Key Points
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Cardiovascular disease (CVD) is the leading cause of death in the United States and other countries, accounting for more than half of all deaths. The burden of CVD is increasing among developing countries.
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About one third of U.S. residents have some form of CVD, and the economic cost of CVD in the United States exceeds $475 billion annually.
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CVD morbidity rates, mortality rates, and risk factors vary geographically in the United States and internationally, according to evidence from World Health Organization Multinational Monitoring of Trends and Determinants in Cardiovascular Disease (WHO-MONICA).
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CVD mortality rates have been declining substantially in most countries, whereas they have risen in Eastern European and Asian nations.
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CVD risk factors such as hypertension, hypercholesterolemia, cigarette smoking, obesity, and diabetes are very common in adult populations in the United States and around the world. Some of these risk factors are also increasing among children and adolescents.
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Many CVD risk factors have been declining, in accordance with improved awareness and medical care for these conditions, whereas other risk factors, such as physical inactivity, obesity, and diabetes, are rapidly increasing.
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Primary and secondary prevention strategies by the medical care system in the United States and other developed countries have contributed to the decline in CVD mortality rates. A particular area of concern for the future is congestive heart failure.
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Future projections indicate that CVD will be the leading cause of death in both developed and developing regions of the world by the year 2020.
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In Western developed countries, specific steps should be taken to deal with the existing high burden of CVD. Primordial prevention should be emphasized, including increased physical activity, the promotion of a heart healthy diet, and a decreased prevalence of obesity.
Cardiovascular disease (CVD) continues to be the leading cause of death in the United States and other developed countries. The burden from CVD has been increasing in developing countries as well. According to current projections, overall CVD rates will continue to increase in the twenty-first century and will be the leading cause of death in both developed and the developing nations. The large global burden of CVD is occurring despite the availability of proven primary and secondary preventive strategies that have not been effectively disseminated. However, before a large-scale CVD prevention program is implemented, key decision-makers must be aware of the scope of the problem.
This chapter provides an overview of the data on differences between populations and secular trends in CVD risk factors, morbidity, and mortality. Specifically, we present data across age, gender, and geographic entities, and we provide a brief overview of time trends in CVD incidence and risk factors.
Cardiovascular Disease Morbidity and Mortality: Rates and Trends
The bulk of the U.S. data concerning the current burden from CVD and trends in CVD events were obtained from published reports of the National Center for Health Statistics (NCHS); the National Heart, Lung and Blood Institute (NHLBI); the American Heart Association (AHA); and region-specific surveillance studies. International data were extracted primarily from World Health Organization (WHO) reports, as well as the World Health Organization Multinational Monitoring of Trends and Determinants in Cardiovascular Disease (WHO-MONICA) Project.
International Comparisons of Morbidity and Mortality from Cardiovascular Disease
CVD (codes 390 to 459 in the ninth edition of the International Classification of Diseases and codes I00 to I99 in the tenth edition ) is the leading cause of death in most countries, particularly in economically developed countries. Significant international variation in rates of mortality and morbidity from CVD has been documented from nation-specific data and in WHO-MONICA communities. Figure 2-1 shows rates of mortality from coronary heart disease (CHD) in 36 countries. CHD death rates (per 100,000 population) among men aged 35 to 74 in these populations were highest in Eastern Europe and lowest in Asia, with more than a tenfold variation between the two regions. Among women aged 35 to 74, a similar pattern of CHD death rates was observed, with an approximately tenfold variation between the highest rates, also observed in Eastern Europe, and lowest rates, also observed in Asia. Of these 36 countries, the United States has the tenth highest rates of mortality from CHD among both men and women.
Figure 2-2 shows rates of mortality from stroke in 36 countries. Rates of death from stroke (per 100,000 population) among men and women aged 35 to 74 in these populations were highest in the Russian Federation, rural China, Bulgaria, and Romania and lowest in Switzerland, Canada, Australia, and France for men, with an approximately twenty-three–fold variation from lowest to highest. Of the 36 countries, the United States has the twelfth lowest rate of mortality from stroke among men. For women, rates of mortality from stroke range from 257.0 per 100,000 in the Russian Federation to 13.4 per 100,000 in Switzerland, a nearly twentyfold difference. Of the 36 countries, the United States has the sixteenth lowest rate of mortality from stroke among women.
