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Between 2002 and 2019, a total of 6,253,951 stroke mortality in young and middle-aged adults were recorded. Of these, 4,152,412 (66.4%) were men and 2,101,539 (33.6%) were women, 654,701 (10.5%) were young adults, and 5,599,250 (89.5%) were middle-aged adults. Moreover, 2,638,344 (42.2%) mortalities occurred in urban and 3,615,607 (57.8%) in rural areas (Supplementary Table S1 available in www.besjournal.com). The AAMRs per 100,000 changed from 55.99 to 48.70 in men [APC, −0.5% (95% CI, −1.2 to 0.3)] and from 33.72 to 18.91 in women [APC, −3.5% (95% CI, −4.5 to −2.5)]. AAMRs were higher in men than in women during the study period (Supplementary Table S2 available in www.besjournal.com).
Year Men Women Urban Rural 25−44 yrs 45−64 yrs 25−44 yrs 45−64 yrs Number AAMRs Number AAMRs Number AAMRs Number AAMRs Number AAMRs Number AAMRs 2002 17,630 9.38 159,030 119.36 9,644 5.31 93,408 72.35 104,476 42.46 175,236 46.76 2003 22,067 11.03 191,542 139.69 12,707 6.49 130,263 98.26 130,755 47.82 225,823 61.36 2004 23,278 11.29 169,892 117.30 14,096 6.91 108,454 77.23 116,080 39.87 199,640 51.56 2005 21,767 10.74 195,120 133.28 13,932 6.74 135,431 95.16 164,593 55.56 201,658 51.94 2006 22,550 10.06 167,041 104.75 11,935 5.20 98,813 63.27 101,221 32.05 199,118 45.61 2007 26,863 11.89 187,372 111.92 13,313 5.79 99,760 60.66 99,240 29.42 228,068 50.96 2008 27,320 12.25 191,011 108.17 12,553 5.55 100,563 58.25 115,545 31.61 215,903 47.51 2009 28,362 12.74 223,113 122.99 12,147 5.39 118,999 66.69 135,021 34.60 247,601 54.71 2010 29,918 13.30 211,283 128.15 11,638 5.38 108,933 68.30 148,044 40.64 213,728 52.90 2011 26,145 11.60 200,481 117.30 10,510 4.86 98,545 59.30 139,224 35.79 196,458 48.45 2012 25,753 11.38 183,560 103.41 9,945 4.56 91,472 52.64 141,089 33.91 169,641 41.80 2013 32,989 14.89 222,515 120.33 11,188 5.22 106,480 58.55 165,339 37.67 207,833 50.64 2014 32,207 14.73 222,250 116.44 9,828 4.67 104,537 55.34 171,729 36.74 197,093 48.56 2015 29,510 13.88 226,885 115.00 9,462 4.59 106,116 54.12 175,426 36.31 196,546 47.33 2016 26,723 12.81 241,194 117.54 8,068 4.00 108,990 53.48 182,241 35.60 202,734 48.40 2017 25,246 12.38 243,014 115.68 7,297 3.67 108,637 52.03 188,100 35.15 196,093 47.19 2018 23,165 11.55 244,903 113.86 6,352 3.24 107,742 50.38 194,009 34.23 188,153 46.45 2019 22,435 11.56 208,280 99.18 6,158 3.25 83,622 40.19 166,213 29.46 154,282 40.85 Total 463,927 − 3,688,485 − 190,773 − 1910,765 − 2,638,344 − 3,615,607 − Table S1. Death number and age-adjusted mortality rates for stroke (AAMRs per 100,000) among young and middle-aged adults in China by sex, age groups and regions, 2002–2019
Year Men Women Total Urban Rural Total Urban Rural 2002 55.99 55.08 56.44 33.72 30.02 36.26 2003 65.56 58.69 70.28 45.39 36.94 51.77 2004 56.22 49.85 60.56 36.71 29.98 41.90 2005 62.68 65.68 60.13 44.22 45.48 43.18 2006 50.19 42.21 55.24 29.81 22.02 35.49 2007 54.29 40.42 64.17 29.04 18.54 37.15 2008 52.90 43.31 60.14 27.88 20.02 34.35 2009 59.46 47.78 68.94 31.37 21.66 39.93 2010 61.98 54.95 67.63 32.05 25.86 37.55 2011 56.40 50.19 61.79 27.93 21.08 34.48 2012 50.38 46.51 54.17 24.94 21.07 28.94 2013 59.58 52.55 67.16 27.82 22.49 33.56 2014 57.84 51.71 65.04 26.14 21.57 31.46 2015 56.73 51.23 63.40 25.58 21.05 30.90 2016 57.20 50.61 65.70 24.97 20.28 30.73 2017 56.16 50.29 64.17 24.16 19.74 29.87 2018 54.91 48.95 63.70 23.22 19.27 28.86 2019 48.70 43.21 57.37 18.91 15.47 24.06 APC (%)
