ABSTRACT
The Centers for Disease Control and Prevention (CDC) list the ‘decline in deaths from coronary heart disease and stroke’ as one of the ten great public health achievements of the 20th century in the USA (Table 1)1. This list acknowledges the remarkable accomplishments in primary prevention and secondary treatment of these diseases, and heart disease and stroke are the only specific diseases explicitly mentioned. In combining coronary heart disease and stroke, however, the list masks the remarkably greater achievement in the reduction of stroke mortality alone. Mortality from heart disease in the USA reached a peak in 1950 with an age-adjusted rate of 307.4 deaths per 100 000, and had decreased by a remarkable 56% by 1996 to a rate of 134.6 per 100 000 (Figure 1)2. In comparison, the decline in mortality from stroke has persisted since 1900, a period of decline at least twice as long as the decline in mortality from heart disease. Moreover, from 1950 to 1996, during which heart disease declined 56%, stroke mortality declined an even greater 70%, from 88.8 deaths per 100 000 to 26.5 deaths per 100 0002. Thus, the decline in stroke mortality exceeds the decline in coronary disease mortality not only in duration but also in magnitude. Despite this dramatic reduction in mortality, stroke remains
the third leading cause of death in the US, accounting for 158 448 of the 2 337 256 total deaths (7%) in 19983.
