We examined the burden of cardiovascular disease (CVD) and its associated risk factors using statewide representative data from the Pennsylvania Behavior Risk Factors Surveillance System. The data from 35,576 subjects aged ≥18 years participating in the Pennsylvania Behavior Risk Factors Surveillance System in 2005, 2007, and 2009 were analyzed. The age-adjusted prevalence rates of CVD were computed. Logistic regression analysis was applied to examine associations between the risk factors and CVD prevalence, with adjustment for confounding variables. The results showed that no significant changes in the prevalence of CVD, coronary heart disease, and stroke were observed in either European Americans or African Americans from 2005 to 2009 (p >0.05). African Americans had significantly greater CVD rates than European Americans. Although smoking rates significantly decreased, several other CVD risk factors (i.e., obesity, hypertension, and hypercholesterolemia) significantly increased from 2005 to 2009 in European Americans. Similar changes were observed in African Americans, although these changes did not reach statistical significance. Logistic regression analysis indicated that African Americans had a 35% greater risk of CVD. Education level less than high school, smoking, obesity, hypertension, and diabetes were significantly and positively associated with CVD. In conclusion, no significant achievements in CVD control and risk factor reduction were observed from 2005 to 2009 in Pennsylvania. Additional aggressive control of hypertension, obesity, and diabetes for both European and African Americans must be made to reduce the burden of CVD.
Cardiovascular diseases (CVDs), including the major forms of coronary heart disease (CHD) and stroke, are the leading causes of death and contribute to 1 in 3 (approximately 800,000) deaths annually in the United States. Although a number of studies have examined CVD prevalence and outcomes, few have addressed the current burden of CVD and risk factors. The state of Pennsylvania has an average CVD prevalence similar to that of the United States (age-adjusted rate 7.41% in Pennsylvania and 7.39% in the United States in 2009). However, Pennsylvania might face a greater challenge in CVD control because of limited financial support and research capacity. Furthermore, a detailed analysis using large-scale population data to address these serious prevention and public health issues is lacking. Thus, we examined the CVD prevalence and associated risk factors using the data from the statewide population-based surveys for 2005, 2007, and 2009 in the Behavior Risk Factor Surveillance System (BRFSS). We hypothesized that no significant decreases would have occurred in the CVD prevalence rates in previous years and that several preventable risk factors are significantly associated with CVD prevalence.
Methods
The BRFSS is an ongoing, nationally comparative, state-based, and random-digit–dialed telephone surveillance supported by the Centers for Disease Control and Prevention. Using a cross-sectional study design, the BRFSS annually collects information on population health conditions and health behaviors. It is conducted using a probability sample of noninstitutionalized adults aged ≥18 years. This surveillance system is the only available source of timely, accurate data on health-related behaviors and conditions covering a statewide sample from across all of Pennsylvania. The survey instruments consist of a set of a core and state-specific modules, including questions regarding demographic information, lifestyle behaviors, and major chronic conditions. Self-reported health conditions that were professionally diagnosed (i.e., myocardial infarction, angina, coronary heart disease, stroke, prehypertension, hypertension, prediabetes, diabetes mellitus [DM], and hypercholesterolemia) are assessed in the BRFSS. In the present study, we used data from the 2005, 2007, and 2009 BRFSS, because data on CVD prevalence were collected only in odd years in Pennsylvania, and the sample sizes were large enough since the 2005 BRFSS surveys. A detailed description of the survey design and methods has been previously presented.
The prevalence of CVD was defined from 3 structured questions. They included (1) “Has a doctor, nurse, or other health professional ever told you that you had angina or coronary heart disease?”, (2) “Has a doctor, nurse, or other health professional ever told you that you had a heart attack, also called a myocardial infarction?”, and (3) “Has a doctor, nurse, or other health professional ever told you that you had a stroke?” In the present study, CVD was defined to be present if a participant self-reported any of these 3 conditions. The validity of self-reported health conditions has been supported by several studies and confirmed to have a substantial agreement between surveys and medical record reports. The final sample size was 35,576 ( Table 1 ).
