Authors: Muhammad Ahmed, Shaheer Bin Shafiq, Junaid Razzak, Khubaib Tariq Mansoor, Muhammad Abdullah Naveed, Ahila Ali, Muhammad Shaheer Bin Faheem, Sumaya Samadi, Himaja Dutt Chigurupati, Sivaram Neppala
Categories: Research, Stroke, Hyperlipidemia, Mortality, Race, Gender, CDC WONDER
Source: Journal of Epidemiology and Global Health
Authors: Muhammad Ahmed, Shaheer Bin Shafiq, Junaid Razzak, Khubaib Tariq Mansoor, Muhammad Abdullah Naveed, Ahila Ali, Muhammad Shaheer Bin Faheem, Sumaya Samadi, Himaja Dutt Chigurupati, Sivaram Neppala
Stroke is a leading cause of death in the U.S., with mortality trends influenced by hyperlipidemia, a significant risk factor for atherosclerosis and cardiovascular disease that can lead to ischemic stroke. This analysis examines stroke-related mortality in hyperlipidemia among adults aged 25 and older from 1999 to 2023.
A retrospective analysis of CDC WONDER investigated trends in mortality from Stroke (ICD I60-I69) among Hyperlipidemia patients (ICD E78.0, E78.1, E78.3, E78.4, E78.5) aged 25 and older. Joinpoint regression analysis calculated age-adjusted mortality rates (AAMR) per 100,000 individuals, annual percentage changes (APC), Average Annual Percent Change (AAPC), and 95% confidence intervals.
Between 1999 and 2023, stroke and hyperlipidemia caused 241,308 deaths, with AAMRs of 1.38 in 1999 and 7.46 in 2023, an AAPC of + 7.16 (95% CI: 6.66 to 8.52). Adult men had higher AAMRs than women, with increases for both sexes [AAPC: + 7.20 vs. + 7.10; p < 0.001]. Black individuals had the highest AAMRs, followed by Hispanics. AAMR rose for all races, notably for Blacks/African Americans (AAPC: + 8.63%) and adults aged 65 and above (AAPC: + 7.35%). Northeast regions have the highest AAMRs, with the Midwest showing the most significant rise (AAPC: + 7.86%). AAMRs varied by state, from 2.0 in Georgia to 9.43 in Vermont in 2023. Non-metropolitan areas had higher AAMRs (4.31) than metropolitan areas (3.54).
This analysis reveals significant demographic and racial disparities in Stroke mortality among U.S. adults with Hyperlipidemia, which highlights the urgent need for targeted, equity-focused interventions to address these disparities.
The online version contains supplementary material available at 10.1007/s44197-025-00453-3.
Elevated levels of blood lipids, encompassing total cholesterol, low-density lipoprotein (LDL), triglycerides, or any combination thereof, constitute hyperlipidemia, which represents a significant modifiable risk factor for cardiovascular and cerebrovascular diseases. This condition may arise from genetic disorders, such as familial hypercholesterolemia, or from lifestyle factors including poor dietary choices, physical inactivity, obesity, and diabetes [1]. One of the most severe complications associated with hyperlipidemia is atherosclerosis, characterized by the accumulation of plaque within arterial walls, which can lead to thrombosis and embolism, potentially culminating in ischemic events such as strokes [2].
Stroke ranks as the fifth leading cause of mortality and continues to be a significant contributor to long-term disability in the United States, with over 795,000 cases reported annually and approximately 140,000 resulting in death [3]. The majority of strokes, specifically 87%, are ischemic, which are caused by blockages in the arteries that supply the brain [4]. Hyperlipidemia plays a substantial role in the development of stroke by accelerating the accumulation of fatty plaques within arterial walls, a process referred to as atherosclerosis. Over time, this condition can lead to the narrowing or blockage of blood vessels in the brain, thereby increasing the risk of atherothrombotic strokes, which occur when a clot forms on these plaques and disrupts cerebral blood flow [5].
