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Each year, the American Heart Association (AHA), in conjunction with the Centers for Disease Control and Prevention, the National Institutes of Health, and other government agencies, brings together the most up-to-date statistics on heart disease, stroke, other vascular diseases, and their risk factors and presents them in its Heart Disease and Stroke Statistical Update. The Statistical Update is a valuable resource for researchers, clinicians, healthcare policy makers, media professionals, the lay public, and many others who seek the best national data available on disease morbidity and mortality and the risks, quality of care, medical procedures and operations, and costs associated with the management of these diseases in a single document. Indeed, since 1999, the Statistical Update has been cited more than 8700 times in the literature (including citations of all annual versions). In 2009 alone, the various Statistical Updates were cited ≈1600 times (data from ISI Web of Science). In recent years, the Statistical Update has undergone some major changes with the addition of new chapters and major updates across multiple areas. For this year’s edition, the Statistics Committee, which produces the document for the AHA, updated all of the current chapters with the most recent nationally representative data and inclusion of relevant articles from the literature over the past year and added a new chapter detailing how family history and genetics play a role in cardiovascular disease (CVD) risk. Also, the 2011 Statistical Update is a major source for monitoring both cardiovascular health and disease in the population, with a focus on progress toward achievement of the AHA’s 2020 Impact Goals. Below are a few highlights from this year’s Update.

Death Rates From CVD Have Declined, Yet the Burden of Disease Remains HighThe 2007 overall death rate from CVD (International Classification of Diseases 10, I00–I99) was 251.2 per 100 000. The rates were 294.0 per 100 000 for white males, 405.9 per 100 000 for black males, 205.7 per 100 000 for white females, and 286.1 per 100 000 for black females. From 1997 to 2007, the death rate from CVD declined 27.8%. Mortality data for 2007 show that CVD (I00–I99; Q20–Q28) accounted for 33.6% (813 804) of all 2 243 712 deaths in 2007, or 1 of every 2.9 deaths in the United States.

Coronary heart disease caused ≈1 of every 6 deaths in the United States in 2007. Coronary heart disease mortality in 2007 was 406 351. Each year, an estimated 785 000 Americans will have a new coronary attack, and ≈470 000 will have a recurrent attack. It is estimated that an additional 195 000 silent first myocardial infarctions occur each year. Approximately every 25 seconds, an American will have a coronary event, and approximately every minute, someone will die of one.

Each year, ≈795 000 people experience a new or recurrent stroke. Approximately 610 000 of these are first attacks, and 185 000 are recurrent attacks. Mortality data from 2007 indicate that stroke accounted for ≈1 of every 18 deaths in the United States. On average, every 40 seconds, someone in the United States has a stroke. From 1997 to 2007, the stroke death rate fell 44.8%, and the actual number of stroke deaths declined 14.7%.

Prevalence and Control of Traditional Risk Factors Remains an Issue for Many AmericansData from the National Health and Nutrition Examination Survey (NHANES) 2005–2008 indicate that 33.5% of US adults ≥20 years of age have hypertension (Table 7-1). This amounts to an estimated 76 400 000 US adults with hypertension. The prevalence of hypertension is nearly equal between men and women. African American adults have among the highest rates of hypertension in the world, at 44%. Among hypertensive adults, ≈80% are aware of their condition, 71% are using antihypertensive medication, and only 48% of those aware that they have hypertension have their condition controlled.

Sources: Prevalence: National Health and Nutrition Examination Survey (2005–2008, National Center for Health Statistics) and National Heart, Lung, and Blood Institute. Percentages for racial/ethnic groups are age-adjusted for Americans ≥20 years of age. Age-specific percentages are extrapolated to the 2008 US population estimates. Mortality: National Center for Health Statistics. These data represent underlying cause of death only. Hospital discharges: National Hospital Discharge Survey, National Center for Health Statistics; data include those discharged alive, dead, or status unknown.

Hypertension is defined in terms of National Health and Nutrition Examination Survey blood pressure measurements and health interviews. A subject was considered hypertensive if systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90, said “yes” to taking antihypertensive medication, or was told on 2 occasions of having hypertension.

Despite 4 decades of progress, in 2008, among Americans ≥18 years of age, 23.1% of men and 18.3% of women continued to be cigarette smokers. In 2009, 19.5% of students in grades 9 through 12 reported current tobacco use. The percentage of the nonsmoking population with detectable serum cotinine (indicating exposure to secondhand smoke) was 46.4% in 1999 to 2004, with declines occurring, and was highest for those 4 to 11 years of age (60.5%) and those 12 to 19 years of age (55.4%).

Prevalence of total cholesterol ≥200 mg/dL includes people with total cholesterol ≥240 mg/dL. In adults, levels of 200 to 239 mg/dL are considered borderline high. Levels of ≥240 mg/dL are considered high.

*Total data for total cholesterol are for Americans ≥20 years of age. Data for LDL cholesterol, HDL cholesterol, and all racial/ethnic groups are age adjusted for age ≥20 years.

Source for total cholesterol ≥200 mg/dL, ≥240 mg/dL, LDL, and HDL: National Health and Nutrition Examination Survey (2005–2008), National Center for Health Statistics, and National Heart, Lung, and Blood Institute. Estimates from National Health and Nutrition Examination Survey 2005–2008 (National Center for Health Statistics) applied to 2008 population estimates.

