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Prevention of stroke: a strategic global imperative

Key Points

  • Although global stroke incidence and mortality declined from 1990 to 2013, the stroke burden, in terms of absolute numbers of people affected by stroke, continues to increase rapidly throughout the world

  • The ever-increasing burden of stroke suggests that current primary prevention strategies for stroke and cardiovascular disease (CVD) are not sufficiently effective

  • To improve primary stroke prevention strategies, we need to shift the emphasis from a high-risk approach to a more comprehensive approach targeting people at all levels of CVD risk

  • To be cost-effective, primary stroke prevention strategies must be integrated with prevention strategies for other major noncommunicable diseases that share common risk factors with stroke, including CVD, vascular dementia and diabetes

  • Resources for the development and implementation of culturally appropriate and population-specific primary stroke prevention strategies could be taken from revenue resulting from taxation on tobacco, salt, sugar and alcohol

  • Given the already immense and fast-increasing burden of stroke and other major NCDs, which threatens global sustainability, failure to act on primary prevention of these diseases is unacceptable

Abstract

The increasing global stroke burden strongly suggests that currently implemented primary stroke prevention strategies are not sufficiently effective, and new primary prevention strategies with larger effect sizes are needed. Here, we review the latest stroke epidemiology literature, with an emphasis on the recently published Global Burden of Disease 2013 Study estimates; highlight the problems with current primary stroke and cardiovascular disease (CVD) prevention strategies; and outline new developments in primary stroke and CVD prevention. We also suggest key priorities for the future, including comprehensive prevention strategies that target people at all levels of CVD risk; implementation of an integrated approach to promote healthy behaviours and reduce health disparities; capitalizing on information technology to advance prevention approaches and techniques; and incorporation of culturally appropriate education about healthy lifestyles into standard education curricula early in life. Given the already immense and fast-increasing burden of stroke and other major noncommunicable diseases (NCDs), which threatens worldwide sustainability, governments of all countries should develop and implement an emergency action plan addressing the primary prevention of NCDs, possibly including taxation strategies to tackle unhealthy behaviours that increase the risk of stroke and other NCDs.

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Figure 1: Ischaemic stroke prevalence and mortality.
Figure 2: Haemorrhagic stroke prevalence and mortality.
Figure 3: Stroke-related deaths and DALYs by country development status.
Figure 4: Burden of stroke in proportion to all health conditions.
Figure 5: Sex-related differences in stroke burden.
Figure 6: Combining population-wide and high-risk strategies.

References

  1. Feigin, V. L. et al. Global and regional burden of stroke during 1990–2010: findings from the Global Burden of Disease Study 2010. Lancet 383, 245–254 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  2. Roth, G. A. et al. Demographic and epidemiologic drivers of global cardiovascular mortality. N. Engl. J. Med. 372, 1333–1341 (2015).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Feigin, V. L. et al. Update on the global burden of ischemic and hemorrhagic stroke in 1990–2013: the GBD 2013 study. Neuroepidemiology 45, 161–176 (2015).

    Article  PubMed  Google Scholar 

  4. Murray, C. J. & Lopez, A. D. Measuring the global burden of disease. N. Engl. J. Med. 369, 448–457 (2013).

    Article  CAS  PubMed  Google Scholar 

  5. Mensah, G. A., Norrving, B. & Feigin, V. L. The global burden of stroke. Neuroepidemiology 45, 143–145 (2015).

    Article  PubMed  Google Scholar 

  6. Roth, G. A. et al. Methods for estimating the global burden of cerebrovascular diseases. Neuroepidemiology 45, 146–151 (2015).

    Article  PubMed  Google Scholar 

  7. Truelsen, T. et al. Causes of death data in the Global Burden of Disease estimates for ischemic and hemorrhagic stroke. Neuroepidemiology 45, 152–160 (2015).

    Article  PubMed  Google Scholar 

  8. Krishnamurthi, R. V. et al. Stroke prevalence, mortality and disability-adjusted life years in children and youth aged 0–19 years: data from the Global and Regional Burden of Stroke 2013. Neuroepidemiology 45, 177–189 (2015).

    Article  PubMed  Google Scholar 

  9. Krishnamurthi, R. V. et al. Stroke prevalence, mortality and disability-adjusted life years in adults aged 20–64 years in 1990–2013: data from the Global Burden of Disease 2013 study. Neuroepidemiology 45, 190–202 (2015).

    Article  PubMed  Google Scholar 

  10. Barker-Collo, S. et al. Sex differences in stroke incidence, prevalence, mortality and disability-adjusted life years: results from the Global Burden of Disease Study 2013. Neuroepidemiology 45, 203–214 (2015).

    Article  PubMed  Google Scholar 

  11. Feigin, V. L., Mensah, G. A., Norrving, B., Murray, C. J. & Roth, G. A. Atlas of the global burden of stroke (1990–2013): the GBD 2013 study. Neuroepidemiology 45, 230–236 (2015).

    Article  PubMed  Google Scholar 

  12. Norrving, B. et al. Stroke prevention worldwide — what could make it work. Neuroepidemiology 45, 215–220 (2015).

    Article  PubMed  Google Scholar 

  13. Roth, G. A. et al. Global and regional patterns in cardiovascular mortality from 1990 to 2013. Circulation 132, 1667–1678 (2015).

