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Hypothetical interventions to prevent stroke: an application of the parametric g-formula to a healthy middle-aged population

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Abstract

The effects of interventions on multiple lifestyle and metabolic risk factors, initiated in midlife or later in a healthy population, on the long-term risk of first-ever stroke is not known. A particular methodological challenge in observational studies is to estimate the unbiased effect of a time-varying exposure in presence of time-varying confounders, if those confounders are affected by prior exposure. In such cases, the parametric g-formula can be applied to estimate an unbiased effect. We applied the parametric g-formula to estimate the 18-years (1994–2012) cumulative stroke risk under different scenarios of hypothetical interventions on levels of blood pressure, cholesterol, weight, physical activity, smoking and alcohol intake; and compared these to the observed scenario, to calculate the population risk ratios and risk differences. Among 14,796 eligible participants in the prospective, population-based Tromsø study (baseline mean age 46.1 years, 51% women), the observed 18-years stroke risk was 5.9%. A feasible joint hypothetical intervention on six lifestyle and metabolic risk factors would reduce the 18-year stroke risk by 32% (95% confidence interval 16, 44). A combination of more intensive interventions reduced the estimated 18-years stroke risk by 64% (95% confidence interval 40, 80). Blood pressure reduction and quitting smoking significantly reduced the risk when applied separately.

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Acknowledgements

We are grateful to Priyanka Jain, Stein Harald Johnsen, Inger Njølstad, Maja-Lisa Løchen for valuable contribution; and to all the participants in the Tromsø Study.

Funding

The Tromsø Study has been supported by the Research Council of Norway; the Norwegian Council on Cardiovascular Disease; the Northern Norway Regional Health Authority; the University of Tromsø; the Norwegian Foundation for Health and Rehabilitation; and the Odd Berg Research Foundation. AM. Vangen-Lønne receives a research grant from the Northern Norway Regional Health Authority.

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Authors and Affiliations

  1. Department of Clinical Medicine, The Arctic University of Norway, Tromsø, Norway

    Anne M. Vangen-Lønne & Ellisiv B. Mathiesen

  2. Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA

    Anne M. Vangen-Lønne, Peter Ueda, Pablo Gulayin & Goodarz Danaei

  3. Department of Neurology, Innlandet Hospital Trust, Lillehammer, Norway

    Anne M. Vangen-Lønne

  4. Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden

    Peter Ueda

  5. Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina

    Pablo Gulayin

  6. Department of Community Medicine, The Arctic University of Norway, Tromsø, Norway

    Tom Wilsgaard

  7. Department of Neurology, University Hospital of North Norway, Tromsø, Norway

    Ellisiv B. Mathiesen

  8. Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA

    Goodarz Danaei

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  1. Anne M. Vangen-Lønne
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Correspondence to Anne M. Vangen-Lønne.

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Vangen-Lønne, A.M., Ueda, P., Gulayin, P. et al. Hypothetical interventions to prevent stroke: an application of the parametric g-formula to a healthy middle-aged population. Eur J Epidemiol 33, 557–566 (2018). https://doi.org/10.1007/s10654-017-0344-x

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  • DOI: https://doi.org/10.1007/s10654-017-0344-x

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