title: Are changes in mortality from stroke caused by changes in stroke event rates or case fatality? Results from the WHO MONICA Project.
abstract: OBJECTIVE
  Mortality from stroke has been declining over recent decades in most countries, except in Eastern Europe. In this analysis, based on the World Health Organization Monitoring Trends and Determinants in Cardiovascular Disease (WHO MONICA) Project, we explored to what extent these trends are due to changes in stroke event rate and to changes in case fatality.
  
  
  METHODS
  The WHO MONICA Project collected standardized data from 14 populations in 9 countries. All acute strokes occurring in men and women 35 to 64 years of age were included. Registration was carried out between 1982 and 1995, resulting in time spans from 7 to 13 years. Trends in event rates and case fatality were calculated as average annual percentage change.
  
  
  RESULTS
  Up to 6-fold differences were observed in stroke mortality. Mortality declined in 8 of 14 populations in men and in 10 of 14 populations in women. An increase in mortality was observed in Eastern Europe. In the populations with a declining trend, about two thirds of the change could be attributed to a decline in case fatality. In populations with increasing mortality, the rise was explained by an increase in case fatality.
  
  
  CONCLUSIONS
  In most populations, changes in stroke mortality, whether declining or increasing, were principally attributable to changes in case fatality rather than changes in event rates. Whether this was due to changes in the management of stroke or changes in disease severity cannot be established on the basis of these results.
authors.affiliation: Department of Epidemiology and Health Promotion, National Public Health Institute, Mannerheimintie 166, 00300 Helsinki, Finland. cinzia.sarti@ktl.fi
authors.forename: Cinzia
authors.initials: C
authors.lastname: Sarti
authors.forename: Birgitta
authors.initials: B
authors.lastname: Stegmayr
authors.forename: Hanna
authors.initials: H
authors.lastname: Tolonen
authors.forename: Markku
authors.initials: M
authors.lastname: Mähönen
authors.forename: Jaakko
authors.initials: J
authors.lastname: Tuomilehto
authors.forename: Kjell
authors.initials: K
authors.lastname: Asplund
mesh_terms: D000328:Adult; D017677:Age Distribution; D001208:Asia / Q000453:epidemiology; D003710:Demography; D005060:Europe / Q000453:epidemiology; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D009026:Mortality / Q000639:trends; D016012:Poisson Distribution; D012680:Sensitivity and Specificity; D017678:Sex Distribution; D020521:Stroke / Q000401:mortality*; D014944:World Health Organization