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Background: Accurate information on stroke burden in men and women are important for evidence-based healthcare planning and resource allocation. ly, limited research suggested that the absolute of deaths from stroke in women was greater than in men, but the incidence and mortality rates were greater in men. However, sex differences in various metrics of stroke burden on a global scale have not been a subject of comprehensive and comparable assessment for most regions of the world, nor have sex differences in stroke burden been examined for trends over time.

Data inputs included all available information on stroke incidence, prevalence and death and case fatality rates. Analysis was performed separately by sex and 5-year age for countries. Statistical models were employed to produce globally comprehensive over time. IS incidence rates were lower in compared with rates for both sexes male IS incidence Interpretation: Globally, men continue to have a higher incidence of IS than women while ificant sex differences in the incidence of HS were not observed.

Ongoing monitoring of sex differences in the burden of stroke will be needed to determine if disease rates among men and women continue to diverge. Sex disparities related to stroke will have important clinical and policy implications that can guide funding and resource allocation for national, regional and global health programs. The burden of stroke in women was often underestimated until the early s [ 1 ]. Although once considered to be primarily a disease affecting men, stroke is now recognized as a major public health problem in women as well [ 2 ].

Recent data have shown that 60, more women than men have a stroke each year in the US [ 3 ]. Globally, more women die of stroke than men [ 4 ]. Although there is also increasing Ladies seeking sex Danube of sex-specific differences in stroke symptoms, diagnosis, peri-procedural risk, treatment and preventive interventions [ 567891011 ], controversies regarding differences in stroke epidemiology between men and women continue [ 121314151617 ], making this an area worthy of further investigation.

The data on sex-specific Ladies seeking sex Danube burden have remained scarce [ 181920 ]. This is possibly a reflection of the open-ended age category. Projections of GCNKSS rates on the US population gave an estimated 82, incident stroke events in women and 49, events in men, and inan estimatedevents in women compared withevents in men [ 22 ].

Total of deaths was higher for women but the cause-specific mortality rates were lower, possibly because women tend to Ladies seeking sex Danube more affected by multi-morbidity. Examination of the Framingham Study data by Petrea et al. Data from the Framingham Study further suggested that 1 in 5 women and Ladies seeking sex Danube in 6 men reaching the age of 55 years free of stroke will develop a stroke event during their remaining lifetime [ 26 ].

The major methodological limitations of the literature available are the lack of national representativeness in terms of generalizability, as well as potential bias issues, such as study population selection and study time periods [ 7 ]. Epidemiologic studies reveal a clear age-sex interaction in stroke with premenopausal women experiencing fewer strokes than similarly aged men but having higher rates in postmenopausal women than similarly aged men [ 27 ].

Generally, any data on stroke epidemiology are scarce in developing countries. While the above provides an indication of sex differences in stroke epidemiology, comprehensive and comparable assessments of stroke incidence, prevalence, mortality and disability trends over time have not been produced by sex for most regions of the world.

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Methods for determining incidence, all-cause mortality, cause-specific mortality, disability and disease prevalence in the GBD study have been ly described [ 2829 ], including the approach to stroke disease modeling [ 30 ]. Briefly, all available mortality data were compiled. Non-specific cause codes were redistributed based on expert opinion and statistical methods.

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The total for Ladies seeking sex Danube cause-specific deaths was fit to an envelope for all-cause mortality. Deaths were compiled into causes, including ischemic stroke IS and hemorrhagic stroke HS. The parent category Ladies seeking sex Danube cerebrovascular disease was based on the mapping of the detailed causes. Non-specific codes, including I64, I An ensemble model was used to estimate a continuous time series for mortality by age, sex, country and year.

Country-level covariates were incorporated into the model, and out-of-sample validity testing was used to assess model performance. Uncertainty intervals UIs were estimated using 1, draws from the posterior distribution for each age-sex-country group, with the interval taken as the 2. Disease prevalence was estimated using the DisMod-MR disease modeling software [ 32 ].

All available estimates of stroke incidence, prevalence and case fatality from systematic reviews of the scientific literature, population surveys and stroke registries were used. IS and HS were modeled separately. Adjustments were made to for incidence estimates specifying first-ever or any stroke.