(95% CI)−0.5
(−1.2, 0.3)−0.5
(−1.7, 0.6)0.2
(−0.6, 0.9)−3.5*
(−4.5, −2.5)−3.5*
(−5.2, −1.7)−2.8*
(−3.7, −1.9)Note. *Indicates that the annual percent change (APC) is significantly different from zero at the alpha = 0.05 level. Table S2. Age-adjusted mortality rates for stroke (AAMRs per 100,000) among young and middle-aged adults in China by sex and regions, 2002–2019
Among young adults (aged 25–44 years), the AAMRs per 100,000 for urban and rural women showed a downward trend, from 4.60 and 5.86 in 2002 to 2.72 and 4.35 in 2019, respectively. The AAMRs per 100,000 for rural men continued to rise, from 9.40 in 2002 to 15.46 in 2019. The AAMRs for urban men showed an upward trend from 2002 to 2014 [APC, 2.1% (95% CI, 0.5 to 3.7)] but no significant decline from 2014 to 2019 [APC, −4.9% (95% CI, −10.3 to 0.9)] (Figure 1). In middle-aged adults (aged 45 to 64 years), the AAMRs of urban [APC, −3.5% (95% CI, −5.3 to −1.7)] and rural [APC, −2.8% (95% CI, −3.7 to −1.8)] women continued to decline as well; however, the AAMRs of urban [APC, −0.7% (95% CI, −1.9 to 0.6)] and rural [APC, −0.2% (95% CI, −1.0 to 0.6)] men remained stable throughout the study period. Except for 2005, the AAMRs of the rural population in middle-aged adults were higher than that of the urban population at all other study time points (Figure 2). Age-specific stroke mortality variation with time is provided in Supplementary Table S3 (available in www.besjournal.com).
Figure 1. Trends of age-adjusted mortality rates (AAMRs) for stroke by sex and region among young adults in China, 2002–2019.
Figure 2. Trends of age-adjusted mortality rates (AAMRs) for stroke by sex and region among middle-aged adults in China, 2002–2019.
The RR of age, period, and cohort effects of stroke mortality for both sexes in urban and rural areas estimated by the APC-IE analysis are shown in Supplementary Figure S1 (available in www.besjournal.com). After controlling for period and cohort effects, a significant age effect on stroke mortality was found. The mortality risk increased with advancing age for urban and rural men and women. The RR in the group aged 60 to 64 were 32.7, 33.4, 34.2, and 32.6 times greater than those in the group aged 25 to 29 for urban men/women and rural men/women, respectively. The period effect of the mortality risk for urban men, rural men, and rural women showed an upward trend between 2002 and 2019, with the fastest increase in rural men. Compared with the period effect in 2002, the RR of stroke mortality in 2017 was 1.66, 2.15, and 1.25 for urban men, rural men, and rural women, respectively. The period effect of the mortality risk on urban women first dropped and then rose. Compared with the period effect in 2002, the RR of stroke mortality was 0.90 in 2007, 0.98 in 2012, and 1.05 in 2017. The cohort effect for both sexes in urban and rural areas showed significant downward trends before the 1957–1961 cohort, followed by a small platform in the 1962–1966 cohort, and then continued to decline in the 1972–1976 cohort. However, these downward tendencies were slowing down in the recent cohorts, especially for those born after 1977 in urban areas, and showing a slight upward trend for those born after 1977 in rural areas.