Sources: Prevalence: Prevalence of diagnosed and undiagnosed diabetes: National Health and Nutrition Examination Survey 2005–2008, National Center for Health Statistics, and National Heart, Lung, and Blood Institute. Percentages for racial/ethnic groups are age-adjusted for Americans ≥20 years of age. Age-specific percentages are extrapolations to the 2008 US population estimates. Incidence: National Institute of Diabetes and Digestive and Kidney Diseases estimates. Mortality: National Center for Health Statistics. These data represent underlying cause of death only. Hospital discharges: National Hospital Discharge Survey, National Center for Health Statistics; data include those inpatients discharged alive, dead, or status unknown.

The 2011 Update Expands Data Coverage of the Obesity Epidemic and Its Antecedents and ConsequencesThe estimated prevalence of overweight and obesity in US adults (≥20 years of age) is 149 300 000, which represents 67.3% of this group in 2008. Fully 33.7% of US adults are obese (body mass index ≥30 kg/m2). Men and women of all race/ethnic groups in the population are affected by the epidemic of overweight and obesity (Table 15-1).

In January 2007, the American Medical Association’s Expert Task Force on Childhood Obesity recommended new definitions for overweight and obesity in children and adolescents (available at http://www.ama-assn.org/ama1/pub/upload/mm/433/ped_obesity_recs.pdf). However, statistics based on this new definition are not yet available.

Sources: age-adjusted National Health and Nutrition Examination Survey 2005–2008 (National Center for Health Statistics), National Heart, Lung, and Blood Institute, and unpublished data. Estimates from National Health and Nutrition Examination Survey 2005–2008 (National Center for Health Statistics) were applied to 2008 population estimates. In children, age-adjusted National Health and Nutrition Examination Survey 2007–2008 data were applied to 2006 population estimates (JAMA. 2010;303:235–241; and JAMA. 2010;303:242–249).

Among children 2 to 19 years of age, 31.9% are overweight and obese (which represents 23 500 000 children), and 16.3% are obese (12 000 000 children). Mexican American boys and girls and African American girls are disproportionately affected. Over the past 3 decades, the prevalence of obesity in children 6 to 11 years of age has increased from ≈4% to more than 20%.

On the basis of NHANES 2003–2006 data, the age-adjusted prevalence of metabolic syndrome, a cluster of major cardiovascular risk factors related to overweight/obesity and insulin resistance, is 34% (35.1% among men and 32.6% among women).

Data from NHANES indicate that between 1971 and 2004, average total energy consumption among US adults increased by 22% in women (from 1542 to 1886 kcal/d) and by 10% in men (from 2450 to 2693 kcal/d; see Chart 19-1).

Age-adjusted trends in macronutrients and total calories consumed by US adults (20 to 74 years of age), 1971–2004. Data derived from National Center for Health Statistics. Health, United States 2007, With Chartbook on Trends in the Health of Americans.

In light of the current national focus on healthcare utilization, costs, and quality, it is critical to monitor and understand the magnitude of healthcare delivery and costs, as well as the quality of healthcare delivery, related to CVDs. The Update provides these critical data in several sections.

Chapter 21 provides data on trends and current usage of cardiovascular surgical and invasive procedures. For example, the total number of inpatient cardiovascular operations and procedures increased 27%, from 5 382 000 in 1997 to 6 846 000 in 2007 (National Heart, Lung, and Blood Institute computation based on National Center for Health Statistics annual data).

Chapter 22 reviews current estimates of direct and indirect healthcare costs related to CVDs, stroke, and related conditions using Medical Expenditure Panel Survey data. The total direct and indirect cost of CVD and stroke in the United States for 2007 is estimated to be $286 billion. This figure includes health expenditures (direct costs, which include the cost of physicians and other professionals, hospital services, prescribed medications, home health care, and other medical durables) and lost productivity resulting from mortality (indirect costs). By comparison, in 2008, the estimated cost of all cancer and benign neoplasms was $228 billion ($93 billion in direct costs, $19 billion in morbidity indirect costs, and $116 billion in mortality indirect costs). CVD costs more than any other diagnostic group.

The AHA, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current data available in the Statistics Update. The 2007 mortality data have been released. More information can be found at the National Center for Health Statistics Web site, http://www.cdc.gov/nchs/data/nvsr/nvsr58/nvsr58_01.pdf.

Finally, it must be noted that this annual Statistical Update is the product of an entire year’s worth of effort by dedicated professionals, volunteer physicians and scientists, and outstanding AHA staff members, without whom publication of this valuable resource would be impossible. Their contributions are gratefully acknowledged.Véronique L. Roger, MD, MPH, FAHA

Note: Population data used in the compilation of NHANES prevalence estimates is for the latest year of the NHANES survey being used. Extrapolations for NHANES prevalence estimates are based on the census resident population for 2008 because this is the most recent year of NHANES data used in the Statistical Update.

The American Heart Association (AHA) works with the Centers for Disease Control and Prevention’s (CDC’s) National Center for Health Statistics (NCHS); the National Heart, Lung, and Blood Institute (NHLBI); the National Institute of Neurological Disorders and Stroke (NINDS); and other government agencies to derive the annual statistics in this Update. This chapter describes the most important sources and the types of data we use from them. For more details, see Chapter 24 of this document, the Glossary.

Prevalence is an estimate of how many people have a disease at a given point or period in time. The NCHS conducts health examination and health interview surveys that provide estimates of the prevalence of diseases and risk factors. In this Update, the health interview part of the NHANES is used for the prevalence of cardiovascular diseases (CVDs). NHANES is used more than the NHIS because in NHANES, angina pectoris (AP) is based on the Rose Questionnaire; estimates are made regularly for heart failure (HF); hypertension is based on blood pressure (BP) measurements and interviews; and an estimate can be made for total CVD, including myocardial infarction (MI), AP, HF, stroke, and hypertension.