    Article  PubMed  Google Scholar 

  14. Maher, D., Waswa, L., Baisley, K., Karabarinde, A. & Unwin, N. Epidemiology of hypertension in low-income countries: a cross-sectional population-based survey in rural Uganda. J. Hypertens. 29, 1061–1068 (2011).

    Article  CAS  PubMed  Google Scholar 

  15. Ibrahim, M. M. & Damasceno, A. Hypertension in developing countries. Lancet 380, 611–619 (2012).

    Article  PubMed  Google Scholar 

  16. Kumara, W. A. N., Perera, T., Dissanayake, M., Ranasinghe, P. & Constantine, G. R. Prevalence and risk factors for resistant hypertension among hypertensive patients from a developing country. BMC Res. Notes 6, 373 (2013).

    Article  PubMed  PubMed Central  Google Scholar 

  17. Mehndiratta, M. M. Stroke in Asia: geographical variations and temporal trends. J. Neurol. Neurosurg. Psychiatry 85, 1308–1312 (2014).

    Article  PubMed  Google Scholar 

  18. Bernick, C. et al. Silent MRI infarcts and the risk of future stroke: the cardiovascular health study. Neurology 57, 1222–1229 (2001).

    Article  CAS  PubMed  Google Scholar 

  19. Lee, S., Shafe, A. C. & Cowie, M. R. UK stroke incidence, mortality and cardiovascular risk management 1999–2008: time-trend analysis from the General Practice Research Database. BMJ Open 1, e000269 (2011).

    PubMed  PubMed Central  Google Scholar 

  20. Soljak, M. et al. Does higher quality primary health care reduce stroke admissions? A national cross-sectional study. Br. J. Gen. Pract. 61, e801–e807 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  21. Kissela, B. M. et al. Age at stroke: temporal trends in stroke incidence in a large, biracial population. Neurology 79, 1781–1787 (2012).

    Article  PubMed  PubMed Central  Google Scholar 

  22. George, M. G., Tong, X., Kuklina, E. V. & Labarthe, D. R. Trends in stroke hospitalizations and associated risk factors among children and young adults, 1995–2008. Ann. Neurol. 70, 713–721 (2011).

    Article  CAS  PubMed  Google Scholar 

  23. Feigin, V. L. et al. New strategy to reduce the global burden of stroke. Stroke 46, 1740–1747 (2015).

    Article  PubMed  Google Scholar 

  24. United Nations General Assembly. Resolution adopted by the General Assembly: 66/2. Political declaration of the high-level meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases. World Health Organization http://www.who.int/nmh/events/un_ncd_summit2011/political_declaration_en.pdf (2012).

  25. Lyle, C. A., Bernard, T. J. & Goldenberg, N. A. Childhood arterial ischemic stroke: a review of etiologies, antithrombotic treatments, prognostic factors, and priorities for future research. Semin. Thromb. Hemost. 37, 786–793 (2011).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  26. Murray, C. J. et al. Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990–2013: quantifying the epidemiological transition. Lancet 386, 2145–2191 (2015).

    Article  PubMed  Google Scholar 

  27. Feigin, V. L. et al. Global burden of stroke and risk factors in 188 countries, during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet Neurol. http://dx.doi.org/10.1016/S1474-4422(16)30073-4 (2016).

  28. O'Donnell, M. J. et al. Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case–control study. Lancet 376, 112–123 (2010).

    Article  PubMed  Google Scholar 

  29. Go, A. S. et al. Heart Disease and Stroke Statistics — 2014 update: a report from the American Heart Association. Circulation 129, e28–e292 (2014).

    Article  CAS  PubMed  Google Scholar 

  30. Lim, S. S. et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 380, 2224–2260 (2012).

    Article  PubMed  PubMed Central  Google Scholar 

  31. Spring, B. et al. Better population health through behavior change in adults: a call to action. Circulation 128, 2169–2176 (2013).

    Article  PubMed  PubMed Central  Google Scholar 

  32. Rose, G. Strategy of prevention: lessons from cardiovascular disease. Br. Med. J. (Clin. Res. Ed.) 282, 1847–1851 (1981).

    Article  CAS  Google Scholar 

  33. Goldstein, L. B. et al. Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 42, 517–584 (2011).

    Article  PubMed  Google Scholar 

  34. Tikk, K. et al. Primary preventive potential for stroke by avoidance of major lifestyle risk factors: the European Prospective Investigation into Cancer and Nutrition–Heidelberg cohort. Stroke 45, 2041–2046 (2014).

    Article  PubMed  Google Scholar 

  35. SPRINT Research Group et al. A randomized trial of intensive versus standard blood-pressure control. N. Engl. J. Med. 373, 2103–2116 (2015).

  36. Ettehad, D. et al. Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. Lancet 387, 957–967 (2016).

    Article  PubMed  Google Scholar 

  37. Ruff, C. T. et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet 383, 955–962 (2014).

    Article  CAS  PubMed  Google Scholar 

  38. Martinez, C. et al. Increasing incidence of non-valvular atrial fibrillation in the UK from 2001 to 2013. Heart 101, 1748–1754 (2015).

    Article  CAS  PubMed  Google Scholar 

  39. Miyasaka, Y. et al. Secular trends in incidence of atrial fibrillation in Olmsted County, Minnesota, 1980 to 2000, and implications on the projections for future prevalence. Circulation 114, 119–125 (2006).