Disability due to acute stroke was considered to last for up to days while chronic stroke lasted from 30 days until death [ 29 ]. YLDs were Ladies seeking sex Danube as the product of a disability weight and prevalent cases of stroke. DALYs were calculated as the sum of years of life lost prematurely, based on maximum observed global longevity, and YLDs. Countries were stratified by development status i. Table 1 shows overall trends in the of women and men with stroke by stroke type in and While the of women and men with IS was similar in and increased over time, this increase was more marked for men.

The of women with HS was lower than that of men, though with a similar proportional increase over time to men. Figure 1 presents the incidence rates of HS and IS broken down into 5-year age bands for men and women in and The age-related patterns of incidence for men and women remain relatively similar across time and stroke types.

The global age-adjusted incidence of IS showed a trend to decline in both men and women, but no ificant change was detected as UI overlapped between and table 2. For HS, there was little change detected in incidence over time. Stroke prevalence rates for both stroke types were ificantly higher for men compared with women in both and remained so in The increase in of prevalent cases of stroke between and despite ificant declines in incident stroke are consistent with change due to population growth, population ageing and, for some regions, decreases Ladies seeking sex Danube stroke-related mortality table 3.

Therefore, there were no detectable change in age-standardized prevalence rates for IS from to In contrast to IS rates, HS age-standardized prevalence rates increased over time for both sexes. Table 3 Global median percent change in and age-standardized rate perpersons for deaths, DALYs and YLDs from to by stroke type and sex. The age-standardized death rate table 4 from IS declined at a similar rate for men and women, although absolute values were higher in men. Mortality due to HS also declined over time in both sexes. While mortality in women with Ladies seeking sex Danube was slightly lower than that of men init was higher than that of men inwith no overlap of UIs.

DALYs due to IS in men rose ificantly from to while among women the trend toward an increase was not ificant table 4. DALYs related to HS were higher in men than in women, though increases from to were not ificant for either sex. YLDs related to IS remained similar for women and for men over time. The increase in of IS deaths was ificantly greater among men than women. There was a trend toward a greater increase among men for HS though the UI in percentage change overlapped.

Online supplementary Web Appendix A for all online suppl. Overall death rates in ranged from a low of Overall, DALYs for ranged from a low of YLDs ranged from a low of 2. Men had higher YLD than women in all countries. Over time, the global burden of stroke has been increasing for both men and women but the increases have been greater among men.

There is a trend toward a decreased incidence of IS in women from towith no ificant change detected for men. Improved vascular risk factor control and better healthcare interventions are likely explanations for reductions in stroke incidence over this period seen for both sexes. It is possible that differences between men and women in the extent of improvement are partly explained by women in some countries being more sensitive to health information, having better health-seeking behavior and having better access to primary prevention [ 3334 ]. An alternative explanation is that neurovascular risk factors are more frequent and severe in men and have declined faster in women, for example, tobacco [ 3536 ].

These findings are in contrast to those ly reported in which the reduction in incidence rates was more marked in men than in women. One explanation for difference between those findings and the present are that they were from a relatively smaller study catchment. Our inclusion of all countries le to greater UIs which blunts our ability to detect trends in some subgroups.

Our uncertainty for prevalence and incidence was considerably greater than for mortality because there is data on deaths from almost all countries but data on incidence and prevalence from a limited of countries. In their comprehensive review of literature, Reeves et al. Our findings demonstrated that the risk rate of stroke and absolute of IS and HS events both incident and prevalent strokes in was ificantly greater in men than in women, suggesting changes in the sex distribution of stroke burden in the world.

Similarly, sex-specific data from the Framingham Heart Study showed decreases in stroke incidence of The decline in IS incidence and mortality rates over the past decades represents a major improvement in population health and is observed for both sexes and across age groups [ 40 ]. These ificant improvements are concurrent with cardiovascular risk factor control interventions.

An American study concluded that efforts in arterial hypertension control initiated in the s appeared to have had the most substantial influence Ladies seeking sex Danube the accelerated decline in stroke risk and mortality. Although implemented later, control of diabetes mellitus and dyslipidemia and smoking cessation programs, particularly in combination with treatment of hypertension, were also implicated Ladies seeking sex Danube contributing to the decline in stroke incidence and mortality [ 40 ]. A history of hypertension, current smoking, waist-to-hip ratio, diet, physical activity, diabetes mellitus, alcohol intake, psychosocial stress and depression, cardiac causes and ratio of apolipoproteins B to A1 was estimated to for However, sex interacts with these risk factors.