Stroke and high cholesterol not only impact health but also impose significant financial burdens. In the United States, strokes incur approximately 15.6 billion to our healthcare expenditures, excluding the effects on individuals'daily lives [7]. As the population continues to confront issues such as aging, obesity, and diabetes, the human and economic repercussions are poised to escalate. As people age, hyperlipidemia tends to become more common, and it is increasingly being observed in younger adults under 40. This means they face a higher risk of strokes at an earlier age [8]. For seniors, the danger is heightened due to prevalent conditions such as high blood pressure and heart rhythm issues, which complicate stroke prevention and treatment.
The increasing prevalence of coexisting hyperlipidemia and stroke underscores the significance of comprehending their complex relationship to enhance patient care and treatment methodologies. Despite the established risks associated with hyperlipidemia and stroke, the specific patterns and trends in stroke-related mortality among individuals with hyperlipidemia have not received a comprehensive investigation. Therefore, we are conducting this study utilizing the CDC WONDER database to gain a deeper understanding of the mortality trends correlated with stroke in patients suffering from hyperlipidemia. This study aims to explore and analyze the variations in mortality rates based on age, race, gender, and geographical location among stroke and hyperlipidemic patients aged 25 and above.
Deaths occurring within the United States associated with Hyperlipidemias and Strokes were extracted from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) database [9]. The Multiple Cause-of-Death Public Use record death certificates were analyzed to identify instances where Hyperlipidemias or Strokes were documented as either the underlying or a contributing cause of death. We extracted data where hyperlipidemia and stroke were listed as causes of death on certificates, regardless of position, which captures the broader mortality burden. The study population comprised individuals with Hyperlipidemias and Strokes identified utilizing International Classification of Diseases, 10th Revision (ICD-10) codes, including Stroke (ICD I60-I69) among Hyperlipidemia patients (ICD E78.0, E78.1, E78.3, E78.4, E78.5) [10]. Geographic data were assessed at both the state and regional levels, encompassing all U.S. states and the District of Columbia. States including West Virginia, Oklahoma, Rhode Island, Tennessee, and Ohio were analyzed individually for mortality trends. The National Center for Health Statistics Urban–Rural Classification Scheme was employed to categorize the population into two groups based on the 2013 U.S. Metropolitan (large metropolitan area [population, ≥ 1 million], medium/small metropolitan area [population, 50,000–999,999]), and non-metropolitan (population, < 50,000). The U.S. Census Bureau defines the regions as Northeast, Midwest, South, and West categories.
Hyperlipidemias and stroke mortality rates, population demographics, and locations of death were extracted from the CDC WONDER database. Demographic variables such as age, sex, race/ethnicity, geographic location (state and urban–rural classifications), and cause of death rankings were also included. Age groups were classified as 25–44 years, 45–64 years, and 65 years and older, while sex was categorized as male and female. Classifications of race and ethnicity adhered to the standard categories established by CDC WONDER, which include American Indian or Alaska Native, Asian or Pacific Islander, Black or African American, White, and Hispanic or Latino.
Crude and age-adjusted mortality rates per 100,000 population were determined. Crude mortality rates were calculated by dividing the number of deaths related to Hyperlipidemias and strokes by the corresponding U.S. population for each year. Age-adjusted mortality rates were standardized to the 2000 U.S. population to account for variations in age distribution across years. Trend analysis was conducted utilizing log-linear regression models, and the Annual Percent Change (APC), Average Annual Percent Change (AAPC) were calculated to assess significant alterations in mortality rates over time. The Joinpoint Regression Program (Joinpoint v4.9.0.0, National Cancer Institute) was employed to identify inflection points where notable shifts in mortality trends transpired. APCs with 95% confidence intervals (CI) were computed at the identified join points employing the Monte Carlo permutation test, and trends were designated as increasing or decreasing if the mortality slope was significantly distinct from zero based on two-tailed t-testing. Statistical significance was established at P < 0.05.
