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Burden of Stroke in Qatar

Article  in  Journal of stroke and cerebrovascular diseases: the official journal of National Stroke Association · October 2015
DOI: 10.1016/j.jstrokecerebrovasdis.2015.08.024

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 Burden of Stroke in Qatar

Faisal Ibrahim, MD, MRCP, Dirk Deleu, MD, PhD, FRCP, FESO, Naveed Akhtar, MD,
Wafa Al-Yazeedi, MD, Boulenouar Mesraoua, MD, FAAN, Sadaat Kamran, MD, and
Ashfaq Shuaib, MD, FRCPC, FAHA

Background: Qatar is located on the northeastern coast of the Arabian Peninsula.

The total population is over 2.1 million with around 15% being Qatari citizens.
Hamad General Hospital (HGH) is the only tertiary referral governmental hos-
pital in Qatar which admits acute (thrombolysis-eligible) stroke patients. Objective:
To provide an overview of the burden of stroke in Qatar. Methods: Data from
literature databases, online sources and our stroke registry were collated to iden-
tify information on the burden of stroke in Qatar. Results: Overall, over 80% of
all stroke patients in Qatar are admitted in HGH. In 2010, the age-standardized
incidence for first-ever ischemic stroke was 51.88/100,000 person-years. To date
our stroke registry reveals that 79% of all stroke patients are male and almost
50% of stroke patients are 50 years or less. Hypertension, diabetes and dyslipidemia
are the main predisposing factors for stroke, with ischemic stroke being more common
(87%) than hemorrhagic stroke (13%). Despite the lack of a stroke unit, 9% of isch-
emic stroke patients are being thrombolyzed. However the presence of a stroke
ward allows swift turnover of patients with a length of stay of less than 5 days
before discharge or, if required, transfer to the fully-equipped hospital-based re-
habilitation service. Several community awareness programs are ongoing, in addition
to several research programs funded by the Qatar National Research Fund and
Hamad Medical Corporation. Conclusion: In a country where over 15% of the pop-
ulation suffers from diabetes there is continuous need for national community-
based awareness campaigns, prevention and educational programs particularly
targeting patients and health care workers. Key Words: Stroke—Ischemic
stroke—Hemorrhagic stroke—Qatar—Thrombolysis.
© 2015 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Introduction Western countries as well as in low- and middle-

Stroke is the leading cause of disability in adults and
the second leading cause of mortality worldwide.1 In
From the Division of Neurology, Neuroscience Institute, Hamad
Medical Corporation, Doha, Qatar.
Received July 8, 2015; revision received August 7, 2015; accepted
August 19, 2015.
No conflict of interest—No financial disclosures.
Address correspondence to Dirk Deleu, Division of Neurology,
Neuroscience Institute, P.O. Box 3050, Hamad Medical Corporation,
Doha, Qatar. E-mail: ddeleu@hamad.qa.
1052-3057/$ - see front matter
© 2015 National Stroke Association. Published by Elsevier Inc. All
rights reserved.
http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2015.08.024
income countries, it is responsible for 85% of all
deaths.2
Qatar is located on the northeastern coast of the Arabian
Peninsula, covering a territory of approximately 11,437 km2
having a sole land border, with Saudi Arabia to the south
and the rest of its territory surrounded by the Arabian
Gulf. In August 2015, Qatar’s total population was just over
2.1 million with around 15% Qatari citizens and the re-
maining citizens being expatriates (also referred to as
non-Qatari).3
Qatar’s natural resources (petroleum and gas) are the
cornerstone of Qatar’s economy, providing it a gross do-
mestic product per capita that ranks among the highest
in the world. Over the past few years, Qatar’s public
healthcare budget witnessed a rapid increase and is one

