Temporal Trends and Demographic and Geographic Disparities in Stroke Mortality Among US Adults Aged 25-64 Years (1999-2020): A CDC Wide-Ranging Online Data for Epidemiologic Research (WONDER) Analysis

Abstract

Background: Stroke remains a major contributor to mortality in the United States. Understanding long-term temporal changes and demographic and geographic disparities in stroke mortality is essential for identifying high-risk populations and guiding targeted prevention strategies. Methods: This retrospective observational study analyzed stroke mortality among US adults aged 25-64 years from 1999 to 2020 using the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) database. Deaths with stroke recorded as the underlying cause were identified using International Classification of Diseases, 10th Revision (ICD-10) codes I60-I64 and were analyzed collectively as overall stroke mortality. Age-adjusted mortality rates per 100,000 population were assessed overall and stratified by sex, race, US Census region, and urbanization level. Joinpoint regression was used to identify temporal changes and estimate the annual percent change (APC) for each temporal segment and the average annual percent change (AAPC) across the complete study period. Results: A total of 382,253 stroke deaths were identified. The overall age-adjusted mortality rate (AAMR) decreased significantly from 1999 to 2012 (APC, -2.41%; 95% CI, -2.77 to -2.21), remained statistically unchanged from 2012 to 2018, and increased significantly from 2018 to 2020 (APC, 4.36%; 95% CI, 1.51 to 6.06). The full-period AAPC was -1.23% (95% CI, -1.42 to -1.11). Men had higher AAMRs than women and experienced a significant increase during 2018-2020. Black or African American adults had the highest race-specific AAMR, the South had the highest regional AAMR, and noncore counties had the highest urbanization-specific AAMR. Full-period AAPCs were significantly negative across all examined subgroups; however, significant later-period increases occurred among men, American Indian or Alaska Native adults, White adults, residents of the West, large fringe metropolitan counties, and noncore counties. Conclusion: Premature stroke mortality declined substantially over the complete study period, but progress was uneven across demographic and geographic groups. Persistently elevated mortality and recent reversals in selected populations highlight the need for targeted prevention and continued surveillance.