Between the years 1999 and 2023, a total of 241,308 fatalities occurred in individuals afflicted with Hyperlipidemia and Stroke (Supplementary Table 1). Of the total fatalities, 54.24% (130,870) were attributed to females, whereas males constituted 45.76% (110,438). In terms of race and ethnicity, 190,127 fatalities were reported among the White population, 25,944 among the Black population, 14,604 among Hispanics, and 8,701 among Asians. An age-based analysis revealed that there were 1,008 (0.42%) fatalities in Young Adults (ages 25–44), 25,041 (10.38%) in Middle-Aged Adults (ages 45–64), and 215,259 (89.2%) fatalities in Older Adults (ages 65 and above) (Fig. 1).Fig. 1Central illustration depicting trends in demographics and disparities in Stroke-related Mortality among adults with Hyperlipidemia patients in the United States from 1999 to 2023
In 1999, the AAMR for hyperlipidemia and stroke-related deaths among adults was 1.38, which increased to 7.46 by 2023, reflecting an AAPC of + 7.20% (95% CI: 6.85 to 7.84; p < 0.001). The overall AAMR exhibited a significant increase from 1999 to 2004 (APC: 15.76, 95% CI: 12.78 to 21.86), followed by a non-significant rise from 2004 to 2011 (APC: 5.55, 95% CI: 4.15 to 7.34). A further modest increase was observed until 2018 (APC: 1.08, 95% CI: −1.28 to 1.91), followed by a notable escalation until 2021 (APC: 15.91, 95% CI: 13.03 to 18.05). Subsequently, from 2021 to 2023, the rate again increased, although at a lesser magnitude this time (APC: 2.03, 95% CI: −1.55 to 5.51) (Supplementary Table 2).
Throughout the study period, men consistently exhibited higher AAMRs compared to women. In 1999, the AAMR for men was recorded at 1.45 (95% CI: 1.36–1.54), which escalated to 8.05 (95% CI: 7.89 to 8.22) by 2023 (AAPC: + 7.20%; 95% CI: 6.85 to 7.84; p < 0.001). Similarly, the AAMR for women increased from 1.31 (95% CI: 1.25–1.38) in 1999 to 6.89 (95% CI: 6.76 to 7.02) in 2023 (AAPC: + 7.10%; 95% CI: 6.72 to 7.79; p < 0.001) (Supplementary Table 3 and Fig. 2).Fig. 2Overall and sex-stratified Stroke-related age-adjusted mortality rates per 100,000 adults with Hyperlipidemia in the United States from 1999 to 2023
Throughout the study period, adults residing in various census regions demonstrated consistently differing age-adjusted mortality rates associated with hyperlipidemia-related strokes. In the Northeast, the AAMR escalated from 0.95 (95% CI: 0.85- 1.05) in 1999 to 6.04 (95% CI: 5.83- 6.26) in 2023, exhibiting an AAPC of + 7.86% (95% CI: 7.43- 8.37; p < 0.001). Similarly, in the Midwest, the AAMR increased from 0.95 (95% CI: 0.85–1.05) in 1999 to 6.04 (95% CI: 5.83–6.26) in 2023, with an AAPC of + 6.33% (95% CI: 7.43–8.37; p < 0.001). In the South, the AAMR rose from 1.36 (95% CI: 1.26- 1.45) in 1999 to 8.4 (95% CI: 8.22- 8.58) in 2023, corresponding to an AAPC of + 7.95% (95% CI: 7.55–8.40; p < 0.001). The Western region similarly exhibited an increase in AAMR, rising from 1.82 (95% CI: 1.67- 1.96) in 1999 to 6.74 (95% CI: 6.52–6.95) in 2023, along with an AAPC of + 6.28% (95% CI: 5.79–7.23; p < 0.001) (Supplementary Table 4 and Fig. 3).Fig. 3Stroke-related age-adjusted mortality rates per 100,000 Stratified by Regions in Adults (≥ 25 Years) with Hyperlipidemia in the United States, 1999 to 2023
Elderly individuals consistently exhibited the highest AAMRs associated with hyperlipidemia-induced strokes in comparison to other age groups throughout the duration of the study. In the middle-aged population (45–64 years), the AAMR escalated from 0.51 (95% CI: 0.46–0.57) in 1999 to 2.06 (95% CI: 1.97–2.15) in 2023, showcasing an AAPC of + 6.27% (95% CI: 5.37–7.75; p < 0.001). Conversely, the elderly demographic (65 years and older) experienced the most significant increase, with the AAMR rising from 6.14 (95% CI: 5.88–6.4) in 1999 to 34.4 (95% CI: 33.9–34.9) in 2023, reflecting an AAPC of + 7.35% (95% CI: 7.03–7.91; p < 0.001). (Supplementary Table 5 and Fig. 4).Fig. 4Stroke age-adjusted mortality rates per 100,000 stratified by Age in Adults (≥ 25 Years) with Hyperlipidemia in the United States, 1999 to 2023
Comparisons conducted on a state-by-state basis revealed substantial variation. The State of Vermont reported the highest AAMR at 9.43, followed by Oregon at 6.55, Hawaii at 6.29, and North Dakota at 5.89. Notably, Nevada, Georgia, Massachusetts, and Connecticut documented the lowest AAMRs—all below 2.1, specifically at 1.58, 1.92, 2.08, and 2.1, respectively. (Supplementary Table 6).
