The annual count of new strokes has increased by 73% between 1990 and 2023, reaching 13.2 million diagnoses per year, although in that same interval the age-adjusted incidence, mortality and disability rates have decreased, according to the latest analysis of the Global Burden of Disease (GBD), published in the journal "Neuroepidemiology".
The study, coordinated by Auckland University of Technology (New Zealand), estimates that in 2023 6.8 million people died from stroke and that almost 105 million live with sequelae of this pathology. Stroke thus remains the second leading cause of death worldwide and the third if deaths and disability are combined.
Between 1990 and 2023, age-standardized stroke mortality fell by 52%, disability-adjusted life years (DALYs) linked to this disease were reduced by 48% and adjusted incidence fell by 25%. Nevertheless, in absolute terms, deaths increased by 22% and DALYs by 18% in that same period.
The authors underline that this apparent paradox reflects that, although age-specific rates are improving, the global burden of stroke continues to grow. "Population growth and aging explain part of the increase, but not all of it," says Professor Valery L. Feigin, the study's lead author.
"It used to be said that stroke was a disease of old people. That is no longer true: 52% of strokes now occur in people of working age, under 70," he notes.
The team estimates that currently 1.9 million strokes a year are recorded in the 15 to 49 age group. This rise in young adults is linked, according to Feigin and his colleagues, to earlier and more intense exposure to metabolic risk factors, especially poorly controlled blood pressure and rising rates of childhood obesity, which later translate into hypertension and diabetes in adulthood.
The researchers recall that stroke is largely preventable, but its total impact continues to rise "with marked regional disparities". For this reason, they urgently call for more ambitious prevention programs adapted to each area, focused on the main risk factors, along with equitable access to urgent care and rehabilitation, with the aim of reducing the avoidable mortality and disability associated with stroke throughout the planet.
Hypertension, the major trigger of stroke
Uncontrolled arterial hypertension remains the predominant risk factor, responsible for around 60% of the global burden of stroke. Even so, close to half of patients who receive antihypertensive medication abandon it after a few months, often when blood pressure figures have normalized, and only around 20% of people perceive physical symptoms related to elevated pressure.
Feigin defines hypertension as "a silent killer," and warns that many people do not realize that something is wrong until they suffer "a stroke or a heart attack".
The study also identifies extreme temperatures as an emerging factor. High temperatures have seen their weight in the global burden of stroke grow by 122% between 1990 and 2023, to exceed 2.2 million DALYs in 2023 alone, with special concentration in northern and central Africa, the Middle East, and South Asia.
Likewise, low temperatures pose an added risk, Feigin indicates, especially in traditionally warm regions, where cold spells are now associated with an increase in strokes and heart attacks.
Inequalities between countries remain notable: more than 80% of stroke deaths and DALYs are concentrated in low- and middle-income states, where the main driver of the increase in cases is greater exposure to risk factors, rather than the aging of the population.
The high-risk strategy, insufficient to stop stroke
Feigin believes that prevention has relied too heavily on the "high-risk" approach, focused on detecting and treating only those with a very high cardiovascular profile.
"Even in the best-case scenario, treating high-risk people only prevents around 11% of strokes and heart attacks, since approximately 80% of strokes occur in people classified as low or moderate risk," he says, recalling that, according to recent reviews of randomized controlled trials, the mere detection of risk, without follow-up, does not manage to significantly reduce events.
As an alternative, it proposes combining population interventions —such as reducing salt consumption, taxes on sugary drinks, or strengthening anti-tobacco policies— with individual prevention supported by digital tools, for example mobile cardiovascular risk assessment applications, capable of reaching people with any level of risk.
"We need a strategy that treats all people with even a single elevated risk factor, not only those who exceed a high-risk threshold. Otherwise, we are heading toward a crisis that health systems will have difficulty absorbing," he says.