    Article  PubMed  Google Scholar 

  40. Stefansdottir, H., Aspelund, T., Gudnason, V. & Arnar, D. O. Trends in the incidence and prevalence of atrial fibrillation in Iceland and future projections. Europace 13, 1110–1117 (2011).

    Article  PubMed  Google Scholar 

  41. WorldHealth Organization. Prevention of cardiovascular disease: guidelines for assessment and management of cardiovascular risk. http://apps.who.int/iris/bitstream/10665/43685/1/9789241547178_eng.pdf (2007).

  42. WorldHealth Organization. Preventing chronic diseases: a vital investment http://www.who.int/chp/chronic_disease_report/en/ (2005).

  43. Rose, G. Sick individuals and sick populations. Int. J. Epidemiol. 14, 32–38 (1985).

    Article  CAS  PubMed  Google Scholar 

  44. Pearson, T. A. et al. AHA guidelines for primary prevention of cardiovascular disease and stroke: 2002 update: consensus panel guide to comprehensive risk reduction for adult patients without coronary or other atherosclerotic vascular diseases. Circulation 106, 388–391 (2002).

    Article  PubMed  Google Scholar 

  45. Puska, P. Successful prevention of non-communicable diseases: 25 year experiences with North Karelia project in Finland. Public Health Med. 4, 5–7 (2002).

    Google Scholar 

  46. Miura, K. Epidemiology and prevention of hypertension in Japanese: how could Japan get longevity? EPMA J. 2, 59–64 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  47. Record, N. B. et al. Community-wide cardiovascular disease prevention programs and health outcomes in a rural county, 1970–2010. JAMA 313, 147–155 (2015).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  48. Emberson, J., Whincup, P., Morris, R., Walker, M. & Ebrahim, S. Evaluating the impact of population and high-risk strategies for the primary prevention of cardiovascular disease. Eur. Heart J. 25, 484–491 (2004).

    Article  PubMed  Google Scholar 

  49. Mehta, S. et al. Under-utilisation of preventive medication in patients with cardiovascular disease is greatest in younger age groups (PREDICT-CVD 15). J. Prim. Health Care 3, 93–101 (2011).

    Article  PubMed  Google Scholar 

  50. Goldstein, L. B. et al. Primary prevention of ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council: cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 113, e873–e923 (2006).

    Article  PubMed  Google Scholar 

  51. [No authors listed.] Life After Stroke: New Zealand Guideline for Management of Stroke (Stroke Foundation of New Zealand Inc., 2003).

  52. Cox, J. L., Carr, B., Vallis, T. M., Szpilfogel, C. & O'Neill, B. J. A novel approach to cardiovascular health by optimizing risk management (ANCHOR): a primary prevention initiative examining the impact of health risk factor assessment and management on cardiac wellness. Can. J. Cardiol. 27, 809–817 (2011).

    Article  PubMed  Google Scholar 

  53. Zannad, F. et al. Prevention of cardiovascular disease guided by total risk estimations — challenges and opportunities for practical implementation: highlights of a CardioVascular Clinical Trialists (CVCT) Workshop of the ESC Working Group on CardioVascular Pharmacology and Drug Therapy. Eur. J. Prev. Cardiol. 19, 1454–1464 (2012).

    Article  PubMed  PubMed Central  Google Scholar 

  54. Ebrahim, S. et al. Multiple risk factor interventions for primary prevention of coronary heart disease. Cochrane Database Syst. Rev. 1, CD001561 (2011).

    Google Scholar 

  55. Mc Namara, K. P. et al. Engaging community pharmacists in the primary prevention of cardiovascular disease: protocol for the Pharmacist Assessment of Adherence, Risk and Treatment in Cardiovascular Disease (PAART CVD) pilot study. BMC Health Serv. Res. 10, 264 (2010).

    Article  PubMed  PubMed Central  Google Scholar 

  56. Selak, V. et al. IMProving Adherence using Combination Therapy (IMPACT): design and protocol of a randomised controlled trial in primary care. Contemp. Clin. Trials 32, 909–915 (2011).

    Article  PubMed  Google Scholar 

  57. Gorelick, P. B. Primary prevention of stroke: impact of healthy lifestyle. Circulation 118, 904–906 (2008).

    Article  PubMed  Google Scholar 

  58. Jackson, R. et al. Alcohol and ischaemic heart disease: probably no free lunch. Lancet 366, 1911–1912 (2005).

    Article  PubMed  Google Scholar 

  59. Powers, B. J. et al. The effectiveness of personalized coronary heart disease and stroke risk communication. Am. Heart J. 161, 673–680 (2011).

    Article  PubMed  Google Scholar 

  60. Sheridan, S. L. et al. The effect of giving global coronary risk information to adults: a systematic review. Arch. Intern. Med. 170, 230–239 (2010).

    Article  PubMed  Google Scholar 

  61. Guarneri, M., Mercado, N. & Suhar, C. Integrative approaches for cardiovascular disease. Nutr. Clin. Pract. 24, 701–708 (2009).

    Article  PubMed  Google Scholar 

  62. National Vascular Disease Prevention Alliance. Guidelines for the management of absolute cardiovascular disease risk. Heart Foundation https://heartfoundation.org.au/images/uploads/publications/Absolute-CVD-Risk-Full-Guidelines.pdf (2012).

