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William L. Roper, MD, MPH, Chapel Hill, NC, Chairman
Virginia A. Caine, MD, Indianapolis, IN
David W. Fleming, MD, Seattle, WA
William E. Halperin, MD, DrPH, MPH, Newark, NJ
Margaret A. Hamburg, MD, Washington, DC
King K. Holmes, MD, PhD, Seattle, WA
Deborah Holtzman, PhD, Atlanta, GA

John K. Iglehart, Bethesda, MD
Dennis G. Maki, MD, Madison, WI
Sue Mallonee, MPH, Oklahoma City, OK
Stanley A. Plotkin, MD, Doylestown, PA

Patricia Quinlisk, MD, MPH, Des Moines, IA

Patrick L. Remington, MD, MPH, Madison, WI
Barbara K. Rimer, DrPH, Chapel Hill, NC
John V. Rullan, MD, MPH, San Juan, PR
Anne Schuchat, MD, Atlanta, GA

Dixie E. Snider, MD, MPH, Atlanta, GA
John W. Ward, MD, Atlanta, GA

phone 9-1-1 was low; the percentage who met all th measures was 16.4%. In addition, disparities were obser by race/ethnicity, sex, and education level. Public hea agencies, clinicians, and educators should continue to s the importance of learning to recognize stroke symptom and the need to telephone 9-1-1 when someone appeas be having a stroke.

BRFSS is a state-based, random-digit-dialed teleph survey of the U.S. civilian, noninstitutionalized popu tion aged ≥18 years and is conducted in all 50 states, Du Guam, Puerto Rico, and the U.S. Virgin Islands. Howe in 2005, the optional heart attack and stroke module wa included in the BRFSS surveys of 13 states and DC. J total of 71,994 respondents answered questions regardin symptoms of stroke. An incorrect symptom was include in another question ("Do you think sudden chest pain a discomfort is a symptom of stroke?") to assess the possi ity that respondents might answer "yes" to all of the qua tions in the series without actually considering the Respondents also were asked to select the one action the would do first, from the following list of actions, if the thought that someone was having a heart attack or strass take the person to the hospital, advise the person to call doctor, call 9-1-1, call a spouse or family member, or something else. Median response rate for the 13 states an DC, based on Council of American Survey and Resear Organizations (CASRO) guidelines, was 54.5% (rang 45.1%-61.3%). Data were weighted to 2005 state pop lation estimates. Age-adjusted prevalence estimates an 95% confidence intervals (CIs) were calculated; statis cally significant differences between characteristics we determined by nonoverlapping Cls.

Respondent awareness of stroke warning symptoms w 92.6% for sudden numbness or weakness of the face, ar or leg, especially on one side; 86.5% for sudden confus or trouble speaking; 83.4% for sudden trouble walkin dizziness, or loss of balance; 68.8% for sudden trouble s ing in one or both eyes; and 60.4% for a severe headac with no known cause. In addition, 85.9% of responder said they would call 9-1-1 if they thought someone w having a heart attack or stroke. However, 39.5% of respo

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ts incorrectly identified sudden chest pain or discom(which is a warning symptom of a heart attack) as a ning symptom of stroke (Table 1).

wareness of individual stroke warning symptoms varied. race/ethnicity, sex, and level of education. Whites, hen, and persons at higher education levels were more y to be aware of individual stroke warning symptoms more likely to call 9-1-1 if they thought that someone having a heart attack or stroke than were blacks, panics, men, and persons at lower levels of education ɔle 1).

wareness of individual stroke warning symptoms also ed by area. Respondent awareness ranged from 87.2% uisiana) to 96.4% (Minnesota) for sudden numbness veakness of the face, arm, or leg, especially on one side; a 79.0% (Louisiana) to 92.9% (West Virginia) for sud

den confusion or trouble speaking; from 77.1% (Louisiana) to 91.4% (Minnesota) for sudden trouble walking, dizziness, or loss of balance; from 62.0% (Oklahoma) to 76.5% (Minnesota) for sudden trouble seeing in one or both eyes; and from 51.8% (DC) to 68.8% (Minnesota) for severe headache with no known cause. The percentage of respondents who reported that they would call 9-1-1 if they thought someone was having a heart attack or stroke ranged from 77.7% (Mississippi) to 89.0% (Minnesota) (Table 1).