For example, women with diabetes have a higher risk of death from cardiovascular disease than men with diabetes, and after menopause, blood pressure and cholesterol levels rise drastically [ 42 ]. In contrast to IS, there were no major changes in HS incidence for women or men. Prior studies suggested the risk for intracerebral hemorrhage ICH to be marginally greater in men than in women. HS incidence rates are reportedly slightly higher in Eastern Asia, where ICH has historically ed for a larger percentage of all strokes than in Western populations, possibly due to the increased prevalence of hypertension [ 45464748 ].

Studies of incidence trends for HS in recent decades have produced mixed. There was a trend toward a reduced ICH incidence in Oxfordshire between and [ 49 ], and during the s in several Chinese cities [ 45 ].

Also, ICH has a high mortality rate, especially with increased age. There are some reports that suggest that withdrawal of aggressive care practices may be different between sexes this may also vary by region and cultureand this may for some of the mortality differences in sex in ICH [ 53 ].

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Women with strokes have also been found to present with non-traditional stroke symptoms more often than men [ 54 ]. Delays in presentation, evaluation, diagnosis and treatment of women with ICH may contribute to the association between female sex and more severe Ladies seeking sex Danube. The increasing global population over time, even in the context of declining incident stroke rate, will lead to an increasing of strokes. Population aging will also increase the of strokes, and this has implications on the burdens faced by healthcare systems. The of deaths, DALYs and YLDs increased for both men and women since for both stroke subtypes, with these increases being much higher in men [ 55 ].

Inwomen had higher of deaths and DALYs, which in examining country-level statistics, seems to be driven by developing countries and countries with recent histories of adversity e. One possible explanation for this is the differential smoking rate, with men having a much greater prevalence of smoking than women [ 56 ].

Although the overall of adult smokers has decreased during the last 20 years, the of women in their 10s and 20s who smoke has increased. This increases the risk of stroke in young women. It must also be noted here that there is no data from some of countries, so the are purely modeled by the geospatial model. As such, any conclusions drawn Ladies seeking sex Danube these particular data points must be tentative at the best. Alternatively, this may have a direct relationship to accessing care. More specifically, it is possible that the global trends in IS for women, especially in the Middle East, where the rates did not mirror global rates may be due to ascertainment and diagnosis patterns that Ladies seeking sex Danube be different in men compared to women.

For example, an Egyptian study of acute myocardial infarction found ificant sex differences in presentation and treatment with women less likely to Ladies seeking sex Danube aspirin upon admission or aspirin or statins at discharge, and had poorer in-hospital mortality rates [ 57 ]. Similarly, stroke mortality rate may also be influenced by access to emergency services, with elderly women possibly living alone and thus potentially having more difficulty accessing emergency medical services.

While women aged years have lower stroke mortality compared with age-matched men, this advantage declines with advancing age [ 22 ]. There are limitations to the GBD methods. These include the extrapolation of data from subnational regions to the whole country and missing data overall, in particular from low-income countries.

Strengths include the use of consistent methods to enable comparison between subtypes of stroke and between diseases, the ability to highlight regions where stroke is a particular problem. This highlights the importance of studies being clear on how stroke and its subtypes are defined e. While age-adjusted incidence and death rates from stroke have been declining since the late 20th century, the global stroke burden measured as the absolute s of people affected by stroke, disabled due to stroke or deaths from stroke are increasing for both men and women, with larger increases in men.

This increasing burden is a reflection of population growth and aging and lifestyle and environmental changes. That women tend to survive longer and experience stroke at an older age suggests that in the future, alongside the aging of the population, we can expect a dramatic increase of stroke in older women.

To combat this, it is important that preventive efforts and guidelines for treatment reflect sex differences in the profile of stroke. Specifically, women have strokes associated with a higher prevalence of arterial hypertension, atrial fibrillation and pre-stroke disability but a lower prevalence of heart disease, peripheral vascular disease, smoking and alcohol use than men, and these will need to be taken into [ 22 ].

In terms of treatment, women are less likely to receive intravenous alteplase treatment and lipid testing while in hospital in some countries [ 22 ]. These disparities suggest the need to explore whether differential strategies are required to target primary and secondary prevention of stroke in women and to determine if treatment protocols must also accommodate sex differences. Further strategies are particularly needed to lower high case fatality. These could include investment in pre-hospital and acute care in some regions and could perhaps include better home care provided in treatment and monitoring of blood pressure.

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Sex Differences in Stroke Incidence, Prevalence, Mortality and Disability-Adjusted Life Years: from the Global Burden of Disease Study