Tanne D, Yaari S, Goldbourt U
Center for Stroke Research, Department of Neurology, Henry Ford Hospital & Health Sciences Center (Detroit Campus of Case Western University), Detroit, MI, USA.
Circulation. 1998 Oct 6;98(14):1365-71. doi: 10.1161/01.cir.98.14.1365.
Multinational comparisons demonstrate marked ethnic and regional variation in stroke mortality and risk-factor distribution. We assessed the role of ethnicity and estimated the cumulative effect of multiple risk factors on long-term ischemic stroke mortality.
Civil servants and municipal employees in Israel (n=9734 men; age, >/=42 years), chosen by stratified sampling in 6 prespecified areas of birth (those born in Israel and those who were immigrants from 5 other regional-ethnic strata), were included in the Israeli Ischemic Heart Disease (IIHD) Project. Over a 21-year follow-up period, age-adjusted mortality rates per 10 000 person-years attributed to ischemic stroke (n=282; International Classification of Diseases [ICD]-9 codes 433 to 438) were higher among immigrants to Israel from northern Africa and the Mideast (17.1 to 19.0), than from 3 parts of Europe (11.3 to 12.4). Crude rates per 1000 subjects observed in those born in Asia or Africa (29.4 to 31.2) exceeded rates predicted by risk-factor profiles (21.4 to 24.9). Adjusted hazard ratios were 3.00 for age (per 10 years), 2.15 for left ventricular hypertrophy, 1.69 for systolic blood pressure (BP, per 20 mm Hg), 1.86 for diabetes mellitus, 1.83 for peripheral vascular disease, 1.79 for smoking (>20 cigarettes per day), 1.51 for coronary heart disease, 1.16 for percent cholesterol contained in the HDL fraction (%HDL, per 5% decrease), and 1.88 for diastolic BP (per 12 mm Hg; assessed in an alternative model). Accounting for regression dilution bias and assessed from repeat measurements, we found that hazard ratio estimates associated with diastolic BP, systolic BP, and percent HDL (per increments described) increased to 3.22, 2.23, and 1.23, respectively. Ischemic stroke mortality rates were 30-fold greater among subjects at the highest versus the lowest quintile of predicted probability according to risk-factor profiles (81.2 versus 2.6 per 1000 subjects).
Assessment of multiple risk factors provides useful quantitative prediction of long-term ischemic stroke mortality risk. Regional-ethnic variations are consistent with a hypothesis that other, undetermined inherent genetic or sociocultural factors act to increase ischemic stroke mortality rates in immigrants to Israel from the Mideast and northern Africa over that predicted by conventional risk factors.
跨国比较显示，中风死亡率和危险因素分布存在显著的种族和地区差异。我们评估了种族的作用，并估计了多种危险因素对长期缺血性中风死亡率的累积影响。
以色列缺血性心脏病（IIHD）项目纳入了以色列的公务员和市政雇员（n = 9734名男性；年龄≥42岁），这些人员通过在6个预先指定的出生地区进行分层抽样选取（出生在以色列的人和来自其他5个地区 - 种族阶层的移民）。在21年的随访期内，每10000人年归因于缺血性中风（n = 282；国际疾病分类[ICD]-9编码433至438）的年龄调整死亡率，来自北非和中东的以色列移民（17.1至19.0）高于来自欧洲3个地区的移民（11.3至12.4）。在亚洲或非洲出生的人群中，每1000名观察对象的粗死亡率（29.4至31.2）超过了根据危险因素概况预测的死亡率（21.4至24.9）。调整后的风险比为：年龄（每10岁）3.00、左心室肥厚2.15、收缩压（BP，每20 mmHg）1.69、糖尿病1.86、外周血管疾病1.83、吸烟（每天>20支）1.79、冠心病1.51、高密度脂蛋白部分所含胆固醇百分比（%HDL，每降低5%）1.16，以及舒张压（每12 mmHg；在另一种模型中评估）1.88。考虑到回归稀释偏差并通过重复测量评估，我们发现与舒张压、收缩压和%HDL（按所述增量）相关的风险比估计值分别增至3.22、2.23和1.23。根据危险因素概况，预测概率最高与最低五分位数的受试者中，缺血性中风死亡率相差30倍（每1000名受试者中分别为81.2和2.6）。
对多种危险因素的评估可为长期缺血性中风死亡风险提供有用的定量预测。地区 - 种族差异与以下假设一致，即其他未确定的内在遗传或社会文化因素致使从中东和北非移民到以色列的人群中缺血性中风死亡率高于传统危险因素预测的水平。