All five stroke warning symptoms were identified by 43.6% of respondents; 18.6% were aware of all stroke warning symptoms and knew that sudden chest pain is not a stroke warning sign; 38.1% were aware of all stroke warning symptoms and would first call 9-1-1 if they thought that someone was having a heart attack or stroke, and 16.4%

LE 1. Age-adjusted percentage of respondents who recognized stroke warning symptoms, misidentified an incorrect symptom,* said they would first call 9-1-1 if someone appeared to be having a stroke or heart attack, by symptom, selected characteristics, Behavioral Risk Factor Surveillance System, 13 states and the District of Columbia (DC), 2005

area

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87.6 (85.7-89.3)

95.3 (94.4-96.0)

70.0 (67.8-72.1)

81.8 (80.0-83.5)

60.8 (58.5-63.0)

35.8 (33.6-38.1)

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82.0 (80.0-83.8) 90.0 (88.5-91.3) 62.8 (60.7-64.9) 79.1 (77.1-81.9)
84.0 (82.6-85.3) 91.1 (89.9-92.1) 67.6 (66.0-69.2)
90.3 (89.1-91.3) 94.6 (93.7-95.3) 71.1 (69.5-72.7)
79.0 (77.0-80.8) 87.2 (85.7-88.6) 62.9 (60.7-65.0)
87.8 (86.3-89.2) 93.2 (91.9-94.2) 67.9 (66.0-69.8) 84.6 (83.2-86.0)
91.7 (90.2-92.9) 96.4 (95.5-97.1) 76.5 (74.5-78.4) 91.4 (90.2-92.6)
87.1 (85.8-88.3) 93.0 (92.0-93.9) 65.2 (63.3-67.0) 80.3 (78.8-81.8) 59.9 (58.0-61.8)
86.8 (85.1-88.4) 93.6 (91.7-95.2) 66.1 (64.0-68.2) 83.1 (81.4-84.8) 53.6 (51.4-55.8)
89.0 (87.5-90.3) 94.7 (93.6-95.6) 70.7 (68.8-72.5) 87.6 (86.2-88.9) 57.8 (55.8-59.8)
83.7 (82.4-85.0) 90.2 (89.1-91.3) 62.0 (60.5-63.4) 79.4 (78.1-80.7)
86.1 (84.4-87.5) 90.6 (89.2-91.9) 72.3 (70.4-74.1) 80.8 (79.0-82.5)
88.4 (87.0-89.6) 94.2 (93.1-95.0) 69.3 (67.5-71.1) 84.8 (83.4-86.1)
92.9 (91.7-93.9) 95.6 (94.7-96.3) 75.1 (73.4-76.7) 89.4 (88.2-90.5) 67.6 (65.7-69.5)

51.8 (49.6-53.9)

39.9 (37.7-42.1)

82.0 (80.6-83.3)

60.3 (58.6-61.9)

40.8 (39.2-42.5)

86.2 (84.4-87.9) 86.4 (84.8-87.9) 87.0 (85.7-88.2)

88.7 (87.5-89.4)

61.7 (60.0-63.4)

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77.1 (75.2-79.0)

60.0 (57.8-62.1) 54.6 (52.6-56.6) 68.8 (66.6-70.8)

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den chest pain or discomfort, which is a symptom for heart attack but not for stroke. fidence interval.

were aware of all five stroke warning symptoms, knew that sudden chest pain is not a stroke warning symptom, and would call 9-1-1 if they thought that someone was having a heart attack or stroke (Table 2). Awareness of all five stroke warning symptoms and calling 9-1-1 was higher among whites (41.3%), women (41.5%), and persons at higher education levels (47.6% for persons with a college degree or more) than among blacks and Hispanics (29.5% and 26.8%, respectively), men (34.5%), and persons at lower education levels (22.5% for those who had not received a high school diploma). Among states, the same measure ranged from 27.9% (Oklahoma) to 49.7% (Minnesota).

Reported by: J Fang, MD, NL Keenan, PhD, C Ayala, PhD. S MD, PhD, R Merritt, MA, Div for Heart Disease and Stroke Preve National Center for Chronic Disease Prevention and Health Prom CH Denny, PhD, Div of Birth Defects and Developmental Disar: · National Center on Birth Defects and Developmental Disabilities, L Editorial Note: Immediate emergency transportation tra hospital to receive timely urgent care can reduce disab and even death associated with stroke. The American Stre Association and National Stroke Association are work with state and local health departments to increase pub recognition of stroke warning symptoms and 9-1-1 c that prioritize these symptoms as “possible stroke.”

TABLE 2. Age-adjusted percentage of respondents who recognized five correct stroke warning symptoms, identified one incorrec symptom,* and said they would first call 9-1-1 if someone appeared to be having a stroke or heart attack, by selected characteristic and area - Behavioral Risk Factor Surveillance System, 13 states and the District of Columbia (DC), 2005

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Aware of all five warning symptoms and knew that chest pain was not a warning symptom of stroke.