A major emphasis of this Update is to present the latest estimates of the number of people in the United States who have specific conditions to provide a realistic estimate of burden. Most estimates based on NHANES prevalence rates are based on data collected from 2005 to 2008 (in most cases, these are the latest published figure). These are applied to census population estimates for 2008. Differences in population estimates based on extrapolations of rates beyond the data collection period by use of more recent census population estimates cannot be used to evaluate possible trends in prevalence. Trends can only be evaluated by comparing prevalence rates estimated from surveys conducted in different years.

The NHANES 2005–2008 data are used in this Update to present estimates of the percentage of people with high lipid values, diabetes mellitus, overweight, and obesity. The NHIS is used for the prevalence of cigarette smoking and physical inactivity. Data for students in grades 9 through 12 are obtained from the YRBSS.

An incidence rate refers to the number of new cases of a disease that develop in a population per unit of time. The unit of time for incidence is not necessarily 1 year, although we often discuss incidence in terms of 1 year. For some statistics, new and recurrent attacks or cases are combined. Our national incidence estimates for the various types of CVD are extrapolations to the US population from the Framingham Heart Study (FHS), the Atherosclerosis Risk in Communities (ARIC) study, and the Cardiovascular Health Study (CHS), all conducted by the NHLBI, as well as the GCNKSS, which is funded by the NINDS. The rates change only when new data are available; they are not computed annually. Do not compare the incidence or the rates with those in past editions of the Heart Disease and Stroke Statistics Update (also known as the Heart and Stroke Statistical Update for editions before 2005). Doing so can lead to serious misinterpretation of time trends.

The first set of statistics for each disease in this Update includes the number of deaths for which the disease is the underlying cause. Two exceptions are Chapter 7 (High Blood Pressure) and Chapter 9 (Heart Failure). High BP, or hypertension, increases the mortality risks of CVD and other diseases, and HF should be selected as an underlying cause only when the true underlying cause is not known. In this Update, hypertension and HF death rates are presented in 2 ways: (1) as nominally classified as the underlying cause and (2) as any-mention mortality.

Prevalence and mortality estimates for the United States or individual states comparing demographic groups or estimates over time either are age specific or are age adjusted to the 2000 standard population by the direct method.

In this Update, we estimate the annual number of new (incidence) and recurrent cases of a disease in the United States by extrapolating to the US population in 2008 from rates reported in a community- or hospital-based study or multiple studies. Age-adjusted incidence rates by sex and race are also given in this report as observed in the study or studies. For US mortality, most numbers and rates are for 2007. For disease and risk factor prevalence, most rates in this report are calculated from the 2005–2008 NHANES. Rates by age and sex are also applied to the US population in 2008 to estimate the numbers of people with the disease or risk factor in that year. Because NHANES is conducted only in the noninstitutionalized population, we extrapolated the rates to the total US population in 2008, recognizing that this probably underestimates the total prevalence, given the relatively high prevalence in the institutionalized population. The numbers and rates of hospital inpatient discharges for the United States are for 2007. Numbers of visits to physician offices, hospital EDs, and hospital OPDs are for 2007. Except as noted, economic cost estimates are for 2007.

For data on hospitalizations, physician office visits, and mortality, CVD is defined according to ICD codes given in Chapter 24 of the present document. This definition includes all diseases of the circulatory system, as well as congenital CVD. Unless so specified, an estimate for total CVD does not include congenital CVD. Prevalence of CVD includes people with hypertension, heart disease, stroke, peripheral artery disease, and diseases of the veins.

Data published by governmental agencies for some racial groups are considered unreliable because of the small sample size in the studies. Because we try to provide data for as many racial groups as possible, we show these data for informational and comparative purposes.

If you have questions about statistics or any points made in this Update, please contact the AHA National Center, Office of Science & Medicine at gro.traeh@scitsitats or 214-706-1423. Direct all media inquiries to News Media Relations at gro.traeh@seiriuqni or 214-706-1173.

We do our utmost to ensure that this Update is error free. If we discover errors after publication, we will provide corrections at our World Wide Web site, http://www.americanheart.org/statistics, and in the journal Circulation.

1. US Census Bureau population estimates. [Accessed September 27, 2010]; Available at: http://www.census.gov/popest/national/asrh/files/NC-EST2008-ALLDATA-R-File14.csv.

4. Anderson RN, Rosenberg HM. Age standardization of death rates: implementation of the year 2000 standard. Natl Vital Stat Rep.1998;47:1–16. 20. [PubMed]

Beginning in 2011, and recognizing the substantial time lag in the nationally representative data sets, the annual Statistical Update will begin to evaluate and publish metrics and information that gives AHA directional insights into progress and/or areas critical for greater concentration, to meet their 2020 goals. In this chapter, baseline data are presented that were derived from the existing national data available on January 20, 2010, the official announcement date of the 2020 Impact Goals.

Among children (Chart 2-1), the prevalence (unadjusted) of ideal levels of cardiovascular health behaviors and factors currently varies from 0% for the healthy diet score (ie, essentially no children meet 4 or 5 of the 5 dietary components) to more than 80% for the smoking and fasting glucose metrics. More than 90% of US children meet 0 or only 1 of the 5 healthy dietary components.

