Ericka Samantha Teleg, MD

Sacco RL. Stroke Disparities: From Observations to Actions: Inaugural Edward J. Kenton Lecture 2020. Stroke. 2020;51:3392–3405.*

Disease equalizes us all. However, health disparities exist across all cultures, race, ethnicity, and socioeconomic status. It is at this particular time that it can never be more important that Dr. Ralph Sacco pays tribute to Dr. Ed Kenton in this inaugural lecture to address stroke disparities, emphasize the necessity to shift from observations into actions, and provide a foundation for initiating interventions that are culturally tailored for the benefit of all humans. The advocacy for social justice in health is indeed in effect.

Dr. Sacco highlighted the definition of health disparity, that it involves inequality in a condition or rank between groups. More so, it is the lack of equality, opportunity, treatment, or status. He highlights the design and the results of the Northern Manhattan Study (NOMAS), which was set up in the 1990s. The NOMAS study is a population-based study that assessed stroke incidence, stroke subtypes, risk factors, and outcomes. What has started as a population-based stroke incidence and surveillance study has evolved over time. Dr. Sacco tells us that initially, it began as three case-control studies, as they matched stroke cases by age, gender, and race to community-derived controls collected through random-digit dialing. Over time, this was expanded and evolved into a prospective cohort study likened to the Framingham Study. The NOMAS study is meant to be a lifelong follow-up on these particular groups. The Northern Manhattan area in the United States is a densely populated tri-ethnic community of Hispanic population as a majority. Dr. Sacco gives us the history with the importance of collecting stroke data and using this registry to evaluate characteristics of the stroke cases. Over the years, the prospective cohort has been in the hands of advocate and leaders, and an important message that he tells us is the role of young investigators, and that value of collaborating for such important endeavors can remain lifelong.

The summary of the observations on stroke incidence disparities from NOMAS and the other studies has been highlighted in this lecture. In summary, Dr. Sacco has highlighted the significant findings by discussing: (1) race and ethnic differences in stroke subtype and risk factors; (2) results of NOMAS; (3) risk factor disparities and stroke incidence; and more importantly, (4) discussing what we must do with the observations: Observations into Actions.

It is known that Black individuals had twice the mortality from stroke, and little is known about Hispanic individuals. There were no Latino-focused epidemiological studies and they were not even included in several of the earlier cardiovascular health studies. They found that Black versus White individuals had nearly a fourfold difference in their study for differences in intracerebral hemorrhage risk. Also, there is observed a greater relative risk for extracranial atherosclerotic stroke and nearly 5-fold greater rates for intracranial atherosclerotic stroke among Black versus White people and for Hispanic versus White people. From this, they suggested that there were some vascular risk factor differences that could contribute to the rationale of why a group would render more susceptible to intracranial atherosclerosis than another group. Dr. Sacco explains how such stroke disparities can be explained by differences in stroke risk factors. In the NOMAS methodology, they collected risk factors, particularly: behaviors, diet, social factors, metabolic and cardiac factors, living conditions, inflammation, and infection makers. They sought to evaluate the impact of various factors on the risk of stroke and evaluate for any differences across race and ethnicity. Some examples that he has cited include some differences: Smoking was worse for Black individuals, while all three race ethnic groups were equally poor for diet. Blood pressure and blood glucose were worse for Black and Hispanic individuals. Physical activity was worse in the Hispanic groups, suggesting that it is important to tailor risk factor modification.

Risk factors and outcomes have been studied in the REGARDS, ARIC, BASIC, and many other studies that Dr. Sacco mentioned in this lecture. There is an ongoing need to not only reduce smoking and lower blood pressure and cholesterol, but to address stroke disparities and control risk factors and modify behaviors across race, ethnicity, and in all regions. Unless this is addressed, the cerebrovascular health of the population will be unlikely to improve.

Dr. Sacco tells us to remember the three D’s: develop, demonstrate, and disseminate interventions. The healthcare system must be geared to eliminate disparities and influence policymakers, for which he demonstrated what has been done in the state of Florida. The Florida Stroke Registry has adapted performance metrics that disseminated hospital disparities dashboards. It is used to measure and track performance and provide a basis to eliminate disparity in the management and treatment of stroke.

*This article is part of a Focused Updates series of articles on topics related to health equity published in the November 2020 issue of Stroke.