the same period, the estimated population in EU-28 only grew by 1.9%, from 503 to 512 million in 201922 (Table S8). Despite EU-28 showing a lower population growth, the median population age was higher (41.9 years in EU-28 versus 38.6 years in EU-53), suggesting an older population.22
To achieve a 10% reduction in the absolute number of strokes by 2030 and reach the target proposed by the European Stroke Action Plan,7 ≈84 000 strokes would need to be prevented over 2020 to 2029 in the EU-28. The population in EU-28 is projected to remain relatively stable, with estimates suggesting a population of 512.48 million in 2027.3 Assuming that the EU-28 population remains stable, an annual 0.08% reduction in stroke incidence is necessary to achieve a total number of stroke of 760 000 in 2030.
In contrast to absolute numbers, age-adjusted incidence, prevalence, death, and DALY stroke rates, have decreased consistently in both EU-53 and EU-28, and European subregions. However, although the EU-53, and especially Eastern Europe showed considerable improvements in stroke burden within the last decade, its rates remain considerably higher than other European subregions. Interestingly, Kyrgyzstan was one of the countries with the largest reductions in age-adjusted prevalence, death, and DALY rates between 2010 and 2019. Similar to previous publications, >90% of the stroke burden remains attributable to modifiable risk factors, especially high blood pressure (Figure 5).1,23–25 Here, again, there are significant discrepancies between countries, with Bulgaria and Romania showing high rates of high blood pressure, dietary risks, and tobacco consumption, similar to other Central and Eastern European countries that are not part of the EU-28 (Figure 5).
Finally, alongside risk-factor prevention, nationwide implementation of stroke units could substantially improve acute stroke management and poststroke rehabilitation. Unfortunately, there is no Europewide accepted definition of what a stroke unit should actually be, and here again, large disparities can be observed between countries.6 For example, although significant improvements have been made in the amount of resource allocation for stroke unit creation in Spain, stroke units tend to be concentrated in highly populated areas, so that autonomous regions like Madrid, Catalunya, and the Vasque Country have significantly more stroke units, while poorer but more extensive areas, such as Andalucia have less stroke units, making access for the population in this area more difficult.26 French data indicate that only 50% of stroke patients are treated in stroke units,27 while 73% of patients with Finnish who live within a specific catchment area of a stroke unit are treated in stroke units, compared with only 9% of patients treated in stroke units when they live outside a catchment area.28 These findings suggest large within-country and national variations in the quality and accessibility of stroke treatment. Similarly, there are also significant variations regarding intravenous thrombolysis and endovascular therapy.29,30 Country-level data show that access to and delivery of acute stroke care are poor or totally lacking in many countries,31 with under 20% of patients with acute ischemic stroke being provided with intravenous thrombolysis, and an overall rate of intravenous thrombolysis in incident IS of only 7.3%.28
Limitations of This Study
This study has chosen to focus on the epidemiological burden of stroke, looking specifically at differences observed between different European definitions, regions, and countries. However, an analysis of risk-factor prevalence and causalities has not been performed, so causative conclusions cannot be drawn from this analysis. Stroke unit accessibility and treatments used have also not been investigated, so a deeper understanding into stroke treatment and mortality cannot be made. Lastly, it is possible that reporting quality is not the same for all 53 included countries, so direct comparisons between for example Sweden, which has a nationwide stroke register and Tajikistan may be susceptible to reporting errors.
Conclusions
Although a substantial effort has been made regarding stroke management in Europe, this analysis shows increasing absolute numbers of first-ever-in-a-lifetime-strokes and stroke prevalence in the last 10 years. Furthermore, the disparity of stroke burden across individual European countries, subregions, and EU definitions (EU-28 versus EU-53) is significant and warrants further analysis.