Among US adults (Chart 2-2), the age-standardized prevalence of ideal levels of cardiovascular health behaviors and factors currently varies from 0.2% for the healthy diet score up to 72% for the smoking metric (ie, 72% of US adults have never smoked or are current nonsmokers who have quit for more than 12 months).

Charts 2-4 and 2-5 display the age-standardized prevalence estimates for the population of US adults meeting different numbers of criteria for Ideal Cardiovascular Health (out of 7 possible), overall, and stratified by age groups, sex, and race.

Compared with younger adults, older adults tend to have fewer of the 7 metrics at ideal levels; more than half of those over age 60 years have only 2 or fewer at ideal levels (Chart 2-4).

Age-standardized prevalence estimates of US adults meeting different numbers of criteria for Ideal Cardiovascular Health, overall and by age and sex subgroups, National Health and Nutrition Examination Survey (NHANES) 2005–2006 (baseline available data as of January 1, 2010).

Age-standardized prevalence estimates of US adults meeting different numbers of criteria for Ideal Cardiovascular Health, overall and in selected race subgroups from National Health and Nutrition Examination Survey (NHANES) 2005–2006 (baseline available data as of January 1, 2010).

2. Heron MP, Hoyert DL, Murphy SL, Xu JQ, Kochanek KD, Tejada-Vera B. Deaths: Final Data for 2006. Hyattsville, Md: National Center for Health Statistics; 2009. National Vital Statistics Reports. Vol 57, No 14.

ICD-9 390–459, 745–747, ICD-10 I00 –I99, Q20–Q28; see Glossary (Chapter 24) for details and definitions. See Tables 3-1 through 3-4 and Charts 3-1 through 3-21.

Population GroupPrevalence, 2008 Age ≥20 yMortality, 2007 All Ages*Hospital Discharges, 2007 All AgesCost, 2007Both sexes82 600 000 (36.2%)813 8045 890 000$286.6 Billion

Sources: Prevalence: National Health and Nutrition Examination Survey 2005–2008, National Center for Health Statistics (NCHS) and National Heart, Lung, and Blood Institute (NHLBI). Percentages for racial/ethnic groups are age-adjusted for Americans ≥20 years of age. Age-specific percentages are extrapolated to the 2008 US population estimates. Mortality: NCHS. These data represent underlying cause of death only. Data include congenital cardiovascular disease mortality. Hospital discharges: National Hospital Discharge Survey, NCHS. Data include those inpatients discharged alive, dead, or of unknown status. Cost: NHLBI. Data include estimated direct and indirect costs for 2007.

An estimated 82 600 000 American adults (>1 in 3) have 1 or more types of CVD. Of these, 40 400 000 are estimated to be ≥60 years of age. Total CVD includes diseases listed in the bullet points below, with the exception of congenital CVD. Because of overlap, it is not possible to add these conditions to arrive at a total.High blood pressure (HBP)—76 400 000 (defined as systolic pressure ≥140 mm Hg and/or diastolic pressure ≥90 mm Hg, use of antihypertensive medication, or being told at least twice by a physician or other health professional that one has HBP).

The following age-adjusted prevalence estimates from the NHIS, NCHS are for diagnosed conditions for people ≥18 years of age in 2009Among whites only, 11.9% have heart disease (HD), 6.4% have CHD, 23.0% have hypertension, and 2.5% have had a stroke.

Among American Indians or Alaska Natives, 8.0% have HD, 4.1% (figure considered unreliable) have CHD, and 21.8% have hypertension. An estimate for stroke is not reported because of its large relative standard error.

The average annual rates of first cardiovascular events rise from 3 per 1000 men at 35 to 44 years of age to 74 per 1000 men at 85 to 94 years of age. For women, comparable rates occur 10 years later in life. The gap narrows with advancing age.

Among American Indian men 45 to 74 years of age, the incidence of CVD ranges from 15 to 28 per 1000 population. Among women, it ranges from 9 to 15 per 1000.

Data from the FHS indicate that the subsequent lifetime risk for all CVD in recipients starting free of known disease is 2 in 3 for men and >1 in 2 for women at 40 years of age (personal communication, Donald Lloyd-Jones, MD, Northwestern University, Chicago, Ill) (see Table 3-4).

ICD-10 I00 –I99, Q20–Q28 for CVD (CVD mortality includes congenital cardiovascular defects); C00–C97 for cancer; C33–C34 for lung cancer; C50 for breast cancer; J40–J47 for chronic lower respiratory disease (CLRD); G30 for Alzheimer disease; E10–E14 for diabetes mellitus (DM); and V01–X59, Y85–Y86 for accidents.Mortality data show that CVD (I00 –I99, Q20–Q28) as the underlying cause of death (including congenital cardiovascular defects) accounted for 33.6% (813 804) of all 2 423 712 deaths in 2007, or 1 of every 3 deaths in the United States. CVD any-mentions (1 342 314 deaths in 2007) constituted 55.4% of all deaths that year (NHLBI; NCHS public-use data files).

The 2007 overall death rate due to CVD (I00 –I99) was 251.2. The rates were 294.0 for white males, 405.9 for black males, 205.7 for white females, and 286.1 for black females. From 1997 to 2007, death rates due to CVD (ICD-10 I00 –I99) declined 27.8%. In the same 10-year period, the actual number of CVD deaths per year declined 14.2% (NHLBI tabulation).