Mortality from Cardiovascular Disease in the United States
In the United States, about 1.4 million people died from CVD in 2006; this number represents approximately 56% of all deaths. CVD was the underlying cause in about 830,000 deaths, or about 35% of all U.S. deaths. CVD is the overall leading cause of death in the United States and is the leading cause of death in men older than 45 years and in women older than 65 years. In addition, CVD is the leading cause of death for all race/gender groups in the United States. Approximately 81 million Americans, or about one third of the population, have some form of CVD, which accounted for about 6.1 million hospital discharges in 2006. More than half of CVD deaths result from CHD, and about one per five result from stroke. The economic costs of CVD in the United States are enormous, estimated to be $475 billion in 2009.
Table 2-1 presents 2005 U.S. data for rates of mortality from all causes and from CVD and years of potential life lost (YPLL) before the age of 75 by race/ethnicity group. Overall, heart disease contributed to 211 deaths and 1110 YPLL before age 75 per 100,000 population, and stroke was associated with 47 deaths and 193 YPLL per 100,000 population. The highest CVD burden in the United States was found in the African American population: Rates of death from heart disease were approximately 30% higher among African Americans than among non-Hispanic white Americans. This gap was even wider for rates of death from stroke: Those rates among African Americans were 41% higher than those among non-Hispanic white Americans. Rates of mortality from heart disease were lowest among Asian/Pacific Islanders (113 per 100,000). Rates of mortality from stroke were lowest among American Indian/Alaska Natives (35 per 100,000) and Hispanics (36 per 100,000) (NCHS). YPLL before age 75 for stroke were highest for African Americans and lowest for non-Hispanic white Americans; the difference in YPLL between these groups was nearly threefold. Thus, substantial differences in CVD burden in the United States were observed across race/ethnic groups.
| Race/Gender Group | All Causes | Diseases of the Heart | Cerebrovascular Disease | |||
|---|---|---|---|---|---|---|
| Mortality Rate | YPLL | Mortality Rate | YPLL | Mortality Rate | YPLL | |
| All persons | 799 | 7300 | 211 | 1110 | 47 | 193 |
| American Indian/Alaska Native | 663 | 8624 | 142 | 1010 | 35 | 209 |
| Asian/Pacific Islander | 440 | 3533 | 113 | 514 | 39 | 163 |
| Black | 1017 | 11891 | 271 | 2046 | 65 | 442 |
| Hispanic | 591 | 5758 | 157 | 727 | 36 | 185 |
| Non-Hispanic white | 797 | 6853 | 210 | 1046 | 46 | 156 |
There are also substantial differences in rates of mortality from CVD, ischemic heart disease, and stroke within the United States. Table 2-2 presents 2006 death rates by state, Puerto Rico, and Washington, D.C., and the rankings of incidence from the highest to lowest. For CVD mortality, Mississippi had the highest rate (348.8 per 100,000), about 83% higher than the rate of the lowest ranked state, Minnesota (190.9 per 100,000). For CHD, Washington, D.C., had the highest rate (193.5 per 100,000), more than double the rate of the lowest ranked state, Utah (77.5 per 100,000). Arkansas had the highest rate of death from stroke (58.8 per 100,000), nearly double that of New York (29.7 per 100,000); of interest is that New York had the lowest rate of deaths from stroke but the second highest rate of death from CHD. Although the specific factors responsible for the great variation in ischemic heart disease and stroke rates are unclear, these data may suggest where statewide prevention programs are most needed.