Rural areas exhibited higher rates of strokes related to hyperlipidemia, as evidenced by AAMRs of 4.31 and 3.54, respectively, for rural and urban regions. The AAMRs in rural areas demonstrated a more pronounced increase over the study period from 1999 to 2020, compared to urban areas, with an AAPC of + 7.91% (95% CI: 7.49–8.72; p < 0.001) for rural areas and an AAPC of + 7.28% (95% CI: 6.83–8.05; p < 0.001) for urban areas (Supplementary Table 7 and Fig. 5).Fig. 5Stroke-related age-adjusted mortality rates per 100,000 Stratified by Urbanization in Adults (≥ 25 Years) with Hyperlipidemia in the United States, 1999 to 2023
The AAMRs for stroke-related deaths induced by hyperlipidemias were highest among non-Hispanic Black or African American individuals, followed by non-Hispanic White individuals, then Asian individuals, and finally Hispanic or Latino populations. The data indicate that non-Hispanic Black or African American adults had the highest AAMR, with a significant increase observed from 1.31 (95% CI: 1.12–1.49) in 1999 to 9.98 (95% CI: 9.59–10.38) in 2023, resulting in an AAPC of + 8.63% (95% CI: 7.88 to 9.97; p < 0.001). Non-Hispanic White adults also experienced a notable rise in AAMR during the same period, increasing from 1.39 (95% CI: 1.33–1.45) in 1999 to 7.49 (95% CI: 7.37–7.61) with an AAPC of + 7.23% (95% CI: 7.6.97 to 7.58; p < 0.001). Similarly, Hispanic or Latino adults demonstrated an upward trend in AAMR, rising from 0.94 (95% CI: 0.74–1.18) in 1999 to 5.8(95% CI: 5.5–6.1) in 2023, with an AAPC of + 8.14% (95% CI: 6.76 to 10.55; p < 0.001). Lastly, the Asian population also exhibited an increase in AAMRs, rising from 1.88 (95% CI: 1.47–2.38) in 1999 to 5.41 (95% CI: 5.02–5.79) in 2023, with an AAPC of + 4.73% (95% CI: 3.87 to 6.23; p < 0.001) (Supplementary Table 8 and Fig. 6).Fig. 6Stroke-related age-adjusted mortality rates per 100,000 Stratified by Race in Adults with Hyperlipidemia in the United States, 1999 to 2023
There is an ascending trend in the AAMR of cerebrovascular diseases from 1999 to 2023. Stroke of unspecified type (I64) exhibited the highest AMR, with an increase in rates from 0.81 to 2.55 per 100,000 population. A similar upward trend in cerebral infarction (I63) was also observed, escalating more than sevenfold. Sequelae of cerebrovascular disease (I69) demonstrated a comparable increase, indicating the long-term disability and complications associated with stroke. Other cerebrovascular diseases (I67) revealed a tenfold increase in AMR, underscoring the expanding impact of less commonly categorized stroke events. Among the hemorrhagic types, the highest AMR was recorded in intracerebral hemorrhage (I61), although all hemorrhagic categories exhibited increasing AMRs. The tables illustrate a steady increase in the AMR of cerebrovascular categories, particularly after 2010, indicating a rise in both short-term problems and chronic complications. These patterns emphasize the necessity for improvements in risk management and long-term rehabilitation strategies to reduce stroke-related mortality and enhance the quality of life of stroke patients. (Supplementary Table 9).