  63. Goff, D. C. Jr et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J. Am. Coll. Cardiol. 63, 2935–2959 (2014).

    Article  PubMed  Google Scholar 

  64. Brindle, P. et al. Predictive accuracy of the Framingham coronary risk score in British men: prospective cohort study. BMJ 327, 1267–1270 (2003).

    Article  PubMed  PubMed Central  Google Scholar 

  65. Dalton, A. R., Soljak, M., Samarasundera, E., Millett, C. & Majeed, A. Prevalence of cardiovascular disease risk amongst the population eligible for the NHS Health Check Programme. Eur. J. Prev. Cardiol. 20, 142–150 (2013).

    Article  PubMed  Google Scholar 

  66. Jansen, J. et al. General practitioners' use of absolute risk versus individual risk factors in cardiovascular disease prevention: an experimental study. BMJ Open 4, e004812 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  67. World Health Organization. Cardiovascular diseases (CVDs): fact sheet. World Health Organization http://www.who.int/mediacentre/factsheets/fs317/en/ (2016).

  68. Zullig, L. L. et al. Patient-reported medication adherence barriers among patients with cardiovascular risk factors. J. Manag. Care Spec. Pharm. 21, 479–485 (2015).

    PubMed  Google Scholar 

  69. McKenzie, S. J., McLaughlin, D., Clark, J. & Doi, S. A. The burden of non-adherence to cardiovascular medications among the aging population in Australia: a meta-analysis. Drugs Aging 32, 217–225 (2015).

    Article  PubMed  Google Scholar 

  70. Wong, M. C. et al. The association between multimorbidity and poor adherence with cardiovascular medications. Int. J. Cardiol. 177, 477–482 (2014).

    Article  PubMed  Google Scholar 

  71. McLaren, L., McIntyre, L. & Kirkpatrick, S. Rose's population strategy of prevention need not increase social inequalities in health. Int. J. Epidemiol. 39, 372–377 (2010).

    Article  PubMed  Google Scholar 

  72. [No authors listed.] The 2015/16 health targets. Ministry of Health http://www.health.govt.nz/new-zealand-health-system/health-targets (2015).

  73. Krogsbøll, L. T., Jørgensen, K. J., Grønhøj Larsen, C. & Gøtzsche, P. C. General health checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis. BMJ 345, e7191 (2012).

    Article  PubMed  PubMed Central  Google Scholar 

  74. Jørgensen, T. et al. Effect of screening and lifestyle counselling on incidence of ischaemic heart disease in general population: Inter99 randomised trial. BMJ 348, g3617 (2014).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  75. Sacco, R. L., Frieden, T. R., Blakeman, D. E., Jauch, E. C. & Mohl, S. What the million hearts initiative means for stroke: a presidential advisory from the American Heart Association/American Stroke Association. Stroke 43, 924–928 (2012).

    Article  PubMed  Google Scholar 

  76. Frieden, T. R. & Berwick, D. M. The 'Million Hearts' initiative — preventing heart attacks and strokes. N. Engl. J. Med. 365, e27 (2011).

    Article  PubMed  Google Scholar 

  77. Sanghavi, D. M. & Conway, P. H. Paying for prevention: a novel test of medicare value-based payment for cardiovascular risk reduction. JAMA 314, 123–124 (2015).

    Article  CAS  PubMed  Google Scholar 

  78. Asch, D. A. et al. Effect of financial incentives to physicians, patients, or both on lipid levels: a randomized clinical trial. JAMA 314, 1926–1935 (2015).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  79. Probst-Hensch, N., Tanner, M., Kessler, C., Burri, C. & Kunzli, N. Prevention — a cost-effective way to fight the non-communicable disease epidemic: an academic perspective of the United Nations High-level NCD Meeting. Swiss Med. Wkly 141, w13266 (2011).

    PubMed  Google Scholar 

  80. Asaria, P., Chisholm, D., Mathers, C., Ezzati, M. & Beaglehole, R. Chronic disease prevention: health effects and financial costs of strategies to reduce salt intake and control tobacco use. Lancet 370, 2044–2053 (2007).

    Article  PubMed  Google Scholar 

  81. Khatib, R. et al. Availability and affordability of cardiovascular disease medicines and their effect on use in high-income, middle-income, and low-income countries: an analysis of the PURE study data. Lancet 387, 61–69 (2016).

    Article  PubMed  Google Scholar 

  82. Notara, V., Panagiotakos, D. B. & Pitsavos, C. E. Secondary prevention of acute coronary syndrome. Socio-economic and lifestyle determinants: a literature review. Cent. Eur. J. Public Health 22, 175–182 (2014).

    Article  PubMed  Google Scholar 

  83. Boden-Albala, B. & Quarles, L. W. Education strategies for stroke prevention. Stroke 44 (6 Suppl. 1), S48–S51 (2013).

    Article  PubMed  Google Scholar 

  84. Yusuf, S., Wood, D., Ralston, J. & Reddy, K. S. The World Heart Federation's vision for worldwide cardiovascular disease prevention. Lancet 386, 399–402 (2015).

    Article  PubMed  Google Scholar 

  85. World Health Organization. Global action plan for the prevention and control of noncommunicable diseases 2013–2020. http://www.who.int/nmh/events/ncd_action_plan/en/ (2015).

  86. Cooney, M. T., Dudina, A., D'Agostino, R. & Graham, I. M. Cardiovascular risk-estimation systems in primary prevention: do they differ? Do they make a difference? Can we see the future? Circulation 122, 300–310 (2010).