The 2007 CVD (I00 –I99) death rates were 300.3 for males and 211.6 for females. Death rates for cancer (malignant neoplasms) were 217.5 for males and 151.3 for females. Breast cancer claimed the lives of 40 599 females in 2007; lung cancer claimed 70 388. Death rates for females were 22.9 for breast cancer and 40.0 for lung cancer. One in 30 deaths in females was due to breast cancer, whereas 1 in 6.4 was due to CHD. For comparison, 1 in 4.5 females died of cancer, whereas 1 in 2.9 died of CVD (I00 –I99, Q20–Q28). On the basis of 2007 mortality data, CVD caused ≈1 death per minute among females, or 421 918 deaths in females in 2007. That represents more female lives than were claimed by cancer, CLRD, Alzheimer disease, and accidents combined (unpublished NHLBI tabulation).

According to the NCHS, if all forms of major CVD were eliminated, life expectancy would rise by almost 7 years. If all forms of cancer were eliminated, the estimated gain would be 3 years. According to the same study, the probability at birth of eventually dying of major CVD (I00 –I78) is 47%, and the chance of dying of cancer is 22%. Additional probabilities are 3% for accidents, 2% for DM, and 0.7% for HIV.

In 2007, the leading causes of death in women ≥65 years of age were diseases of the heart (No. 1), cancer (No. 2), stroke (No. 3), and CLRD (No. 4). In older men, they were diseases of the heart (No. 1), cancer (No. 2), CLRD (No. 3), and stroke (No. 4).

A study of the decrease in US deaths due to CHD from 1980 to 2000 suggests that ≈47% of the decrease was attributable to increased use of evidence-based medical therapies and 44% to changes in risk factors in the population due to lifestyle and environmental changes.

Analysis of data from NCHS was used to determine the number of disease-specific deaths attributable to all non-optimal levels of each risk factor exposure, by age and sex. In 2005, tobacco smoking and high BP were estimated to be responsible for 467 000 deaths, accounting for ≈1 in 5 or 6 deaths among US adults. Overweight/obesity and physical inactivity were each estimated to be responsible for nearly 1 in 10 deaths. High dietary salt, low dietary omega-3 fatty acids, and high dietary trans fatty acids were the dietary risks with the largest estimated mortality effects.

AftermathAmong an estimated 45 million people with functional disabilities in the United States, HD, stroke, and hypertension are among the 15 leading conditions that caused those disabilities. Disabilities were defined as difficulty with activities of daily living or instrumental activities of daily living, specific functional limitations (except vision, hearing, or speech), and limitation in ability to do housework or work at a job or business.

Most sudden deaths in athletes were attributable to CVD (56%). Of the cardiovascular deaths that occurred, 29% occurred in blacks, 54% in high school students, and 82% with physical exertion during competition/training, and only 11% occurred in females, although this proportion has increased over time.

A total of 875 students in 4 Michigan high schools were given a survey to obtain data on the perception of risk factors and other knowledge-based assessment questions about CVD. Accidents were rated as the greatest perceived lifetime health risk (39%). Nearly 17% selected CVD as the greatest lifetime risk, which made it the third most popular choice after accidents and cancer. When asked to identify the greatest cause of death for each sex, 42% correctly recognized CVD for men, and 14% correctly recognized CVD for women; 40% incorrectly chose abuse/use behavior with a substance other than cigarettes as the most important CVD risk behavior.

Risk FactorsData from the 2003 CDC BRFSS survey of adults ≥18 years of age showed the prevalence of respondents who reported having ≥2 risk factors for HD and stroke was successively higher at higher age groups. The prevalence of having ≥2 risk factors was highest among blacks (48.7%) and American Indians/Alaska Natives (46.7%) and lowest among Asians (25.9%); prevalence was similar in women (36.4%) and men (37.8%). The prevalence of multiple risk factors ranged from 25.9% among college graduates to 52.5% among those with less than a high school diploma (or its equivalent). People reporting household income of ≥$50 000 had the lowest prevalence (28.8%), and those reporting household income of $10 000 had the highest prevalence (52.5%). Adults who reported being unable to work had the highest prevalence (69.3%) of ≥2 risk factors, followed by retired people (45.1%), unemployed adults (43.4%), homemakers (34.3%), and employed people (34.0%). Prevalence of ≥2 risk factors varied by state/territory and ranged from 27.0% (Hawaii) to 46.2% (Kentucky). Twelve states and 2 territories had a multiple-risk-factor prevalence of ≥40%: Alabama, Arkansas, Georgia, Indiana, Kentucky, Louisiana, Mississippi, North Carolina, Ohio, Oklahoma, Tennessee, West Virginia, Guam, and Puerto Rico.

Data from the Chicago Heart Association Detection Project (1967 to 1973, with an average follow-up of 31 years) showed that in younger women (18 to 39 years of age) with favorable levels for all 5 major risk factors (BP, serum cholesterol, body mass index [BMI], DM, and smoking), future incidence of CHD and CVD is rare, and long-term and all-cause mortality are much lower than for those who have unfavorable or elevated risk factor levels at young ages. Similar findings applied to men in this study.

Analysis of several data sets by the CDC showed that in adults ≥18 years of age, disparities were common in all risk factors examined. In men, the highest prevalence of obesity (29.7%) was found in Mexican Americans who had completed a high school education. Black women with or without a high school education had a high prevalence of obesity (48.4%). Hypertension prevalence was high among blacks (41.2%) regardless of sex or educational status. Hypercholesterolemia was high among white and Mexican American men and white women regardless of educational status. CHD and stroke were inversely related to education, income, and poverty status. Hospitalization for total HD and acute MI was greater among men, but hospitalization for congestive heart failure (CHF) and stroke was greater among women. Among Medicare enrollees, CHF hospitalization was higher in blacks, Hispanics, and American Indians/Alaska Natives than among whites, and stroke hospitalization was highest in blacks. Hospitalizations for CHF and stroke were highest in the southeastern United States. Life expectancy remains higher in women than in men and in whites than in blacks by ≈5 years. CVD mortality at all ages tended to be highest in blacks.