Journal of Stroke and Cerebrovascular Diseases, Vol. 24, No. 12 (December), 2015: pp 2875–2879 2875
2876
of the highest in the Arabian Gulf region. In 2012, the
total expenditure on health care per capita was U.S.$1805
or 2.2% of GDP.4 Qatar’s total population is relatively
young, with a median age of 30 years.5 The median age
of the Qatari population is younger than that of the non-
Qatari population (19 years compared with 30 years,
respectively).5 Qatar’s median population age is lower than
the average median age in the European Union (41 years
in 2011).6
The high rate of urbanization and changes in lifestyle
profile—reduced physical activity and increased con-
sumption of calories and diets rich in fat—and the rapidly
aging population contribute to cardiovascular morbidi-
ty and mortality.7-10 The prevalence of diabetes is estimated
to exceed 15% in Qatar as compared to 11% in the United
States.11
Hamad General Hospital (HGH) is the only tertiary
referral governmental hospital in Qatar that admits
patients with acute (thrombolysis-eligible) stroke. In
addition, patients with non–thrombolysis-eligible and
nonacute stroke are admitted in HGH and its satellite
hospitals (Al Khor and Al Wakra). Private hospitals in
Qatar are not involved in stroke admission and care. In
2014, 899 stroke patients were admitted in Qatar, of
which 81.5% were admitted in HGH, 10.8 % in Al
Khor, and 7.6% in Al Wakra. Free healthcare service for
all Qatari nationals is the cornerstone of the healthcare
program. In addition, when expatriates are admitted
through the emergency department of governmental
hospitals (HGH and all satellite hospitals), medical care
is free for the first 4 days of admission. This unique
setting, in addition to the availability of an excellent
physical medicine and rehabilitation stroke service as
well as allied health services (occupational, speech, and
physiotherapy) and stroke clinics, makes HGH an excel-
lent opportunity for studying stroke.
This paper provides an overview on the burden of stroke
in Qatar. In particular, epidemiological data, risk factor
profile, acute stroke service and tissue plasminogen ac-
tivator treatment, burden, and barriers in delivering
thrombolysis therapy in this fast developing country will
be considered.
Mortality
In 2012, Qatar’s crude death rate was 1.1 deaths/1000
population for the total population: 2.5 for the Qatari
population and 0.9 for the non-Qatari population.5
Cardiovascular disease (20%) accounted for the primary
cause of death in the expatriate population (17%) and
was the second commonest cause of death following
cancer (22%) in Qatari nationals. Overall, 12% of
registered deaths were related to cardiovascular disease:
15% in the Qatari population and 11% in the expatriate
population. The difference in percentage between the 2
populations reflects their different demographic compo-
F. IBRAHIM ET AL.
sitions. In 2010, the age-standardized mortality rate for
ischemic stroke was 9.17/100,000 person-years com-
pared with 31.27/100,000 person-years in 1990.12 The
age-standardized mortality rates for hemorrhagic stroke
was 13.21/100,000 person-years compared with 35.30/
100,000 person-years in 1990.12 At HGH, the overall
in-hospital 30-day mortality rate in 1997 was 16%13 and
gradually decreased to 9.3% in 200514 and 4% in 2014
(unpublished data).
Epidemiology
In 2010, the age-standardized incidence for first-ever
ischemic stroke was 51.88/100,000 person-years com-
pared with 46.52/100,000 person-years in 1990.12 The
age-standardized incidence for first-ever hemorrhagic
stroke was 14.55/100,000 person-years compared with
11.07/100,000 person-years in 1990.12 Thus far, 3 studies
have been published on the epidemiology of stroke in
Qatar. A retrospective study of first-ever stroke (n = 217;
157 men and 60 women) was conducted in the Neurol-
ogy Division of HGH in 1997.13 The large majority of
patients experienced ischemic stroke (80%), while intra-
cerebral hemorrhage and subarachnoid hemorrhage
accounted for 19% and 1%, respectively. The mean age
of patients experiencing their first stroke was 57 years.
Thirty-nine (18%) patients were younger than 45 years.
Khan et al.14 conducted a 1-year prospective study in
2004 on first-ever stroke (n = 270) at the same institu-
tion. Ischemic stroke was diagnosed in 80% of patients.
Lacunar infarct was the most common subtype of
ischemic stroke. A 2-year prospective case–control study
performed at HGH in 2006 revealed that 54% of stroke
patients were younger than 55 years, 66% of them
being male.15
To date, our stroke registry reveals that from the 1491
stroke patients included, 19% are Qatari (55% male and
45% female) and 81% are non-Qatari (85% male and
15% female). This results in an overall male-to-female
ratio in our stroke population of 3.76 (79% male). The
large preponderance of male non-Qatari patients is ex-
plained by the huge male labor force represented in the
country’s population. In the non-Qatari population, the
male-to-female ratio is 3.76,16 whereas its male-to-
female ratio for stroke patients is 5.67, indicating that
non-Qatari men are more at risk for having a stroke
than their female counterparts. While in the Qatari pop-
ulation these figures are more balanced. However also
in the Qatari population there is a male preponderance
(male-to-female ratio 0.96),16 while the male-to-female
ratio for stroke patients is 1.22.