    Article  PubMed  Google Scholar 

  87. Mancia, G. et al. 2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J. Hypertens. 31, 1281–1357 (2013).

    Article  CAS  PubMed  Google Scholar 

  88. Hill, S. et al. Absolute risk representation in cardiovascular disease prevention: comprehension and preferences of health care consumers and general practitioners involved in a focus group study. BMC Public Health 10, 108 (2010).

    Article  PubMed  PubMed Central  Google Scholar 

  89. Fagerlin, A., Zikmund-Fisher, B. J. & Ubel, P. A. Helping patients decide: ten steps to better risk communication. J. Natl Cancer Inst. 103, 1436–1443 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  90. Maniar, S. et al. in PanVascular Medicine 2nd edn (ed. Lanzer, P.) 1695–1718 (Springer, 2015).

    Book  Google Scholar 

  91. Wald, D. S. & Raiman, L. Medication adherence in cardiovascular disease: how to address one of the challenges of preventive medicine. Prim. Care Cardiovasc. J. 6, 60–62 (2013).

    Google Scholar 

  92. Bowry, A. D., Shrank, W. H., Lee, J. L., Stedman, M. & Choudhry, N. K. A systematic review of adherence to cardiovascular medications in resource-limited settings. J. Gen. Intern. Med. 26, 1479–1491 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  93. Webster, R. & Rodgers, A. Polypill: progress and challenges to global use — update on the trials and policy implementation. Curr. Cardiol. Rep. 17, 121 (2015).

    Article  PubMed  Google Scholar 

  94. Gaziano, T. A., Opie, L. H. & Weinstein, M. C. Cardiovascular disease prevention with a multidrug regimen in the developing world: a cost-effectiveness analysis. Lancet 368, 679–686 (2006).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  95. [No authors listed]. Community–clinical linkages to improve hypertension identification, management, and control. Association of State and Territorial Health Officials http://www.astho.org/Prevention/Community-Clinical-Linkages-Issue-Brief/ (2015).

  96. Foltz, J. L., Belay, B. & Blackburn, G. L. Improving the weight of the nation by engaging the medical setting in obesity prevention and control. J. Law Med. Ethics 41, 19–26 (2013).

    Article  PubMed  Google Scholar 

  97. [No authors listed]. Chronic disease prevention and health promotion domains. Centers for Disease Control and Prevention http://www.cdc.gov/chronicdisease/about/foa/docs/four-domains-nov2012.pdf (2012).

  98. [No authors listed]. Cardiovascular disease prevention and control: interventions engaging community health workers. The Community Guide http://www.thecommunityguide.org/cvd/CHW.html (2015).

  99. Feigin, V. L. Stroke in developing countries: can the epidemic be stopped and outcomes improved? Lancet Neurol. 6, 94–97 (2007).

    Article  PubMed  Google Scholar 

  100. Chandra, V. et al. in Neurological Disorders (eds Jamison, D. T. et al.) 627–643 (Oxford Univ. Press & World Bank, 2006).

    Google Scholar 

  101. Zhao, X. et al. Using a low-sodium, high-potassium salt substitute to reduce blood pressure among Tibetans with high blood pressure: a patient-blinded randomized controlled trial. PLoS ONE 9, e110131 (2014).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  102. Luo, B., Wan, L., Liang, L. & Li, T. The effects of educational campaigns and smoking bans in public places on smokers' intention to quit smoking: findings from 17 cities in China. BioMed Res. Int. 2015, 853418 (2015).

    PubMed  PubMed Central  Google Scholar 

  103. Selmer, R. M. et al. Cost and health consequences of reducing the population intake of salt. J. Epidemiol. Commun. Health 54, 697–702 (2000).

    Article  CAS  Google Scholar 

  104. Johnson, R. K. et al. Dietary sugars intake and cardiovascular health: a scientific statement from the American Heart Association. Circulation 120, 1011–1020 (2009).

    Article  CAS  PubMed  Google Scholar 

  105. Martineau, F., Tyner, E., Lorenc, T., Petticrew, M. & Lock, K. Population-level interventions to reduce alcohol-related harm: an overview of systematic reviews. Prev. Med. 57, 278–296 (2013).

    Article  PubMed  Google Scholar 

  106. Wilson, N. Salt tax could reduce population's salt intake. BMJ 329, 918 (2004).

    PubMed  PubMed Central  Google Scholar 

  107. Hopkins, D. P. et al. Reviews of evidence regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke. Am. J. Prev. Med. 20, 16–66 (2001).

    Article  CAS  PubMed  Google Scholar 

  108. Goodchild, M., Perucic, A. M. & Nargis, N. Modelling the impact of raising tobacco taxes on public health and finance. Bull. World Health Organ. 94, 250–257 (2016).

    Article  PubMed  PubMed Central  Google Scholar 

  109. World Health Organization. WHO report on the global tobacco epidemic, 2015: raising taxes on tobacco. World Health Organization http://apps.who.int/iris/bitstream/10665/178574/1/9789240694606_eng.pdf (2015).

  110. Ruff, R. R. & Zhen, C. Estimating the effects of a calorie-based sugar-sweetened beverage tax on weight and obesity in New York City adults using dynamic loss models. Ann. Epidemiol. 25, 350–357 (2015).