| Variable | 2005 (n = 13,378) | 2007 (n = 13,117) | 2009 (n = 9,081) | p Value |
|---|---|---|---|---|
| Age (y) | 47.25 ± 0.26 | 47.77 ± 0.33 | 47.94 ± 0.31 | 0.276 |
| Men (%) | 47.63 ± 0.68 | 47.81 ± 0.82 | 48.04 ± 0.79 | 0.925 |
| Race/ethnicity (%) | 0.289 | |||
| European American | 84.57 ± 0.58 | 83.51 ± 0.73 | 83.12 ± 0.75 | |
| African American | 7.86 ± 0.43 | 8.13 ± 0.50 | 8.89 ± 0.56 | |
| Other | 7.58 ± 0.45 | 8.35 ± 0.62 | 7.99 ± 0.58 | |
| CVD ∗ | 8.82 ± 0.34 | 9.31 ± 0.43 | 8.61 ± 0.33 | 0.663 |
| CHD ∗ | 7.10 ± 0.31 | 7.38 ± 0.39 | 7.03 ± 0.30 | 0.867 |
| Stroke ∗ | 2.47 ± 0.17 | 3.29 ± 0.30 | 2.43 ± 0.17 | 0.874 |
Eight major CVD risk factors were studied in the present study: hypertension, DM, high total cholesterol, smoking status, educational attainment, physical activity, weight, and race/ethnicity. Hypertension was defined as those who self-reported a physician diagnosis of hypertension. Women who had had hypertension or who had been told they had borderline high blood pressure or prehypertension only during pregnancy were excluded (n = 131 in 2005, n = 93 in 2007, and n = 51 in 2009). DM was defined as those who self-reported a physician diagnosis of DM. Women who had had DM only during pregnancy and those who had been told they had borderline DM or pre-DM were excluded (n = 120 in 2005, n = 99 in 2007, and n = 62 in 2009). High total cholesterol was defined as those who self-reported a physician diagnosis of high total cholesterol (i.e., hypercholesterolemia). Smoking status was categorized as ever smoking versus never smoking. Educational attainment was categorized as less than high school, completion of high school, attendance without completion at college or technical school, and completion of college or technical school. Physical activity was categorized as those who met the Centers for Disease Control and Prevention’s recommended physical activity level, those with some activity but who did not meet the recommended levels, and those with no physical activity at all. The recommended level has been defined as moderate physical activity for ≥30 min/day, ≥5 days/week, or vigorous, intensive activity for ≥20 min/day, ≥3 days/wk. Those who did not meet the recommendation were those who did >10 minutes total each week of moderate or vigorous, intensive lifestyle activities (i.e., household, transportation, or leisure time activity) but less than the recommended level of activity. No physical activity was defined as those with <10 minutes total each week of moderate or vigorous, intensity lifestyle activities. Participants considered overweight were those with a body mass index of 25–29.9 kg/m 2 and those considered obese, those with a body mass index of ≥30 kg/m 2 . We focused on the comparison between European Americans and African Americans, because the sample size for Hispanic or other ethnicities was small (n = 660 in 2005, n = 593 in 2007, and n = 337 in 2009).
Statistical analysis
In the first set of analyses, we calculated the crude rates of CVD, CHD, and stroke by survey years. In the second set of analyses, the age-adjusted prevalence rates of CVD, CHD, and stroke by race/ethnicity and survey years were computed using the United States 2000 standard population. The trends of the rates of CVD and its associated risk factors were tested using logistic regression analysis. Finally, we estimated the associations between CVD risk factors and the presence of CVD using multivariate logistic regression analysis to estimate the age- and gender-adjusted odds ratios (ORs) and 95% confidence intervals (CIs) (model 1) and age-, gender-, and race-adjusted ORs and 95% CIs of risk factors for CVD (model 2). In the final analysis, we combined all 3 years of survey data to increase the statistical power when performing multivariate modeling.
All statistical analysis was performed using the Statistical Analysis System, version 9.2 (SAS Institute, Cary, North Carolina). Because the BRFSS surveys applied multistage and complex study designs in the data collection stages, the SAS analysis procedures for complex sample surveys were used to produce weighted estimates and sampling errors.
Results
No significant changes were found in the proportions of age, gender, and race and the crude prevalence of CVD from 2005 to 2009 ( Table 1 ). Similarly, no significant change was seen in the age-adjusted prevalence rates of CVD ( Table 2 ). In the combined-race group, changes in stroke rates were significant, with a difficult-to-interpret increase in 2007 and then a decrease in 2009, with a final rate similar to that in 2005. African Americans had significantly greater age-adjusted rates of CVD than European Americans (p <0.001) in 2005 (10.09% vs 7.49%), 2007 (13.80% vs 7.38%) and 2009 (8.89% vs 7.15%). Figure 1 shows that the prevalence of CVD increased at a younger age in African Americans than in European Americans.
