New research, published in the European Heart Journal, has shown deaths from conditions that affect the blood supply to the brain, such as stroke, are declining overall in Europe, but that in some countries the decline is leveling off or death rates are even increasing.

Cerebrovascular disease includes strokes, mini-strokes, and narrowing and blockage or rupturing of the blood vessels supplying blood to the brain, and it is the second single largest cause of death in Europe after heart disease, accounting for 9% of deaths in men and 12% of deaths in women each year.

The researchers from the Nuffield Department of Population Health at the University of Oxford, the University of Bath, University of Edinburgh, and Deakin University, Australia, used data from the World Health Organization (WHO) to examine mortality trends in three particular types of cerebrovascular disease in Europe for 37 years between 1980 and 2016: ischemic stroke (a lack of blood flow to the brain), hemorrhagic stroke (bleeding in the brain), and subarachnoid hemorrhage (SAH), in which bleeding occurs between the brain and the surrounding membrane. Not all countries had data available for the full 37 years.

The study found that across the whole of the WHO European region for the most recent period for which data were available, there had been significant decreases in death rates from all three types of cerebrovascular disease in 33 (65%) countries for men and women. However, there had been increases in three countries (6%) for men (Azerbaijan, Georgia, and Tajikistan) and in two countries (4%) for women (Azerbaijan and Uzbekistan).

There was evidence of a recent plateau in trends (where the rate of reductions in mortality in the most recent period was less pronounced than in the previous period) in seven countries in men (Austria, Denmark, France, Germany, Greece, Czech Republic, and Hungary) and six countries in women (Austria, Belgium, France, Germany, Ireland, and Switzerland). There were also a number of countries (eight in men and ten in women) in which death rates showed no change over the most recent period. This means that in both sexes, more than one-third of countries showed either a slowing of the decrease in death rates, no decrease, or an increase in the most recent trend.

Age-standardized mortality rates from stroke, which adjust to take account of differences in population size and age structure, were higher in men than in women for all countries. For stroke, they were much lower in western Europe than the rest of the continent. In men, death rates in western Europe ranged from 49 per 100,000 of the population in France to 131 per 100,000 in San Marino. In central Europe, male death rates ranged from 110 per 100,000 in the Czech Republic to 391 per 100,000 in Bulgaria. In eastern Europe, male death rates ranged from 82 in Estonia to 331 in Russia per 100,000. In central Asia, they ranged from 152 in Armenia to 345 in Azerbaijan per 100,000. In the UK, the death rate was 68 per 100,000 in men and 65 per 100,000 in women.

When the researchers looked at each of the three types of stroke individually, data were only available by stroke subtype for 43 countries; most of the countries with missing data were in eastern Europe and central Asia. Over the whole period since 1980, more than half of countries with available data had significant decreases in age-standardized death rates from ischemic stroke (56% of countries in men and 51% in women) and hemorrhagic stroke (58% and 67% of countries, respectively). However, eight countries (19%) had increases in death rates from ischemic stroke among men and nine countries (21%) in women, compared to none for hemorrhagic stroke. Although significant decreases in death rates from SAH occurred in 56% of countries for men, they only did so in 42% of countries in women. Two countries (5%) showed increases in SAH among men and four countries (9%) did so for women.

Dr. Nick Townsend, associate professor in public health epidemiology at the University of Bath, who led the research, said: "Our findings highlight a need to counter inequalities by understanding local contexts in disease occurrence and treatment. In particular, we need to encourage the implementation of evidence-based recommendations in the prevention and treatment of stroke in all countries. Many countries have been able to reduce the mortality burden from stroke in recent years. We must understand why this is not happening in all countries and identify barriers to the implementation of evidence-based recommended practice in countries that are slow to adopt them. In addition, we only studied between-country inequalities, but we must consider within-country inequalities as well if we are to have an impact on the disease."