# Stroke as the Leading Cause of Death in Rural Ludhiana, India: A Verbal Autopsy From the Population-Based Rural Stroke Registry of Ludhiana

## TL;DR

Stroke is the top cause of death in rural Ludhiana, India, with high mortality rates linked to uncontrolled hypertension and poor access to acute care.

## Contribution

This study provides a population-based verbal autopsy analysis showing stroke as the leading cause of death in rural Ludhiana, India.

## Key findings

- Stroke accounted for 22.2% of all deaths in rural Ludhiana, with a crude mortality rate of 55.4 per 100,000.
- 83.6% of stroke deaths occurred within 30 days of symptom onset, and 81.7% of stroke victims had uncontrolled hypertension.
- Women had a higher cause-specific mortality fraction (24.7%) compared to men (20.5%) despite lower crude rates.

## Abstract

Introduction

Stroke is the second leading cause of global mortality, with a disproportionately high burden in low- and middle-income countries (LMICs). In regions with limited medical certification of death, verbal autopsy (VA) serves as a critical tool for determining the cause-of-death distribution. This study aimed to determine the stroke mortality in rural Ludhiana, Punjab, India.

Materials and methods

A prospective, population-based study was conducted between December 2016 and November 2018 across two rural blocks in Ludhiana (Pakhowal and Sidhwan Bet), covering a total population of 236,266. Frontline health workers identified all-cause mortality, followed by home-based VA. To ensure data integrity and minimize misclassification, two independent neurologists adjudicated stroke deaths using World Health Organization (WHO) standards and Indian Council of Medical Research (ICMR) VA tools, with a third expert resolving discrepancies. We cross-referenced registry data with municipal corporation and maintained consistency through monthly field audits and random interview re-evaluations. Cause-specific mortality fractions (CSMF), crude stroke mortality rates (CSMR), and age-standardized mortality rates (ASMR) were calculated.

Results

A total of 1,182 deaths were recorded, of which stroke was identified as the leading cause, accounting for 262 (22.2%) deaths. This represents a CSMF of 22.2% (95% confidence interval {CI}: 19.8-24.5). The annualized crude stroke mortality rate was 55.4 per 100,000 (95% CI: 48.9-62.5). While men had a higher crude rate (57.4), women exhibited a higher CSMF (24.7% versus 20.5%). After adjusting for the age distribution of the population using the WHO World Standard, the annualized ASMR was 29.7 per 100,000 person-years (95% CI: 26.1-33.4). Hypertension (214, 81.7%) and diabetes (89, 34.0%) were the most prevalent risk factors. Alarmingly, 219 (83.6%) of stroke deaths occurred within 30 days of symptom onset, with 126 (48.1%) occurring within the first seven days.

Conclusion

Stroke has emerged as the leading cause of death in rural Ludhiana, accounting for 262 (22.2%) of all mortality. While VA-based diagnosis carries inherent recall limitations, our rigorous adjudication protocol provides a reliable estimate of this burden. The high acute mortality rate, coupled with a 214 (81.7%) prevalence of uncontrolled hypertension, reveals critical gaps in both primary prevention and hyperacute care. These findings highlight an urgent need for integrated public health strategies, specifically focusing on community awareness and the implementation of "hub-and-spoke" acute care pathways to mitigate this rising epidemic.