ARTICLE INFORMATION
Supplemental Material
Tables S1–S8
Figures S1–S6
Appendix S1
APPENDIX
GBD Europe Stroke Collaborators
Carlota Fernandez Prendes, Barbara Rantner, Tarek Hamwi, Jan Stana, Prof Valery L Feigin, Konstantinos Stavroulakis, Nikolaos Tsilimparis, Prof Victor Aboyans, Rufus Olusola Akinyemi, Prof Rustam Al-Shahi Salman, Anton A Artamonov, Avinash Aujayeb, Marzia Baldereschi, Sanjay Basu, Prof Yannick Béjot, Luis Belo, Derrick A Bennett, Akshaya Srikanth Bhagavathula, Boris Bikbov, Prof Hermann Brenner, Florentino Luciano Caetano dos Santos, Prof Juan J Carrero, Prof Felix Carvalho, Prof Alberico L Catapano, Periklis Charalampous, Prof Hanne Christensen, Sheng-Chia Chung, Paolo Angelo Cortesi, Vera Marisa Costa, Malgorzata Cyganska, Emanuele D’Amico, Kairat Davletov, Klara Georgieva Dokova, Abdel Douiri, Adeniyi Francis Fagbamigbe, Florian Fischer, Nermin Ghith, Simona Giampaoli, Prof Paramjit Singh Gill, Elena V Gnedovskaya, Rasmus J Havmoeller, Sorin Hostiuc, Prof Ivo Iavicoli, Prof Milena D Ilic, Prof Gaetano Isola, Jacek Jerzy Jozwiak, Mikk Jürisson, Gbenga A Kayode, Moien AB Khan, Prof Khaled Khatab, Prof Adnan Kisa, Prof Mika Kivimäki, Ai Koyanagi, Mukhtar Kulimbet, Dian Kusuma, Prof Carlo La Vecchia, Ben Lacey, Prof Tea Lallukka, Prof Stefan Lorkowski, Prof Azeem Majeed, Prof Lorenzo Giovanni Mantovani, Giampiero Mazzaglia, Alexios-Fotios A Mentis, Atte Meretoja, Junmei Miao Jonasson, Andreea Mirica, Prof Erkin M Mirrakhimov, Shafiu Mohammed, Mariam Molokhia, Lorenzo Monasta, Prof Ute Mons, Jakub Morze, Ruxandra Irina Negoi, Prof Bo Norrving, Prof Bogdan Oancea, Rónán O’Caoimh, Hans Orru, Alicia Padron-Monedero, Paolo Pedersini, Norberto Perico, Roman V Polibin, Suzanne Polinder, Alberto Raggi, Prof Salman Rawaf, Prof Giuseppe Remuzzi, Michele Romoli, Prof Simona Sacco, Prof Mohammad Reza Saeb, João Vasco Santos, Prof Milena M Santric-Milicevic, Anna Aleksandrovna Skryabina, Lee Smith, Antonina V Starodubova, Aleksandar Stevanović, Prof Saverio Stranges, Yvonne Teuschl, Roman Topor-Madry, Mathilde Touvier, Marcos Roberto Tovani-Palone, Brigid Unim, Prof Tommi Juhani Vasankari, Victor Volovici, Hatem A Wafa, Yanzhong Wang, Ronny Westerman, Prof Charles D A Wolfe, Metin Yesiltepe, Aurora Zanghì, Prof Mikhail Sergeevich Zastrozhin.
Affiliations are listed in the Supplemental Material.
Acknowledgments
See the Appendix in Supplemental Material for more detailed information about individual contributions to the research, divided into the following categories: providing data or critical feedback on data sources; developing methods or computational machinery; providing critical feedback on methods or results; drafting the article or revising it critically for important intellectual content; and managing the estimation or publications process.
Footnote
Nonstandard Abbreviations and Acronyms
- DALY
- disability-adjusted life years
- EU-28
- European Union as defined in 2019, with its 28 member countries
- EU-53
- European Region as defined by the World Health Organization, with its 53 member countries
- GBD
- Global Burden of Disease
- ICH
- intracerebral hemorrhage
- IS
- ischemic stroke
- SAH
- subarachnoid hemorrhage
- UI
- uncertainty interval
Supplemental Material
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© 2024 American Heart Association, Inc.
History
Received: 23 November 2022
Revision received: 10 September 2023
Accepted: 21 September 2023
Published online: 22 January 2024
Published in print: February 2024
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Disclosures
Disclosures Dr Feigin has intellectual property disclosure for Prevents/MD and Stroke Riskometer app, Dr Stavroulakis is a consultant for Boston Scientific Corporation, Philips, ShockWave Medical, Inc, and Terumo Cardiovascular Systems Corporation, and Dr Tsilimparis is a consultant for Cook Medical. The other authors report no conflicts.
Sources of Funding
The GBD is funded by the Bill & Melinda Gates Foundation.
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