Analysis of 5 cross-sectional, nationally representative surveys from the National Health Examination Survey (NHES) 1960–1962 to the NHANES 1999–2000 showed that the prevalence of key risk factors (ie, high cholesterol, HBP, current smoking, and total DM) decreased over time across all BMI groups, with the greatest reductions observed among overweight and obese groups. Total DM prevalence was stable within BMI groups over time; however, the trend has leveled off or been reversed for some of the risk factors in more recent years.

Data from BRFSS 2006–2008 demonstrated that during this 3-year period, 25.6% of non-Hispanic blacks, non-Hispanic whites, and Hispanics were obese, but prevalent obesity varied across groups: 35.7% for non-Hispanic blacks, 28.7% for Hispanics, and 23.7% for non-Hispanic whites.

Analysis of >14 000 middle-aged subjects in the ARIC study sponsored by the NHLBI showed that >90% of CVD events in black subjects, compared with ≈70% in white subjects, appeared to be explained by elevated or borderline risk factors. Furthermore, the prevalence of participants with elevated risk factors was higher in black subjects; after accounting for education and known CVD risk factors, the incidence of CVD was identical in black and white subjects. Thus, the observed higher CVD incidence rate in black subjects appears to be largely attributable to a greater prevalence of elevated risk factors. These results suggest that the primary prevention of elevated risk factors might substantially impact the future incidence of CVD, and these beneficial effects would likely be applicable not only for white but also for black subjects.

Data from the MEPS 2004 Full-Year Data File showed that nearly 26 million US adults ≥18 years of age were told by a doctor that they had HD, stroke, or any other heart-related disease—

56.6% of those surveyed said they engaged in moderate-to-vigorous PA 3 times per week; 57.9% of those surveyed who had not been told they had HD engaged in regular PA, more than those who had been told they had HD (46.3%).

Moderate to vigorous PA ≥3 times per week varied according to age. Younger people (18 to 44 years of age) were more likely (59.9%) than those who were older (45 to 64 and ≥65 years of age, 55.3% and 48.5%, respectively) to engage in regular PA.

A greater percentage of those 18 to 44 years of age had a healthy weight (43.7%) than did those 45 to 64 years of age and ≥65 years of age (31.4% and 37.3%, respectively).

People ≥65 years of age were more likely to be current nonsmokers (89.7%) than were people 18 to 44 years of age and 45 to 64 years of age (76.1% and 77.7%, respectively).

Non-Hispanic whites were more likely than Hispanics or non-Hispanic blacks to engage in moderate-to-vigorous PA (58.5% versus 51.4% and 52.5%, respectively).

A greater percentage of adults with at least some college education engaged in moderate-to-vigorous PA ≥3 times per week (60.8%) than did those with a high school education or less than a high school education (55.3% and 48.3%, respectively).

A greater percentage of adults with at least some college education had a healthy weight (41.2%) than did those with a high school or less than high school education (36.2% and 36.1%, respectively).

Participants (18 to 64 years of age at baseline) in the Chicago Heart Association Detection Project in Industry without a history of MI were investigated to determine whether traditional CVD risk factors were similarly associated with CVD mortality in black and white men and women. In general, the magnitude and direction of associations were similar by race. Most traditional risk factors demonstrated similar associations with mortality in black and white adults of the same sex. Small differences were primarily in the strength and not the direction of the association.

The 2004 HealthStyles survey of 4345 people in the United States indicated that most respondents believe that knowing their family history is important for their own health, but few are aware of the specific health information from relatives necessary to develop a family history.

Much of the literature on CVD has focused on factors associated with increasing risk for CVD and on factors associated with poorer outcomes in the presence of CVD; however, in recent years, a number of studies have defined the potential beneficial effects of healthy lifestyle factors and lower CVD risk factor burden on CVD outcomes and longevity. These studies suggest that prevention of risk factor development at younger ages may be the key to “successful aging,” and they highlight the need for intensive prevention efforts at younger and middle ages once risk factors develop to increase the likelihood of healthy longevity.The lifetime risk for CVD and median survival were highly associated with risk factor presence and burden at 50 years of age among >7900 men and women from the FHS followed up for 111 000 person-years. In this study, optimal risk factor burden at 50 years of age was defined as BP <120/ 80 mm Hg, total cholesterol <180 mg/dL, absence of DM, and absence of smoking. Elevated risk factors were defined as stage 1 hypertension or borderline high cholesterol (200 to 239 mg/dL). Major risk factors were defined as stage 2 hypertension, elevated cholesterol (≥240 mg/dL), current smoking, and DM. Remaining lifetime risks for atherosclerotic CVD events were only 5.2% in men and 8.2% in women with optimal risk factors at 50 years of age compared with 68.9% in men and 50.2% in women with ≥2 major risk factors at age 50. In addition, men and women with optimal risk factors had a median life expectancy ≥10 years longer than those with ≥2 major risk factors at age 50 years.