    Article  PubMed  Google Scholar 

  111. Briggs, A. D. et al. Overall and income specific effect on prevalence of overweight and obesity of 20% sugar sweetened drink tax in UK: econometric and comparative risk assessment modelling study. BMJ 347, f6189 (2013).

    Article  PubMed  PubMed Central  Google Scholar 

  112. WHO technical staff. Reducing consumption of sugar-sweetened beverages to reduce the risk of unhealthy weight gain in adults. World Health Organization http://www.who.int/elena/bbc/ssbs_adult_weight/en/ (2014).

  113. Meier, P. S. et al. Estimated effects of different alcohol taxation and price policies on health inequalities: a mathematical modelling study. PLoS Med. 13, e1001963 (2016).

    Article  PubMed  PubMed Central  Google Scholar 

  114. Delcher, C., Maldonado-Molina, M. M. & Wagenaar, A. C. Effects of alcohol taxes on alcohol-related disease mortality in New York State from 1969 to 2006. Addict. Behav. 37, 783–789 (2012).

    Article  PubMed  PubMed Central  Google Scholar 

  115. Wagenaar, A. C., Tobler, A. L. & Komro, K. A. Effects of alcohol tax and price policies on morbidity and mortality: a systematic review. Am. J. Public Health 100, 2270–2278 (2010).

    Article  PubMed  PubMed Central  Google Scholar 

  116. Chaloupka, F. J., Grossman, M. & Saffer, H. The effects of price on alcohol consumption and alcohol-related problems. Alcohol Res. Health 26, 22–34 (2002).

    PubMed  PubMed Central  Google Scholar 

  117. Elder, R. W. et al. The effectiveness of tax policy interventions for reducing excessive alcohol consumption and related harms. Am. J. Prev. Med. 38, 217–229 (2010).

    Article  PubMed  PubMed Central  Google Scholar 

  118. Doran, C. M., Byrnes, J. M., Higashi, H. & Truong, K. Revenue implications to the Vietnamese government of using taxes to curb cigarette smoking. Addict. Behav. 35, 1089–1093 (2010).

    Article  PubMed  Google Scholar 

  119. Andreyeva, T., Chaloupka, F. J. & Brownell, K. D. Estimating the potential of taxes on sugar-sweetened beverages to reduce consumption and generate revenue. Prev. Med. 52, 413–416 (2011).

    Article  PubMed  Google Scholar 

  120. Doran, C. M., Byrnes, J. M., Cobiac, L. J., Vandenberg, B. & Vos, T. Estimated impacts of alternative Australian alcohol taxation structures on consumption, public health and government revenues. Med. J. Aust. 199, 619–622 (2013).

    Article  PubMed  Google Scholar 

  121. Feigin, V. L., Krishnamurthi, R., Barber, P. A. & Arroll, B. Stroke prevention in New Zealand: can we do better? Int. J. Stroke 9, 61–63 (2013).

    Article  PubMed  Google Scholar 

  122. Murray, C. J. et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 380, 2197–2223 (2012).

    Article  PubMed  Google Scholar 

  123. Lozano, R. et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 380, 2095–2128 (2012).

    Article  PubMed  Google Scholar 

  124. Cappuccio, F. Epidemiologic transition, migration and cardiovascular disease. Int. J. Epidemiol. 33, 387–388 (2004).

    Article  PubMed  Google Scholar 

  125. Licskai, C., Sands, T. W. & Ferrone, M. Development and pilot testing of a mobile health solution for asthma self-management: asthma action plan smartphone application pilot study. Can. Respir. J. 20, 301–306 (2013).

    Article  PubMed  PubMed Central  Google Scholar 

  126. Brouillette, R. M. et al. Feasibility, reliability, and validity of a smartphone based application for the assessment of cognitive function in the elderly. PLoS ONE 8, e65925 (2013).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  127. Buller, D. B., Borland, R., Bettinghaus, E. P., Shane, J. H. & Zimmerman, D. E. Randomized trial of a smartphone mobile application compared to text messaging to support smoking cessation. Telemed. J. E Health 20, 206–214 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  128. Ly, K. H., Carlbring, P. & Andersson, G. Behavioral activation-based guided self-help treatment administered through a smartphone application: study protocol for a randomized controlled trial. Trials 13, 62 (2012).

    Article  PubMed  PubMed Central  Google Scholar 

  129. Carter, M. C., Burley, V. J., Nykjaer, C. & Cade, J. E. Adherence to a smartphone application for weight loss compared to website and paper diary: pilot randomized controlled trial. J. Med. Internet Res. 15, e32 (2013).

    Article  PubMed  PubMed Central  Google Scholar 

  130. [No authors listed.] Surveillance Strategy: a strategy for improving the Centers for Disease Control and Prevention's activities in public health surveillance. Centers for Disease Control and Prevention http://www.cdc.gov/ophss/docs/cdc-surveillance-strategy-final.pdf (2014).

  131. Spring, B. et al. Multiple behavior changes in diet and activity: a randomized controlled trial using mobile technology. Arch. Intern. Med. 172, 789–796 (2012).

    Article  PubMed  PubMed Central  Google Scholar 

  132. Recio- Rodríguez, J. I. et al. Effectiveness of a smartphone application for improving healthy lifestyles, a randomized clinical trial (EVIDENT II): study protocol. BMC Public Health 14, 254 (2014).

    Article  Google Scholar 

  133. Bond, D. S. et al. B-MOBILE — a smartphone-based intervention to reduce sedentary time in overweight/obese individuals: a within-subjects experimental trial. PLoS ONE 9, e0100821 (2014).