Sudden chest pain or discomfort, which is a symptom for heart attack but not for stroke.

Sudden confusion or trouble speaking; sudden numbness or weakness of face, arm, or leg, especially on one side; sudden trouble seeing in one or b eyes; sudden trouble walking, dizziness, or loss of balance; and a severe headache with no known cause. Confidence interval.

ition, some states with heart disease and stroke preven1 programs are conducting activities to increase public reness of the symptoms of heart attack and stroke and - importance of calling 9-1-1 (8).

he 2005 results in this report indicate no improvement wareness of stroke warning symptoms from the 2001 rey (9), although direct comparisons cannot be made ause the areas participating in the optional heart attack stroke module differed in 2005 (13 states and DC) from 1 (17 states and the U.S. Virgin Islands). In both sur5, few respondents (17.2% in 2001 and 16.4% in 2005) ognized all five stroke warning symptoms, knew that sudchest pain is not a stroke symptom, and said they would 9-1-1 immediately if they thought someone was having roke or heart attack. Urgent public health efforts are needed ncrease the percentage of respondents who meet these isures and should focus on those symptoms with the least reness (i.e., severe headache with no known cause and den trouble seeing in one or both eyes).

Disparities in awareness of stroke warning symptoms and wing the importance of telephoning 9-1-1 suggest that lic health efforts should be targeted to blacks, Hispanmen, and persons with less education. A 2006 study ermined that Hispanics who only spoke Spanish were likely than Hispanics who also spoke English to be re of stroke warning symptoms and what action to take hey thought someone was having a stroke or heart attack ). In areas in which awareness of stroke warning sympis is lower, state and local health departments should sider working together to implement general public reness campaigns.

The findings in this report are subject to at least four itations. First, BRFSS excludes households without iline telephones, including those households with only ular telephones. Second, only 13 states and DC particied in the heart attack and stroke module in 2005; there, the results might not be generalizable to the entire ulation of the United States. Third, the finding in this ort regarding the percentage of respondents who idened all five stroke warning symptoms (43.6%) differed stantially from the previously reported estimate of 78% n the 2001 National Health Interview Survey (NHIS), ch was used as the initial baseline for objective 12-8 in lthy People 2010 (7). However, the two results are not ctly comparable. NHIS results are representative of the

U.S. population, whereas the 2005 BRFSS respondents represented a population with landline telephones in 13 states and DC. Questioning in the two surveys also was structured differently. The NHIS questions did not cover the need to call 9-1-1 and also did not include an incorrect symptom as a check against persons who might answer "yes" to all the stroke symptom awareness questions without actually considering them. Finally, the data collected did not enable determination of whether participants who misidentified the incorrect stroke symptom did not know the correct answer or did not consider the question.

Receiving treatment quickly after a stroke is critical to lowering the risk for disability and even death. Rapid treatment requires that persons 1) recognize the warning symptoms of stroke and 2) call 9-1-1 immediately. These findings indicate a need to increase awareness of stroke warning symptoms in the entire population, and particularly among blacks, Hispanics, men, and persons at lower education levels. In addition, increased education efforts in multiple languages might help improve awareness among nonEnglish-speaking Hispanics and others.

References

1. Thom TJ, Epstein FH. Heart disease, cancer, and stroke mortality trends and their interrelations: an international perspective. Circulation 1994;90:574-82.

2. Lanska DJ, Peterson PM. Geographic variation in the decline of stroke mortality in the United States. Stroke 1995;26:1159–65.

3. Heron MP. Deaths: leading causes for 2004. Natl Vital Stat Rep 2007;56(5).

4. Rosamond W, Flegal K, Furie K, et al. Heart disease and stroke statistics-2008 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2008;117:e25-146.

5. Hacke W, Donnan G, Fieschi C, et al. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet 2004;363:768-74.

6. Kowalski RG, Claassen J, Kreiter KT, et al. Initial misdiagnosis and outcome after subarachnoid hemorrhage. JAMA 2004;291:866–9.

7. US Department of Health and Human Services. Healthy people 2010 midcourse review. Washington, DC: US Department of Health and Human Services; 2006. Available at http://www.healthypeople.gov/ data/midcourse.

8. CDC. State Heart Disease and Stroke Prevention Program. Atlanta, GA: US Department of Health and Human Services, CDC; 2007. Available at http://www.cdc.gov/dhdsp/state_program/index.htm. 9. CDC. Awareness of stroke warning signs-17 states and the U.S. Virgin Islands, 2001. MMWR 2004;53:359–62.

10. DuBard Ca, Garrett J, Gizlice A. Effect of language on heart attack and stroke awareness among U.S. Hispanics. Am J Prev Med 2006;30:189–96.

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