Figure S1. Age, period, and cohort effects on stroke mortality among young and middle-aged adults in China by age-period-cohort analysis. (A) Age effects on stroke mortality; (B) Period effects on stroke mortality; (C) Cohort effects on storke mortality.
We predicted that the stroke mortality rates of the young and middle-aged population would continue to decrease in China, especially among women. The mortality rates in women were substantially lower than that in men. The estimated AAMRs per 100,000 were 20.16 in men and 4.18 in women in 2030, representing a reduction of 53.0% and 73.7% over 11 years, respectively. Given the aging of the population, according to the World Population Organization’s estimation of China’s population, by 2030, the number of people aged 25–64 years will decline. Therefore, the stroke mortality rate in this age group will continue to decline. Between 2020 and 2030, the projected number of stroke deaths among Chinese adults aged 25–64 years was 1,423,584 in men and 401,712 in women (Table 1 and Supplementary Figure S2 available in www.besjournal.com).
Year Men Women Number of deaths AAMRs Number of deaths AAMRs 2020 184,878 42.90 65,350 15.88 2021 170,067 39.43 56,894 13.83 2022 157,303 36.44 49,794 12.10 2023 146,221 33.84 43,760 10.64 2024 136,001 31.48 38,503 9.37 2025 126,312 29.28 33,830 8.26 2026 117,081 27.22 29,626 7.27 2027 108,412 25.30 25,818 6.37 2028 100,182 23.50 22,350 5.55 2029 92,258 21.77 19,241 4.81 2030 84,869 20.16 16,546 4.18 Table 1. Predicted (2020–2030) mortality number and AAMRs per 100,000 in stroke among young and middle-aged adults in China by sex
Figure S2. Trends in stroke mortality among young and middle-aged adults in China by sex: observed rates (2002–2019) and predicted rates (2020–2030). Shading indicates the 95% confidence interval of the predicted rates. (A) Trends in stroke mortality for male; (B) Trends in stroke mortality for female.
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None of the authors has any conflicts of interest.
Age group
(Year)Urban male Rural male Urban female Rural female AAPC (%) 95% CI AAPC (%) 95% CI AAPC (%) 95% CI AAPC (%) 95% CI 25−29 3.3* 1.2, 5.5 5.5* 0.5, 10.7 −0.7 −4.0, 2.7 0.6 −2.3, 3.6 30−34 3.7* 1.5, 5.9 3.7 −5.8, 14.2 −1.1 −3.0, 0.8 1.8* 0.3, 3.3 35−39 0.8 −0.6, 2.2 2.9* 1.8, 4.0 −4.1* −5.1, −3.0 −3.3* −4.9, −1.7 40−44 −0.9 −2.4, 0.6 2.2 −0.4, 5.0 −4.0* −6.0, −1.9 −3.6* −5.3, −1.8 45−49 −2.1 −6.2, 2.1 1.6* 0.0, 3.2 −5.0* −6.8, −3.2 −3.4* −5.2, −1.6 50−54 −2.5 −6.5, 1.6 2.0* 0.6, 3.4 −1.9 −11.9, 9.3 −1.7* −3.3, −0.1 55−59 −1.3* −2.5, −0.2 −1.6* −2.7, −0.5 −5.3* −7.1, −3.5 −4.2* −5.6, −2.8 60−64 −0.2 −1.8, 1.3 −0.7 −1.5, 0.2 −2.8* −4.6, −0.9 −2.2* −3.3, −1.2 Note. *Indicates that the average annual percent change (AAPC) is significantly different from zero at the alpha = 0.05 level. Table S3. Age-specific stroke mortality variation with time (per 100,000) among young and middle-aged adults in China, 2002–2019
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