Our study offers crucial insights concerning stroke-related mortality among individuals with hyperlipidemia (HLD) across diverse demographic groups within the United States from 1999 to 2023. The total number of deaths is 241,308, accompanied by a notable increase in the age-adjusted mortality rate (AAMR) over the past two decades.
Men exhibited consistently higher AAMR than women, demonstrating a significant increase in AAMR relative to their female counterparts, with rates of 7.28% and 6.61% respectively. In terms of racial demographics, Non-Hispanic Blacks presented the highest risk of mortality, followed by Non-Hispanic Whites and subsequently Non-Hispanic Asians. The western and midwestern regions reported the highest AAMR, while rural areas also experienced elevated mortality rates compared to urban settings.
The AAMR trends for Hyperlipidemia (HLD) and Stroke exhibited a significant increase between the years 2000 and 2019. From 2019 to 2022, the AAMR experienced an even greater escalation, followed by a brief period of minimal decline between 2022 and 2023 within the male demographic. These findings are consistent with the predominant literature on a global scale. The overall rise in stroke-related fatalities has been associated with escalating levels of specific risk factors, including obesity, diabetes, suboptimal diets, and a sedentary lifestyle [11] 11. A dramatic increase was observed between 2019 and 2021, likely driven by the COVID-19 pandemic, which profoundly impacted individuals worldwide, particularly those with underlying cardiopulmonary conditions, leading to an exacerbation of health issues among stroke patients [13]. Following the pandemic, the rates remained elevated, signifying the prolonged ramifications of the virus and systemic healthcare disruptions on both chronic and acute conditions such as hyperlipidemia and stroke.
Despite the improvements observed in mortality and disability rates attributed to stroke, the overall number of individuals affected continues to rise, thereby establishing ischemic stroke as a significant global health concern [14]. Conversely, hyperlipidemia represents one of the primary risk factors for atherosclerosis [15] 15, along with being a well-recognized comorbidity that leads to vascular conditions such as stroke and myocardial infarction. The recent study published in Frontiers by Zou et al. (2025) illustrates how various markers of hyperlipidemia, including the WBC/HDL ratio, total cholesterol, triglycerides, LDL, and HDL, are correlated with mortality in individuals experiencing stroke. Notably, the WBC/HDL ratio was found to be significantly associated with an increase in stroke-related deaths, presenting a twofold higher risk of all-cause mortality at 28 days and more than a threefold increase in the risk of death within one year post-admission to the ICU [17].
Moreover, utilizing data from the Global Burden of Disease (GBD) 2021, a study analyzes 30 years of global data on ischemic stroke, which has demonstrated a rising incidence of stroke cases attributed to high LDL (Hyperlipidemia) [18]. Furthermore, cardiovascular conditions exacerbate the global prevalence of stroke-related deaths, with childhood obesity and familial hyperlipidemia identified as significant risk factors [19]. However, contrary to prevailing trends, some studies have posited that hyperlipidemia may serve as a preventive factor against stroke-related mortality, as evidenced by a retrospective cohort study utilizing the Kyoto stroke data. Although certain regional cohort studies, such as the Kyoto Stroke Registry and the Greater Cincinnati/Northern Kentucky Study, have indicated improved survival rates among stroke patients with hyperlipidemia, these findings are derived from selected populations and clinical data. Therefore, they may not be applicable to national mortality trends based on death certificates [20]. Another counterintuitive observation was recorded among stroke patients in the Greater Cincinnati Northern Kentucky region (approximately 1.3 million) between 2005 and 2010, where 77% of the 3813 stroke patients with hyperlipidemia who were not on statins demonstrated a 35% lower risk of mortality at 30 days, a 27% lower risk at one year, and a 17% lower risk at three years [21].