| Variable | 2005 | 2007 | 2009 | Difference (from 2009 to 2005) | p Value ∗ |
|---|---|---|---|---|---|
| Age-adjusted rate | |||||
| Cardiovascular disease | 7.86 ± 0.67 | 8.29 ± 0.95 | 7.41 ± 0.60 | −0.45% | 0.346 |
| Coronary heart disease | 6.31 ± 0.61 | 6.56 ± 0.88 | 6.03 ± 0.55 | −0.28% | 0.709 |
| Stroke | 2.20 ± 0.34 | 2.96 ± 0.61 | 2.11 ± 0.34 | −0.09% | 0.015 |
| European American | |||||
| Cardiovascular disease | 7.49 ± 0.64 | 7.38 ± 0.68 | 7.15 ± 0.60 | −0.34% | 0.849 |
| Coronary heart disease | 6.07 ± 0.58 | 5.97 ± 0.62 | 5.86 ± 0.55 | −0.21% | 0.952 |
| Stroke | 2.06 ± 0.35 | 2.33 ± 0.41 | 1.97 ± 0.33 | −0.09 % | 0.251 |
| African American | |||||
| Cardiovascular disease | 10.09 ± 2.50 | 13.80 ± 4.54 | 8.89 ± 2.77 | −1.20% | 0.078 |
| Coronary heart disease | 6.75 ± 2.03 | 9.29 ± 3.63 | 6.62 ± 2.37 | −0.13% | 0.300 |
| Stroke | 4.35 ± 1.83 | 5.96 ± 3.05 | 3.22 ± 1.56 | −1.13% | 0.221 |
| Cardiovascular disease risk factors | |||||
| European American | |||||
| Education less than high school | 8.73 ± 0.42 | 7.15 ± 0.44 | 6.89 ± 0.42 | −1.84% | 0.003 |
| Current smoking | 22.44 ± 0.61 | 20.44 ± 0.70 | 19.52 ± 0.67 | −2.92% | 0.003 |
| Physical activity | |||||
| Did not meet recommended level | 38.58 ± 0.71 | 37.21 ± 0.82 | 38.20 ± 0.80 | −0.38% | 0.461 |
| No physical activity | 11.55 ± 0.44 | 12.16 ± 0.54 | 10.96 ± 0.47 | −0.59% | 0.296 |
| Overweight † | 37.25 ± 0.69 | 35.52 ± 0.80 | 36.14 ± 0.77 | −1.11% | 0.782 |
| Obesity † | 24.39 ± 0.60 | 27.22 ± 0.73 | 27.34 ± 0.71 | 2.95% | 0.005 |
| High total cholesterol | 37.96 ± 0.71 | 40.31 ± 0.80 | 39.93 ± 0.77 | 1.97% | 0.040 |
| Hypertension | 27.46 ± 0.59 | 28.02 ± 0.67 | 32.64 ± 0.70 | 5.18% | <0.001 |
| Diabetes | 7.87 ± 0.34 | 7.82 ± 0.35 | 8.69 ± 0.36 | 0.82% | 0.201 |
| African American | |||||
| Education less than high school | 13.60 ± 2.10 | 11.63 ± 1.90 | 12.46 ± 2.07 | −1.14% | 0.752 |
| Current smoking | 30.85 ± 2.84 | 27.61 ± 3.04 | 29.30 ± 3.20 | −1.55% | 0.061 |
| Physical activity | |||||
| Did not meet recommended level | 36.70 ± 2.83 | 41.32 ± 3.51 | 34.65 ± 3.30 | −2.05% | 0.496 |
| No physical activity | 20.76 ± 2.46 | 16.52 ± 2.13 | 19.71 ± 2.78 | −1.05% | 0.521 |
| Overweight † | 36.24 ± 2.85 | 33.87 ± 3.11 | 36.33 ± 3.45 | 0.09% | 0.883 |
| Obesity † | 34.31 ± 2.77 | 38.05 ± 3.14 | 36.93 ± 3.19 | 2.62% | 0.781 |
| High total cholesterol | 27.31 ± 2.65 | 37.17 ± 3.46 | 33.61 ± 3.05 | 6.30% | 0.057 |
| Hypertension | 34.98 ± 2.68 | 43.93 ± 3.26 | 38.19 ± 3.14 | 3.21% | 0.141 |
| Diabetes mellitus | 11.51 ± 1.48 | 15.51 ± 2.36 | 15.83 ± 2.13 | 4.32% | 0.166 |
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