    Google Scholar 

  134. Glynn, L. G. et al. Effectiveness of a smartphone application to promote physical activity in primary care: the SMART MOVE randomised controlled trial. Br. J. Gen. Pract. 64, e384–e391 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  135. Martin, C. K. et al. Efficacy of SmartLossSM, a smartphone-based weight loss intervention: results from a randomized controlled trial. Obesity 23, 935–942 (2015).

    Article  PubMed  Google Scholar 

  136. Stephens, J. D., Yager, A. M. & Allen, J. Smartphone technology and text messaging for weight loss in young adults: a randomized controlled trial. J. Cardiovasc. Nurs. http://dx.doi.org/10.1097/JCN.0000000000000307 (2015).

  137. Eyles, H. et al. Using mobile technology to support lower-salt food choices for people with cardiovascular disease: protocol for the SaltSwitch randomized controlled trial. BMC Public Health 14, 950 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  138. Piette, J. D. et al. Hypertension management using mobile technology and home blood pressure monitoring: results of a randomized trial in two low/middle-income countries. Telemed. J. E Health 18, 613–620 (2012).

    Article  PubMed  PubMed Central  Google Scholar 

  139. Block, G. et al. Diabetes prevention and weight loss with a fully automated behavioral intervention by e-mail, web, and mobile phone: a randomized controlled trial among persons with prediabetes. J. Med. Internet Res. 17, e240 (2015).

    Article  PubMed  PubMed Central  Google Scholar 

  140. Rodgers, A. et al. Do u smoke after txt? Results of a randomised trial of smoking cessation using mobile phone text messaging. Tob. Control 14, 255–261 (2005).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  141. Free, C. et al. Smoking cessation support delivered via mobile phone text messaging (txt2stop): a single-blind, randomised trial. Lancet 378, 49–55 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  142. Chow, C. K. et al. Effect of lifestyle-focused text messaging on risk factor modification in patients with coronary heart disease: a randomized clinical trial. JAMA 314, 1255–1263 (2015).

    Article  CAS  PubMed  Google Scholar 

  143. Proudfoot, J. et al. Impact of a mobile phone and web program on symptom and functional outcomes for people with mild-to-moderate depression, anxiety and stress: a randomised controlled trial. BMC Psychiatry 13, 312 (2013).

    Article  PubMed  PubMed Central  Google Scholar 

  144. World Health Organization. mHealth: new horizons for health through mobile technologies. http://apps.who.int/iris/bitstream/10665/44607/1/9789241564250_eng.pdf (2011).

  145. Burke, L. E. et al. Current science on consumer use of mobile health for cardiovascular disease prevention: a scientific statement from the American Heart Association. Circulation 132, 1157–1213 (2015).

    Article  PubMed  PubMed Central  Google Scholar 

  146. Nasser, F. B. & Trevena, L. There's an app for that: a guide for healthcare practitioners and researchers on smartphone technology. Online J. Public Health Inform. 7, e218 (2015).

    Google Scholar 

  147. Morgan, J. The power of the App: can mobile-technology save lives? Lancet Neurol. 15, 668 (2015).

    Article  PubMed  Google Scholar 

  148. World Health Organization. Global status report on noncommunicable diseases 2010 http://www.who.int/nmh/publications/ncd_report_full_en.pdf (2011).

  149. Fustinoni, O. & Biller, J. Ethnicity and stroke: beware of the fallacies. Stroke 31, 1013–1015 (2000).

    Article  CAS  PubMed  Google Scholar 

  150. Sacco, R. L. et al. Stroke incidence among white, black, and Hispanic residents of an urban community: the Northern Manhattan Stroke Study. Am. J. Epidemiol. 147, 259–268 (1998).

    Article  CAS  PubMed  Google Scholar 

  151. Stewart, J. A., Dundas, R., Howard, R. S., Rudd, A. G. & Wolfe, C. D. Ethnic differences in incidence of stroke: prospective study with stroke register. BMJ 318, 967–971 (1999).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  152. van Rossum, C. T., van de Mheen, H., Breteler, M. M., Grobbee, D. E. & Mackenbach, J. P. Socioeconomic differences in stroke among Dutch elderly women: the Rotterdam Study. Stroke 30, 357–362 (1999).

    Article  CAS  PubMed  Google Scholar 

  153. Feigin, V. L. et al. 30-year trends in stroke rates and outcome in Auckland, New Zealand (1981–2012): a multi-ethnic population-based series of studies. PLoS ONE 10, e0134609 (2015).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  154. Mullen Conley, K. et al. Kids Identifying and Defeating Stroke (KIDS): development and implementation of a multiethnic health education intervention to increase stroke awareness among middle school students and their parents. Health Promot. Pract. 11, 95–103 (2010).

    Article  PubMed  Google Scholar 

  155. World Health Organization. Adherence to long-term therapies: evidence for action. World Health Organization http://www.who.int/chp/knowledge/publications/adherence_introduction.pdf (2003).

  156. Davis, P. C. Jr & Rankin, L. L. Guidelines for making existing health education programs more culturally appropriate. Am. J. Health Educ. 37, 250–252 (2006).

    Article  Google Scholar 

  157. Peñalvo, J. L. et al. The Program SI! intervention for enhancing a healthy lifestyle in preschoolers: first results from a cluster randomized trial. BMC Public Health 13, 1208 (2013).