Additionally, lipid disorders significantly increase the likelihood of experiencing a stroke; however, patients with acute ischemic stroke and lipid disorders, such as hyperlipidemia, tend to have more favorable outcomes than those without such disorders [22]. Observations of this nature are associated with the ‘cholesterol paradox,’ which suggests that higher cholesterol levels may correlate with improved recovery or survival in certain medical conditions, including stroke. As detailed later, this finding could have important implications for future clinical practices.
Our analysis indicates that males exhibit consistently higher AAMR throughout the specified period. Historical data reveal an increase in the incidence of stroke among both genders, with a more pronounced rise in men. Disparities persist throughout life, although they tend to diminish with age [23–25]. Several factors may contribute to this trend, including elevated Low-Density Lipoprotein (LDL) levels in men compared to women prior to menopause (at age 50) [26], as well as higher prevalence of risky behaviors in men, such as smoking, alcohol abuse, and neglecting regular health checkups [27–29]. Additionally, women generally benefit from a more robust support system, which plays a critical role in post-stroke recovery. Furthermore, hormonal differences between the two genders also account for variances in mortality and morbidity rates. Specifically, estrogen in females promotes lipid metabolism by increasing High-Density Lipoprotein (HDL) levels and lowering LDL levels, which consequently leads to a reduced risk of atherosclerosis and cardiovascular disease [30].
There exist significant ethnic and racial disparities, with non-Hispanic African Americans and non-Hispanic Whites exhibiting the highest risk of mortality due to hyperlipidemia and stroke [31, 32]. Non-Hispanic African Americans are less likely to undergo regular cholesterol screenings and adhere to prescribed medication for the management of stroke, elevated cholesterol levels, or atherosclerosis related to cardiovascular health, resulting in disparities in hyperlipidemia management [33, 34]. Additionally, hypertension is more prevalent and less effectively controlled among Black individuals, alongside inadequate management of diabetes and hyperlipidemia [5]. Furthermore, these individuals are less frequently administered statin therapy necessary for the maintenance of healthy low-density lipoprotein (LDL) levels [35]. This situation was further emphasized by the National Lipid Association, which noted that non-Hispanic Black adults often remain underdiagnosed and undertreated with appropriate statin therapy [36]. Another contributing factor to undiagnosed metabolic syndrome is their generally lower triglyceride levels, which consequently hampers management and necessary treatment [37]. The National Health and Nutrition Examination Survey (NHANES) reported relatively low triglyceride levels and high levels of high-density lipoprotein (HDL) cholesterol [38], which again results in underdiagnosis and mismanagement of other risk factors. Additionally, lower income, education levels, and health literacy among non-Hispanic Black and certain non-Hispanic White populations, particularly in rural areas, contribute to elevated mortality rates within these groups [39].
From a geographical perspective, the western and midwestern regions exhibited consistently elevated mortality rates. Historically, these states have demonstrated higher incidences of smoking, obesity, diabetes, metabolic disorders, and hypertension, all of which are primary risk factors for cardiovascular complications, atherosclerosis, hyperlipidemia, and stroke [40–42]. Rural areas experienced higher mortality rates compared to urban areas [43]. These discrepancies can primarily be attributed to inadequate access to healthcare, increased health-risk behaviors, and economic limitations [44]. Our findings showed that rural areas had higher stroke mortality among those with hyperlipidemia, likely due to limited access to preventive care, diagnostics, and timely treatment. Expanding Medicaid and telehealth services like telestroke and lipid management may help reduce these disparities by enabling earlier intervention and better care continuity in underserved populations. Furthermore, due to their relative inaccessibility from metropolitan regions, these rural areas encounter challenges stemming from restricted access to well-developed tertiary healthcare facilities [45]. The COVID-19 pandemic has exacerbated these disparities, leading to a more pronounced increase in death rates in rural areas than in urban centers.
Individuals aged 65 and older experience the highest mortality rates, primarily attributable to reduced physiological reserves, the presence of deep-rooted and calcified plaques (atherosclerosis), a slower metabolism, and impaired lipid clearance, along with comorbidities such as hypertension, diabetes, and atrial fibrillation [46–49]. Moreover, the risk of stroke increases by 56% in individuals aged 50 and above, largely as a consequence of long-term loneliness [50].
