Stroke Incidence and Survival in American Indians, Blacks, and Whites: The Strong Heart Study and Atherosclerosis Risk in Communities Study

Clemma J. Muller, Alvaro Alonso, Jean Forster, David M Vock, Ying Zhang, Rebecca F. Gottesman, Wayne Rosamond, W. T. Longstreth, Richard F Maclehose

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Background: American Indians (AIs) have high stroke morbidity and mortality. We compared stroke incidence and mortality in AIs, blacks, and whites. Methods and Results: Pooled data from 2 cardiovascular disease cohort studies included 3182 AIs from the SHS (Strong Heart Study), aged 45 to 74 years at baseline (1988–1990) and 3765 blacks and 10 413 whites from the ARIC (Atherosclerosis Risk in Communities) Study, aged 45 to 64 years at baseline (1987–1989). Stroke surveillance was based on self-report, hospital records, and death certificates. We estimated hazard ratios for incident stroke (ischemic and hemorrhagic combined) through 2008, stratified by sex and birth-year tertile, and relative risk for poststroke mortality. Incident strokes numbered 282 for AIs, 416 for blacks, and 613 for whites. For women and men, stroke incidence among AIs was similar to or lower than blacks and higher than whites. Covariate adjustment resulted in lower hazard ratios for most comparisons, but results for these models were not always statistically significant. After covariate adjustment, AI women and men had higher 30-day poststroke mortality than blacks (relative risk=2.1 [95% CI=1.0, 3.2] and 2.2 [95% CI=1.3, 3.1], respectively), and whites (relative risk=1.6 [95% CI=0.8, 2.5] and 1.7 [95% CI=1.1, 2.4]), and higher 1-year mortality (relative risk range=1.3–1.5 for all comparisons). Conclusions: Stroke incidence in AIs was lower than for blacks and higher than for whites; differences were larger for blacks and smaller for whites after covariate adjustment. Poststroke mortality was higher in AIs than blacks and whites.

Original languageEnglish (US)
Article numbere010229
JournalJournal of the American Heart Association
Issue number12
StatePublished - 2019

Bibliographical note

Funding Information:
Muller received support from the Eva O. Miller dissertation fellowship through the University of Minnesota. The Strong Heart Study was supported by cooperative agreement grants U01-HL41642, U01-HL41652, U01-HL41654, U01-HL65520, and U01-HL65521 and research grants R01-HL109315, R01 HL109301, R01HL109284, R01HL109282, and R01HL109319 from the National Heart, Lung, and Blood Institute (Bethesda, MD). The Atherosclerosis Risk in Communities Study is carried out as a collaborative study supported by National Heart, Lung, and Blood Institute contracts (HHSN268201100005C, HHSN268201100006C, HHSN268201100007C, HHSN26820 1100008C, HHSN268201100009C, HHSN268201100010C, HHSN268201100011C, and HHSN268201100012C). Dr Alonso was supported by grant U01HL096902 from the National Heart, Lung, and Blood Institute.


  • American Indians
  • blacks
  • health disparities
  • stroke

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