    Article  PubMed  PubMed Central  Google Scholar 

  158. Wen, X., Kong, K. L., Eiden, R. D., Sharma, N. N. & Xie, C. Sociodemographic differences and infant dietary patterns. Pediatrics 134, e1387–e1398 (2014).

    Article  PubMed  Google Scholar 

  159. Foltz, J. L. et al. Population-level intervention strategies and examples for obesity prevention in children. Annu. Rev. Nutr. 32, 391–415 (2012).

    Article  CAS  PubMed  Google Scholar 

  160. Hickey, A. et al. Stroke awareness in the general population: knowledge of stroke risk factors and warning signs in older adults. BMC Geriatr. 9, 35 (2009).

    Article  PubMed  PubMed Central  Google Scholar 

  161. Jones, S. P., Jenkinson, A. J., Leathley, M. J. & Watkins, C. L. Stroke knowledge and awareness: an integrative review of the evidence. Age Ageing 39, 11–22 (2010).

    Article  PubMed  Google Scholar 

  162. Ellis, C., Wolff, J. & Wyse, A. Stroke awareness among low literacy Latinos living in the South Carolina low country. J. Immigr. Minor. Health 11, 499–504 (2009).

    Article  PubMed  Google Scholar 

  163. Ryan, T. Stroke awareness among British ethnic minorities. Br. J. Commun. Nurs. 15, 381–384 (2010).

    Article  Google Scholar 

  164. Ellis, C. & Egede, L. E. Racial/ethnic differences in stroke awareness among veterans. Ethn. Dis. 18, 198–203 (2008).

    PubMed  Google Scholar 

  165. Alkadry, M. G. & Tower, L. E. The effect of rurality and gender on stroke awareness of adults in West Virginia. J. Health Hum. Serv. Admin. 33, 63–93 (2010).

    Google Scholar 

  166. Hodgson, C. Community outreach for stroke education. Stroke 39, 2189–2190 (2008).

    Article  PubMed  Google Scholar 

  167. Sullivan, K. A. & Katajamaki, A. Stroke education: promising effects on the health beliefs of those at risk. Top. Stroke Rehabil. 16, 377–387 (2009).

    Article  PubMed  Google Scholar 

  168. Tadros, A. et al. Emergency medical services-based community stroke education: pilot results from a novel approach. Stroke 40, 2134–2142 (2009).

    Article  PubMed  Google Scholar 

  169. Kim, Y. S. et al. Stroke awareness decreases prehospital delay after acute ischemic stroke in Korea. BMC Neurol. 11, 2 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  170. Bray, J. E., Mosley, I., Bailey, M., Barger, B. & Bladin, C. Stroke public awareness campaigns have increased ambulance dispatches for stroke in Melbourne, Australia. Stroke 42, 2154–2157 (2011).

    Article  PubMed  Google Scholar 

  171. Rothwell, P. M. Lack of research funding for stroke. Int. J. Stroke 2, 73 (2007).

    Article  PubMed  Google Scholar 

  172. [No authors listed.] Final report of the Stroke Progress Review Group – January 2012. NIH National Institute of Neurological Disorders and Stroke http://www.ninds.nih.gov/about_ninds/groups/stroke_prg/01-2012-stroke-prg-report.htm (2012).

  173. Yusuf, S. et al. Cardiovascular risk and events in 17 low-, middle-, and high-income countries. N. Engl. J. Med. 371, 818–827 (2014).

    Article  CAS  PubMed  Google Scholar 

  174. [No authors listed.] Be he@lthy, be mobile. ITU http://www.itu.int/en/ITU-D/ICT-Applications/eHEALTH/Pages/Be_Healthy.aspx (2014).

  175. Collins, F. S. & Varmus, H. A new initiative on precision medicine. N. Engl. J. Med. 372, 793–795 (2015).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  176. [No authors listed.] Cardiovascular disease prevention and control. Translating evidence into practice. World Health Organization http://apps.who.int/iris/bitstream/10665/43235/1/9241593253_eng.pdf (2005).

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Acknowledgements

V.L.F. was partly funded by the Health Council of New Zealand, the Brain Research New Zealand Centre of Research Excellence, the “Ageing Well” Programme of the National Science Challenge, and the Ministry of Business, Innovation and Employment of New Zealand. G.A.R. has grant funding from the US National Institute on Ageing and Medtronic Philanthropy. We would like to thank Barbara Bowman at the Centers for Disease Control and Prevention for her valuable comments on early version of the manuscript. The views expressed in this article are those of the authors and do not necessarily represent the views of the National Heart, Lung, and Blood Institute; NIH; Centers for Disease Control and Prevention; or the U.S. Department of Health and Human Services.

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All authors researched data for the article, made substantial contributions to discussions of the content and reviewed and/or edited the manuscript before submission. V.L.F. wrote the article.

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Correspondence to Valery L. Feigin.

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V.L.F. declares that Stroke Riskometer app is copyrighted by the Auckland University of Technology, and funds resulting from the sale of the professional version of this app will be used for further research and education for stroke prevention. The other authors declare no competing interests.

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Feigin, V., Norrving, B., George, M. et al. Prevention of stroke: a strategic global imperative. Nat Rev Neurol 12, 501–512 (2016). https://doi.org/10.1038/nrneurol.2016.107

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