A recent study examined the association between low lifetime predicted risk for CVD (ie, having all optimal or near-optimal risk factor levels) and burden of subclinical atherosclerosis in younger adults in the Coronary Artery Risk Development in Young Adults (CARDIA) and MESA studies of the NHLBI. Among participants <50 years of age, nearly half had low and half had high predicted lifetime risks for CVD. Those with low predicted lifetime risk had lower prevalence and less severe amounts of coronary calcification and less carotid intima-media thickening, even at these younger ages, than those with high predicted lifetime risk. During follow-up, those with low predicted lifetime risk also had less progression of coronary calcium.

In another study, FHS investigators followed up 2531 men and women who were examined between the ages of 40 and 50 years and observed their overall rates of survival and survival free of CVD to 85 years of age and beyond. Low levels of the major risk factors in middle age was associated with overall survival and morbidity-free survival to 85 years of age or more.—

A study of 366 000 men and women from the Multiple Risk Factor Intervention Trial (MRFIT) and Chicago Heart Association Detection Project in Industry defined low-risk status as follows: serum cholesterol level <200 mg/dL, untreated BP 120/80 mm Hg, absence of current smoking, absence of DM, and absence of major electrocardiographic abnormalities. Compared with those who did not have low risk factor burden, those with low risk factor burden had between 73% and 85% lower relative risk (RR) for CVD mortality, 40% to 60% lower relative total mortality rates, and 6 to 10 years’ longer life expectancy.

A study of 84 129 women enrolled in the Nurses’ Health Study identified 5 healthy lifestyle factors, including absence of current smoking, drinking half a glass or more of wine per day (or equivalent alcohol consumption), half an hour or more per day of moderate or vigorous PA, BMI <25 kg/m2, and dietary score in the top 40% (which included diets with lower amounts of trans fats, lower glycemic load, higher cereal fiber, higher marine omega-3 fatty acids, higher folate, and higher polyunsaturated to saturated fat ratio). When 3 of the 5 healthy lifestyle factors were present, the RR for CHD over a 14-year period was 57% lower; when 4 were present, RR was 66% lower; and when all 5 factors were present, RR was 83% lower.

In the Chicago Heart Association Detection Project in Industry, remaining lifetime risks for CVD death were noted to increase substantially and in a graded fashion according to the number of risk factors present in middle age (40 to 59 years of age). However, remaining lifetime risks for non-CVD death also increased dramatically with increasing CVD risk factor burden. These data help to explain the markedly greater longevity experienced by those who reach middle age free of major CVD risk factors.

Seventeen-year mortality data from the NHANES II Mortality Follow-Up Study indicated that the RR for fatal CHD was 51% lower for men and 71% lower for women with none of 3 major risk factors (hypertension, current smoking, and elevated total cholesterol [≥ 240 mg/dL]) than for those with 1 or more risk factors. Had all 3 major risk factors not occurred, it is hypothesized that 64% of all CHD deaths among women and 45% of CHD deaths in men could have been avoided.

Investigators from the Chicago Heart Association Detection Project in Industry have also observed that risk factor burden in middle age is associated with better quality of life at follow-up in older age (≈25 years later) and lower average annual Medicare costs at older ages.

In 2004, coronary atherosclerosis was estimated to be responsible for 1.2 million hospital stays and was the most expensive condition treated. This condition resulted in >$44 billion in expenses. More than half of the hospital stays for coronary atherosclerosis were among patients who also received percutaneous coronary intervention or cardiac revascularization (coronary artery bypass graft; CABG) during their stay. Acute MI resulted in $31 billion of inpatient hospital charges for 695 000 hospital stays. The 1.1 million hospitalizations for CHF amounted to nearly $29 billion in hospital charges.

In 2003, ≈48.3% of inpatient hospital stays for CVD were for women, who accounted for 42.8% of the national cost ($187 billion) associated with these conditions. Although only 40% of hospital stays for acute MI and coronary atherosclerosis were for women, more than half of all stays for nonspecific chest pain, CHF, and stroke were for women. There was no difference between men and women in hospitalizations for cardiac dysrhythmias.

In 2004, nursing home residents had a primary diagnosis of CVD at admission (23.7%) and at the time of interview (25%). This was the leading primary diagnosis for these residents (NCHS, NNHS).

Operations and ProceduresIn 2007, an estimated 6 846 000 inpatient cardiovascular operations and procedures were performed in the United States; 3.9 million were performed on males, and 2.9 million were performed on females (NHDS, NCHS, and NHLBI).

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Annual number of adults having diagnosed heart attack or fatal coronary heart disease (CHD) by age and sex (Atherosclerosis Risk in Communities Surveillance: 1987–2004 and Cardiovascular Health Study: 1989–2004). These data include myocardial infarction (MI) and fatal coronary heart disease but not silent MI. Source: National Heart, Lung, and Blood Institute.