Because there are equal opportunities for all patients
in Qatar to visit emergency departments across the
country free of charge, differences in accessibility to
medical services cannot account for the differences in
stroke rates observed between the Qatari and non-
BURDEN OF STROKE IN QATAR
Qatari population. Laborers tend to have a lower level
of education that has been associated with a higher risk
for developing stroke.17 However, and more impor-
tantly, differences in dietary and lifestyle habits between
the 2 populations likely play a bigger role in the higher
rate of stroke observed in the predominantly male
expatriate population as compared with their Qatari
counterparts. This requires further research particularly
because South Asians represent 46% of this non-Qatari
population.
Risk Factors
A retrospective study performed at HGH by Hamad
et al.,13 covering the period between January and De-
cember 1997, revealed the following as major risks for
stroke: hypertension (63%), diabetes mellitus (42%), isch-
emic heart disease (17%), and atrial fibrillation (4.5%).
Another retrospective study (n = 303) conducted by Deleu
et al.18 at HGH, between January and December 2001,
on ethnic variations in risk factor profile, pattern, and
recurrence of noncardioembolic ischemic stroke re-
vealed that hypertension (69%) was the most commonly
encountered risk factor followed by dyslipidemia (57%),
diabetes mellitus (51%), and obesity (30%). The majori-
ty of strokes were lacunar hemispheric strokes (68%),
followed by lacunar brainstem strokes (15%) and large-
vessel hemispheric infarctions (10%). Sixty-seven percent
of the overall patient population was of Arab origin, and
32% were South Asians. Age was significantly higher in
the Qatari nationals compared with the expatriate pa-
tients (67 versus 56 years). Significant differences between
the Arab and South Asian subgroups of patients were
observed with respect to the number of risk factors (3
versus 2.6), occurrence of obesity (36% versus 20%), and
diabetes (64% versus 46%). Carotid artery stenotic lesions
(17% versus 6%) and ventricular wall motion abnormali-
ties (30% versus 20%) were observed with a higher
frequency in the Arab subgroup of patients compared with
the South Asian group.
The study by Khan et al.14 identified the following
common risk factors in ischemic stroke: hypertension
(74%), diabetes (67%), and dyslipidemia (53%). In the
subgroup of hemorrhagic stroke patients, hypertension
(79%) followed by diabetes (26%) was the most common
risk factor. Risk factor profiles were similar between Qatari
and non-Qatari patients except for hypercholesterol-
emia, which was observed with a higher frequency in
Qatari nationals with ischemic stroke. A case–control study
conducted at HGH revealed that patients with stroke
were more likely than their controls to have diabetes
(odds ratio [OR] = 5.12) followed by hypertension
(OR = 3.59) and metabolic syndrome (OR = 4.74).15 Com-
paring our data from HGH (Qatar) with those of North
America the OR of diabetes in North America is 1.75.
The ORs for diabetes and metabolic syndrome were higher
2877
in Qatari nationals than in the overall population. Obesity
was probably also an important risk factor, however,
that did not reach significance because it was high in
the overall stroke population (30%) and even higher in
Qatari nationals (38%) and Qatari controls (54%).
The proportions of stroke subtypes are well-known to
differ based on race or ethnicity (e.g., lacunar stroke is
more commonly observed in the Asian population than
in Western populations).19,20 Older age, male gender, and
hyperlipidemia appear to be risk factors favoring extra-
cranial atherosclerosis, whereas metabolic syndrome is more
closely associated with intracranial atherosclerosis.20 The
latter likely explains the high frequency of small-vessel
strokes observed in Qatar.
Efforts to boost stroke awareness and care have been
launched in early 2007, resulting in an increasing number
of ischemic stroke patients being thrombolyzed (Fig 1).
Although there is an efficient Emergency Medical Ser-
vices (EMS) service, state-of-the-art neuroimaging
equipment, and treatment free of charge for patients ad-
mitted through the emergency department in all
governmental hospitals, treating stroke patients remains
a challenge. The increasing sedentary lifestyle and western
diet in combination with genetic factors lead to the met-
abolic syndrome, which is a contributing factor to the
development of stroke.
Stroke Service
To date, no stroke unit exists in Qatar. Patients are being
thrombolyzed in the Emergency Department at HGH and
transferred to a monitored bed in the 12-bedded stroke
ward. The number of certified neurologists in Qatar is
less than 20, 11 of them being affiliated to HGH. Most
of them are well-trained in diagnosis and management
of stroke and some of them have special training in acute
stroke. In addition, during the 3-year neurology fellow-
ship program at HGH, the neurology fellows have
extensive exposure to the diagnosis and management of
acute stroke including intravenous thrombolysis.
In the Arabian Peninsula, the thrombolysis rates for
acute ischemic stroke were less than 1% before 2010.21
However, the creation of a stroke task force at HGH has
led to an exponential increase in the number of patients
receiving thrombolysis over the past years (Fig 1). In 2012,