Previous research has consistently documented a significant decline in mortality associated with stroke over recent decades. This decrease is primarily ascribed to advancements in medical therapies, the introduction of lipid-lowering agents, and improvements in lifestyle choices. However, our findings indicate a contrasting trend among individuals with hyperlipidemia, where stroke-related mortality has markedly escalated. This situation is concerning and underscores the urgent need for coordinated, evidence-based strategies across clinical, public health, and policy sectors. The use of statins and cholesterol-lowering trials, such as the SPARCL trial, which demonstrated that high-dose atorvastatin (80 mg daily) significantly reduced the risk of recurrent stroke in patients with a recent stroke or transient ischemic attack (TIA) [51], is essential. Additionally, managing blood pressure is crucial, as hypertension serves as a precursor for numerous conditions related to cardiovascular health, kidneys, and the brain [52]. On a public level, awareness campaigns, such as the FAST Campaign, can positively impact the recognition of stroke symptoms, leading to earlier hospital arrivals and treatments. Moreover, substantial progress can be achieved through public education and the long-term execution of initiatives like The Million Hearts® Initiative (USA), which aims to prevent one million heart attacks and strokes over five years through aspirin use, blood pressure control, cholesterol management, and smoking cessation [53]. Similarly, the AHA's Check.Change.Control.Cholesterol campaign is designed to improve cholesterol levels and, in turn, reduce the risk of hyperlipidemia-related deaths [54]. Dietary education and the implementation of nutritional plans that lower blood pressure and cholesterol in at-risk populations can further alleviate the burden on the health of stroke patients.
Furthermore, policymakers must prioritize the expansion of Medicaid and telehealth access in underserved regions. Stroke-specific telehealth, commonly called telestroke, has proven highly useful and advantageous [55]. The American Heart Association (AHA) underscores that telestroke programs establish connections between patients in remote areas and stroke specialists, thereby facilitating timely diagnoses and subsequent treatments. Additionally, cholesterol levels may be managed through the same protocol. For instance, the Healthy Hearts program illustrated that telehealth-delivered medical nutrition therapy effectively lowered cholesterol levels in rural adults [56].
Our study has several limitations, primarily derived from the retrospective nature of the CDC Wonder database. The primary limitation of our research is that, although the CDC Wonder database provides mortality data, it lacks crucial information regarding disease prevalence. Hyperlipidemia may have been underreported as a contributing cause of death in earlier years, which could lead to an underestimation of mortality rates. Consequently, we have analyzed mortality trends associated with strokes in patients with hyperlipidemia; however, we were unable to ascertain the prevalence of hyperlipidemia within the population or categorize specific lipid imbalances. Additionally, we relied solely on ICD-10 codes assigned by the World Health Organization, which may omit certain diagnoses and contain inaccuracies, thereby failing to capture the complete clinical profile. Furthermore, there is a lack of data regarding patient comorbidities, medication history, lipid laboratory values, vital signs, and lifestyle habits—all essential factors that influence mortality rates. Finally, data pertaining to patients'socioeconomic status were not included, which could have enriched the understanding of healthcare outcomes. Moreover, the classifications of race and ethnicity in CDC WONDER were modified in 2018 with the introduction of multiracial categories, which may have affected the comparability of data on race-specific mortality trends over the study period and potentially led to misclassification bias.
This study elucidates a markedly increasing trend in stroke-related mortality among adult patients diagnosed with hyperlipidemia from 1999 to 2023. The data indicates that male individuals and African American populations experience higher mortality rates, potentially attributable to disparities in healthcare access, social determinants, and systemic challenges. However, due to limitations inherent in death certificate data, causality cannot be definitively established. The Midwestern and Western regions exhibit the highest recorded mortality rates, with Vermont exhibiting a particularly elevated risk, while Georgia reflects the lowest rates. This underscores the critical importance of state-driven policies aimed at enhancing awareness, instituting screening efforts, and ensuring proper management, particularly in counties characterized by notably high mortality rates.
Below is the link to the electronic supplementary material.Supplementary file1 (DOCX 49 KB)