Atherosclerosis, a systemic disease process in which fatty deposits, inflammation, cells, and scar tissue build up within the walls of arteries, is the underlying cause of the majority of clinical cardiovascular events. Individuals who develop atherosclerosis tend to develop it in a number of different types of arteries (large and small arteries and those feeding the heart, brain, kidneys, and extremities), although they may have much more in some artery types than others. In recent decades, advances in imaging technology have allowed for improved ability to detect and quantify atherosclerosis at all stages and in multiple different vascular beds. Two modalities, computed tomography (CT) of the chest for evaluation of coronary artery calcification (CAC) and B-mode ultrasound of the neck for evaluation of carotid artery intima-media thickness (IMT), have been used in large studies with outcomes data and may help define the burden of atherosclerosis in individuals before they develop clinical events such as heart attack or stroke. Another commonly used method for detecting and quantifying atherosclerosis in the peripheral arteries is the ankle-brachial index, which is discussed in Chapter 10. Data on cardiovascular outcomes are starting to emerge for additional modalities for measuring subclinical disease, including brachial artery reactivity testing, aortic and carotid magnetic resonance imaging (MRI), and tonometric methods of measuring vascular compliance or microvascular reactivity. Further research may help to define the role of these techniques in cardiovascular risk assessment. Some guidelines have recommended screening for subclinical atherosclerosis, especially by CAC, or IMT may be appropriate in people at intermediate risk for heart disease (eg, 10-year estimated risk of 10% to 20%) but not for lower-risk general population screening or for people with preexisting HD, DM, or other high-risk conditions.

BackgroundCAC is a measure of the burden of atherosclerosis in the heart arteries and is measured by CT. Other parts of the atherosclerotic plaque, including fatty (eg, cholesterol-rich components) and fibrotic components, often accompany CAC and may be present even in the absence of CAC.

The presence of any CAC, which indicates that at least some atherosclerotic plaque is present, is defined by an Agatston score >0. Clinically significant plaque, frequently an indication for more aggressive risk factor management, is often defined by a score ≥100 or a score ≥75th percentile for one’s age and sex. A score ≥400 has been noted to be an indication for further diagnostic evaluation (eg, exercise testing or myocardial perfusion imaging) for coronary artery disease (CAD).

The NHLBI’s Coronary Artery Risk Development in Young Adults (CARDIA) study measured CAC in 3043 black and white adults 33 to 45 years of age (at the CARDIA year 15 examination).—

Overall, 15.0% of men and 5.1% of women, 5.5% of those 33 to 39 years of age and 13.3% of those 40 to 45 years of age, had prevalent CAC. Overall, 1.6% of subjects had a score that exceeded 100.

Chart 4-1 shows the prevalence of CAC by ethnicity and sex. The prevalence of CAC was lower in black men than in white men but was similar in black and white women at these ages.

The NHLBI’s MESA study measured CAC in 6814 subjects 45 to 84 years of age, including white (n = 2619), black (n = 1898), Hispanic (n = 1494), and Chinese (n = 803) men and women.—

Prevalence (%) of coronary calcium: US adults 45 to 84 years of age. P<0.0001 across ethnic groups in both men and women. Data derived from Bild et al.

Table 4-1 shows the 75th percentile levels of CAC by sex and race at selected ages. These might be considered cut points above which more aggressive efforts to control risk factors (eg, elevated cholesterol or BP) could be implemented and/or at which treatment goals might be more aggressive (eg, LDL cholesterol <100 mg/dL instead of <130 mg/dL).

CAC and Incidence of Coronary EventsThe NHLBI’s MESA study recently reported on the association of CAC scores with first CHD events over a median follow-up of 3.9 years among a population-based sample of 6722 men and women (39% white, 27% black, 22% Hispanic, and 12% Chinese).—

Chart 4-3 shows the relative risks (RRs) or hazard ratios (HRs) associated with CAC scores of 1 to 100, 101 to 300, and >300 compared with those without CAC (score=0), after adjustment for standard risk factors. People with CAC scores of 1 to 100 had ≈4 times greater risk and those with CAC scores >100 were 7 to 10 times more likely to experience a coronary event than those without CAC.

Hazard ratios for coronary heart disease (CHD) events associated with coronary calcium scores: US adults 45 to 84 years of age (reference group coronary artery calcification = 0). All hazard ratios P<0.0001. Major CHD events included myocardial infarction and death due to CHD; any CHD events included major CHD events plus definite angina or definite or probable angina followed by revascularization. Data derived from Detrano et al.

In another report of a community-based sample, not referred for clinical reasons, the South Bay Heart Watch examined CAC in 1461 adults (average age 66 years) with coronary risk factors, with a median of 7.0 years of follow-up.

Chart 4-4 shows the HRs associated with increasing CAC scores (relative to CAC=0 and <10% risk category) in low-risk (<10%), intermediate-risk (10% to 15% and 16% to 20%), and high-risk (>20%) Framingham Risk Score (FRS) categories of estimated risk for CHD in 10 years. Increasing CAC scores further predicted risk in intermediate- and high-risk groups.

Hazard ratios for coronary heart disease events associated with coronary calcium scores: US adults (reference group coronary artery calcification (CAC) = 0 and Framingham Risk Score <10%). Coronary heart disease events included nonfatal myocardial infarction and death due to coronary heart disease. Data derived from Greenland et al.

It is noteworthy that, as recently demonstrated in the MESA study in 5878 subjects with a median of 5.8 years of follow-up, the addition of CAC to standard risk factors resulted in significant improvement of classification of risk for incident CHD events, placing 77% of people in the highest or lowest risk categories compared with 69% based on risk factors alone. Moreover, an additional 23% of those who experienced events were reclassified as high risk and 13% with events were reclassified as low risk.

BackgroundCarotid IMT measures the thickness of 2 layers (the intima and media) of the wall of the carotid arteries, the largest conduits of blood going to the brain. Carotid IMT is thought to be an even earlier manifestation of atherosclerosis than CAC, because thickening precedes the development of frank atherosclerotic plaque. Carotid IMT methods are still being refined, so it is important to know which part of the artery was measured (common carotid, internal carotid, or bulb) and whether near and far walls were both measured. This information can affect the average-thickness measurement that is usually re