Supplementary Material for: Global, regional and national burden of stroke attributable to anxiety: insights from a comparative risk assessment study

Background This study aimed to quantify the stroke burden attributable to anxiety at global, regional, and national levels, across 204 countries and territories, from 1990 to 2021. Methods We systematically searched PubMed, Embase, and MEDLINE from inception to July 24, 2024 for longitudinal studies reporting the association between anxiety and stroke risk. Pooled hazard ratios (HRs) were calculated using random-effects meta-analysis. Anxiety prevalence and stroke-related disability-adjusted life-years (DALYs) for adults aged 20 and older were obtained from the Global Burden of Diseases 2021. Within a comparative risk assessment framework, we computed population attributable fractions, age-standardized DALY rates (ASDRs), and assessed cross-country inequalities using the slope index of inequality (SII) and concentration index. Results Of 5343 initially identified records, six studies met inclusion criteria, yielding a pooled HR of 1.25 (95% confidence interval [CI]: 1.07 to 1.45). The global anxiety-attributable stroke burden remained substantial, with ASDR per 100000 population declining from 195.94 (95% CI: 145.67 to 252.55) in 2000 to 133.50 (95% CI: 100.07 to 171.72) in 2021. Regionally, the middle socio-demographic index (SDI) region and Eastern Mediterranean Region exhibited the highest ASDRs in 2021. Countries with low and low-middle SDI accounted for the highest ASDRs. Inequality metrics confirmed greater burden in lower-SDI countries for males (SII: -111.52, 95% CI: -131.75 to -91.28; concentration index: -0.0921, 95% CI: -0.1333 to -0.0509) and females (SII: -148.95, 95% CI: -177.35 to -120.55; concentration index: -0.1193, 95% CI: -0.1629 to -0.0756) in 2021. Conclusions Our findings underscore the association between anxiety and stroke risk, demonstrating the anxiety-associated stroke burden. Integrating mental health management into public health policies and clinical practice might have the potential to reduce the stroke burden and improve health outcomes.