title: Stroke declines from third to fourth leading cause of death in the United States: historical perspective and challenges ahead.
abstract: OBJECTIVE
  Stroke recently declined from the third to the fourth leading cause of death in the United States, its first rank transition among sources of American mortality in nearly 75 years.
  
  
  METHODS
  This is a narrative review supplemented by new analyses of Centers for Disease Control and Prevention National Vital Statistics Reports from 1931 to 2008.
  
  
  RESULTS
  Historically, stroke transitioned from the second to the third leading cause of death in the United States in 1937, but stroke death rates were essentially stable from 1930 to 1960. Then a long, great decline began, moderate in the 1960s, precipitous in the 1970s and 1980s, and moderate again in the 1990s and 2000s. By 2008, age-adjusted annual death rates from stroke were three fourths less than the historic 1931 to 1960 norm (40.6 versus 175.0 per 100,000). Total actual stroke deaths in the United States declined from a high of 214,000 in 1973 to 134,000 in 2008. Improved stroke prevention, through control of hypertension, hyperlipidemia, and tobacco, contributed most greatly to the mortality decline with a lesser but still substantial contribution of improved acute stroke care. Persisting challenges include race-ethnicity, sex, and geographic disparities in stroke mortality; the burden of stroke disability; the expanding obesity epidemic and aging of the US population; and the epidemic of cerebrovascular disease in low- and middle-income countries worldwide.
  
  
  CONCLUSIONS
  The recent rank decline of stroke among leading causes of American death is testament to a half century of societal progress in cerebrovascular disease prevention and acute care. Renewed commitments are needed to preserve and broaden this historic achievement.
authors.affiliation: Division of Stroke and Critical Care, Department of Neurology, University of Southern California, Los Angeles, CA, USA. towfighi@usc.edu
authors.forename: Amytis
authors.initials: A
authors.lastname: Towfighi
authors.forename: Jeffrey L
authors.initials: JL
authors.lastname: Saver
mesh_terms: D002423:Cause of Death / Q000639:trends*; D054624:Health Status Disparities; D049673:History, 20th Century; D049674:History, 21st Century; D006801:Humans; D006973:Hypertension / Q000453:epidemiology; D020521:Stroke / Q000266:history / Q000401:mortality*; D014481:United States / Q000453:epidemiology