Stroke mortality in Greece (2001–2021): Trends,sex differences,and the impact of population aging

Abstract

Background:

Despite stroke being a leading cause of mortality in Greece, long-term national data on stroke mortality trends remain limited. This study aimed to describe trends in stroke mortality in Greece between 2001 and 2021, accounting for demographic shifts and changes in care delivery, using nationwide mortality and population data.

Methods:

We analyzed cause-of-death data from the Hellenic Statistical Authority (ELSTAT) for 2001–2021. Stroke deaths were defined using International Classification of Diseases, Ninth Revision (ICD-9) (430–438) and Tenth Revision (ICD-10) (I60–I69, G45x) codes. Crude and age-standardized mortality rates (using the GBD 2019 standard) were computed annually and stratified by sex. Negative binomial regression was used to estimate the average annual percent change (AAPC) in mortality. Sex-specific trends, age-specific rate ratios, and time interactions were examined. A decomposition analysis using the Das Gupta method was conducted to quantify the contribution of population aging versus changes in age-specific stroke mortality.

Results:

Between 2001 and 2021, crude stroke mortality declined from 171.1 to 116.5 per 100,000, and age-standardized mortality declined from 90.5 to 36.4 per 100,000. Crude mortality remained higher in women, but age-standardized mortality was consistently lower compared with men. The female advantage in age group-specific stroke mortality has narrowed over time and reversed in the ⩾80 age group where females experience higher mortality than men. The estimated AAPC for the overall population was −1.90%, corresponding to approximately 292 fewer stroke deaths per year. Decomposition analysis revealed that improvements in age-specific mortality outweighed the adverse effects of population aging.

Conclusion:

Despite substantial population aging and rising crude all-cause mortality, stroke mortality in Greece has declined significantly over the past two decades. This trend likely reflects improvements in acute stroke care and reduced case fatality, rather than a decrease in incidence. Although recent efforts have expanded access to acute reperfusion therapies and stroke units, further gains are possible. Continued investment in national stroke systems and implementation of a comprehensive stroke registry are essential for sustaining and accelerating progress.

Data access statement:

The study utilized publicly available aggregate data (https://www.statistics.gr/en/home).

Graphical abstract

Keywords

Stroke mortality population aging Greece sex differences cerebrovascular disease epidemiological trends decomposition analysis

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References

Vadikolias

Tsivgoulis

Heliopoulos

, et al. Incidence and case fatality of subarachnoid haemorrhage in Northern Greece: the Evros registry of subarachnoid haemorrhage. Int J Stroke 2009; 4: 322–327.

Karantali

Vemmos

Tsampalas

, et al. Temporal trends in stroke incidence and case-fatality rates in Arcadia, Greece: a sequential, prospective, population-based study. Int J Stroke 2022; 17: 37–47.

Vemmos

Bots

Tsibouris

, et al. Stroke incidence and case fatality in Southern Greece: the Arcadia stroke registry. Stroke 1999; 30: 363–370.

Stranjalis

Kalamatianos

Gatzonis

Loufardaki

Tzavara

Sakas

DE.

The incidence of the first-ever stroke in a Mediterranean island population: the isle of Lesvos stroke study. Neuroepidemiology 2014; 43: 206–212.

Tsivgoulis

Katsanos

Patousi

, et al. Stroke recurrence and mortality in northeastern Greece: the Evros Stroke Registry. J Neurol 2018; 265: 2379–2387.

Tsivgoulis

Patousi

Pikilidou

, et al. Stroke incidence and outcomes in Northeastern Greece: the Evros Stroke Registry. Stroke 2018; 49: 288–295.

Bergh

Askim

Rønning

Lydersen

Fjaertoft

Thommessen

How achievement of a stroke care pathway is associated with functional outcome after stroke: a national, register-based study. BMC Health Serv Res 2025; 25: 874.

Wilcock

Schwamm

Zubizarreta

, et al. Reperfusion treatment and stroke outcomes in hospitals with telestroke capacity. JAMA Neurol 2021; 78: 527–535.

Das Gupta

. Standardization and decomposition of rates: a user’s manual. Washington, DC: US Department of Commerce, Economics and Statistics Administration, Bureau of the Census, 1993.

10.

Rate decomposition for aggregate data using Das Gupta’s method. Stata J 2017; 17: 490–502.