6% of patients with ischemic stroke received thromboly-
sis, a number that increased to 9% in 2014. In November
2014, the stroke service at HGH/Rumailah Hospital has
been Joint Commission International certified.
Apart from nonenhanced brain computed tomogra-
phy (CT) scan, cerebral CT angiography and CT perfusion
are of paramount importance in the evaluation of acute
stroke and are now routinely used in all patients with
acute ischemic stroke. Since 2015, routine endovascular
therapy has been introduced as the standard of care for
acute ischemic stroke.
2878
60 N⁰ of patients
50
40
30
20
10
0
2007 2008 2009 2010 2011 2012
Economic Impact
In 2010, the age-standardized disability-adjusted life years
(DALYs) for ischemic stroke was 178.34/100,000 person-
years compared with 481.27/100,000 person-years in 1990.12
The age-standardized mortality rates for hemorrhagic stroke
was 228.07/100,000 person-years compared with 642.27/
100,000 person-years in 1990.12 According to the Institute
for Health Metrics and Evaluation, Qatar significantly im-
proved its rank in leading age-standardized rates of
disability-adjusted life years from 11 in 1990 to 4 in 2010.
This improvement ranks it comparable with countries such
as Canada, Norway, and The Netherlands.22
Education
HGH is the teaching hospital for Weill Cornell Medical
College in Qatar. Stroke is part of the neurology curric-
ulum at Weill Cornell Medical College in Qatar, and much
emphasis is put on stroke during the neurology clerkship.
In 2005, a cross-sectional community-based survey on
stroke awareness in the general public conducted at
primary healthcare centers, in urban and semiurban areas,
of several Gulf Cooperation Council (GCC) countries (in-
cluding Qatar), revealed that from the 3750 individuals
only 29% were familiar with the term “stroke,” and 29%
considered the age group 30-50 at the highest risk for
stroke. Individuals identified hypertension (23%) and
smoking (27%) as the most common risk factors.23 People
unfamiliar with the term stroke had a higher incidence
of diabetes and hypertension, and had more than 1 risk
factor. The commonest identified stroke symptoms were
weakness (23%) and speech difficulties (22%). Younger
age, higher level of education, and female gender were
F. IBRAHIM ET AL.
Figure 1. Number of acute ischemic stroke pa-
tients thrombolyzed during the time frame
2007-2014.
2013 2014
better predictors of stroke recognition, while the level of
education, monthly income, and smoking were indepen-
dent variables predicting stroke knowledge.
In 2008, stroke recognition posters were developed to
increase awareness in the community. Similarly, stroke
education sessions were provided to physicians in the
emergency department and nursing staff across HGH. More
recently a nationwide awareness campaign on the signs
of stroke based on Face drooping -Arm weakness-
Speech difficultly-Time to call 999 (F.A.S.T.) was launched,
including educational TV spots.
Prevention and Rehabilitation
HGH has an excellent stroke rehabilitation service in
Rumailah Hospital. The same service has transformed the
outcome of stroke through early rehabilitation at HGH.
A team of stroke rehabilitation physicians, physiothera-
pists, and speech and occupational therapists assessed the
patient within 24 hours of admission to HGH. In 2014,
19% of stroke patients were referred from the stroke in-
patient service to the stroke rehabilitation service at
Rumailah Hospital. As a well-equipped stroke rehabili-
tation service, Rumailah Hospital also improves, in addition
to motor deficit, cognitive, emotional, and communica-
tive skills, and is run by a team of stroke rehabilitation
physicians, physiotherapists, and speech and occupation-
al therapists.
Organization and Clinical Practice
Stroke ranks as a priority in Qatar and different stake-
holders are currently working together to reduce the burden
of stroke. In the near future the development of a na-
 BURDEN OF STROKE IN QATAR
tional stroke registry and national guidelines, in addition
to national awareness campaigns and the establishment
of stroke units in HGH and its satellite hospitals, will
be imperative to improve the stroke service. Further-
more, the rapid population growth of the country and
the corresponding increase in traffic create the opportu-
nity for novel ways of care delivery such as telestroke
and specialized stroke emergency mobile units.
Research
Several major research grants from Hamad Medical Cor-
poration and the Qatar National Research Fund are funding
projects on stroke. It is anticipated that research into
genetic/ethnic differences in stroke pathology and treat-
ment response, clinical trials in stroke, and more
fundamental research projects in stroke will help in shed-
ding some light on the different aspects of stroke and
its consequences in Qatar.
Conclusion
The high percentage of young people with stroke and
the high number of cardiovascular risk factors—in par-
ticular the higher risk associated with diabetes—are striking
and are an indication of the continuous need for nation-
al community-based awareness campaigns and prevention
and educational programs targeting high-risk patients and
healthcare workers.
Acknowledgments: The authors wish to acknowledge Mrs.
Paula Bourke, Mrs. Sujatha Joseph, and Mr. Mark Santos for
their contribution in data collection and analysis.
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