11.

GBD 2019 Demographics Collaborators. Global age-sex-specific fertility, mortality, healthy life expectancy (HALE), and population estimates in 204 countries and territories, 1950–2019: a comprehensive demographic analysis for the Global Burden of Disease Study 2019. Lancet 2020; 396: 1160–1203.

12.

Feigin

Norrving

Mensah

GA.

Global burden of stroke. Circ Res 2017; 120: 439–448.

13.

GBD 2019 Stroke Collaborators. Global, regional, and national burden of stroke and its risk factors, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Neurol 2021; 20: 795–820.

14.

Organisation for Economic Co-operation and Development (OECD) and European Observatory on Health Systems and Policies. Greece: country health profile 2023, state of health in the EU. Paris: OECD Publishing, 2023.

15.

Rathfoot

Edrissi

Sanders

Knisely

Poupore

Nathaniel

Gender differences in comorbidities and risk factors in ischemic stroke patients with a history of atrial fibrillation. BMC Neurol 2021; 21: 209.

16.

Lisabeth

Bushnell

Stroke risk in women: the role of menopause and hormone therapy. Lancet Neurol 2012; 11: 82–91.

17.

Elisaf

Tzouvelekis

Nikas

; Greek EURIKA Investigators. Primary prevention of cardiovascular disease in Greece: Greek results of the EURIKA study. Hellenic J Cardiol 2014; 55: 217–226.

18.

Michas

Karvelas

Trikas

Cardiovascular disease in Greece; the latest evidence on risk factors. Hellenic J Cardiol 2019; 60: 271–275.

19.

Theodorakis

Hitas

Anagnostou

, et al. Burden of cardiovascular hospitalizations and in-hospital mortality in Greece: national trends over five years. Hellenic J Cardiol. Epub ahead of print 15 April 2025. DOI: 10.1016/j.hjc.2025.04.002.

20.

Dimitriadis

Kyriopoulos

Tsivgoulis

Vemmos

Kunz

Mossialos

Moving from traditional to more advanced treatments in stroke care is cost-effective: a case study from Greece. J Stroke Cerebrovasc Dis 2022; 31: 106764.

21.

Tsivgoulis

Kargiotis

Rudolf

, et al. Intravenous thrombolysis for acute ischemic stroke in Greece: the Safe Implementation of Thrombolysis in Stroke registry 15-year experience. Ther Adv Neurol Disord 2018; 11: 1–10.

22.

Palaiodimou

Kargiotis

Katsanos

, et al. Quality metrics in the management of acute stroke in Greece during the first 5 years of Registry of Stroke Care Quality (RES-Q) implementation. Eur Stroke J 2023; 8: 5–15.

23.

Tsivgoulis

Safouris

Mantatzis

, et al. Mechanical thrombectomy for acute ischemic stroke due to large vessel occlusion: a two year experience of Greek centers in SITS registry. Neurologia 2017; 24: 6–17.

24.

Gilligan

Thrift

Sturm

Dewey

Macdonell

Donnan

GA.

Stroke units, tissue plasminogen activator, aspirin and neuroprotection: which stroke intervention could provide the greatest community benefit?

Cerebrovasc Dis 2005; 20: 239–244.

25.

Middleton

McElduff

Ward

, et al. Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial. Lancet 2011; 378: 1699–1706.

26.

Kolovou

Makrygiannis

Marvaki

, et al. Prevalence and risk factors for atherosclerotic cardiovascular disease in 7704 individuals: an analysis from the Greek Registry for the prevalence of Familial Hypercholesterolemia (GRegistry-FH). J Cardiovasc Dev Dis 2024; 11: 411.

27.

Ullberg

Zia

Petersson

Norrving

Changes in functional outcome over the first year after stroke: an observational study from the Swedish stroke register. Stroke 2015; 46: 389–394.

28.

Wafa

Wolfe

CDA

Bhalla

Wang

Long-term trends in death and dependence after ischaemic strokes: a retrospective cohort study using the South London Stroke Register (SLSR). PLoS Med 2020; 17: e1003048.

29.

Wafa

Wolfe

CDA

Emmett

Roth

Johnson

Wang

Burden of stroke in Europe: thirty-year projections of incidence, prevalence, deaths, and disability-adjusted life years. Stroke 2020; 51: 2418–2427.

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