| State | Total CVD * | CHD † | Stroke ‡ | ||||||
|---|---|---|---|---|---|---|---|---|---|
| Rank | Death Rate | % Change 1996-2006 | Rank | Death Rate | % Change 1996-2006 | Rank | Death Rate | % Change 1996-2006 | |
| Alabama | 51 | 330.9 | −17.2 | 25 | 121.7 | −32.4 | 51 | 55.5 | −18.8 |
| Alaska | 11 | 227.5 | −28.5 | 4 | 87.4 | −38.2 | 34 | 46.8 | −31.9 |
| Arizona | 5 | 215.4 | −28.9 | 24 | 120.8 | −31.1 | 3 | 34.5 | −39.6 |
| Arkansas | 48 | 311.0 | −23.8 | 47 | 160.1 | −22.0 | 52 | 58.8 | −35.1 |
| California | 29 | 257.3 | −27.8 | 34 | 139.0 | −36.3 | 29 | 44.9 | −32.3 |
| Colorado | 4 | 212.8 | −29.2 | 6 | 96.3 | −35.9 | 13 | 38.7 | −35.2 |
| Connecticut | 18 | 232.3 | −35.1 | 13 | 110.0 | −42.3 | 8 | 36.5 | −37.7 |
| Delaware | 27 | 255.4 | −26.1 | 37 | 140.8 | −31.4 | 18 | 41.8 | −24.0 |
| District of Columbia (Washington, D.C.) | 50 | 325.7 | −19.1 | 52 | 193.5 | 7.0 | 10 | 37.6 | −45.9 |
| Florida | 10 | 227.4 | −30.1 | 28 | 129.2 | −37.2 | 4 | 35.3 | −33.3 |
| Georgia | 41 | 288.8 | −28.2 | 12 | 108.7 | −41.5 | 43 | 51.4 | −33.6 |
| Hawaii | 2 | 206.2 | −30.9 | 3 | 85.2 | −40.2 | 22 | 43.2 | −32.9 |
| Idaho | 20 | 238.5 | −25.3 | 14 | 110.2 | −34.0 | 44 | 51.6 | −27.3 |
| Illinois | 33 | 268.2 | −29.8 | 31 | 134.8 | −39.4 | 31 | 45.4 | −33.0 |
| Indiana | 40 | 288.7 | −27.7 | 35 | 139.7 | −36.0 | 39 | 49.1 | −34.8 |
| Iowa | 22 | 246.7 | −29.6 | 39 | 141.6 | −36.2 | 20 | 42.9 | −31.6 |
| Kansas | 28 | 255.4 | −26.1 | 17 | 114.1 | −35.0 | 33 | 46.7 | −28.0 |
| Kentucky | 44 | 307.7 | −25.6 | 42 | 148.6 | −32.2 | 42 | 50.5 | −30.4 |
| Louisiana | 46 | 308.4 | −22.4 | 33 | 138.3 | −32.4 | 46 | 52.1 | −24.7 |
| Maine | 17 | 232.2 | −33.1 | 15 | 112.2 | −43.3 | 17 | 41.3 | −28.6 |
| Maryland | 32 | 266.6 | −25.4 | 40 | 141.7 | −29.7 | 23 | 43.6 | −31.6 |
| Massachusetts | 8 | 224.0 | −31.3 | 9 | 105.6 | −39.9 | 11 | 37.7 | −28.2 |
| Michigan | 42 | 291.7 | −27.8 | 45 | 156.6 | −35.2 | 28 | 44.5 | −34.5 |
| Minnesota | 1 | 190.9 | −35.9 | 2 | 79.7 | −45.5 | 14 | 39.3 | −40.1 |
| Mississippi | 52 | 348.8 | −23.4 | 41 | 146.8 | −38.1 | 49 | 53.7 | −25.7 |
| Missouri | 43 | 293.2 | −27.4 | 44 | 155.2 | −34.2 | 41 | 49.4 | −27.3 |
| Montana | 7 | 223.3 | −30.2 | 7 | 99.0 | −36.1 | 16 | 41.2 | −33.9 |
| Nebraska | 13 | 228.8 | −34.5 | 5 | 89.9 | −44.0 | 25 | 43.9 | −29.5 |
| Nevada | 39 | 287.7 | −22.0 | 23 | 119.5 | −38.5 | 15 | 39.7 | −33.8 |
| New Hampshire | 16 | 230.1 | −34.4 | 21 | 116.3 | −42.7 | 5 | 35.4 | −47.4 |
| New Jersey | 26 | 254.1 | −30.1 | 38 | 141.2 | −36.1 | 6 | 35.9 | −33.8 |
| New Mexico | 9 | 224.0 | −24.4 | 18 | 114.6 | −30.8 | 9 | 37.5 | −35.9 |
| New York | 37 | 278.6 | −30.9 | 51 | 181.2 | −32.9 | 1 | 29.7 | −37.2 |
| North Carolina | 34 | 268.2 | −30.4 | 27 | 126.1 | −39.3 | 47 | 52.4 | −36.0 |
| North Dakota | 23 | 246.7 | −28.8 | 30 | 133.7 | −26.6 | 40 | 49.2 | −29.8 |
| Ohio | 38 | 283.8 | −28.0 | 43 | 154.0 | −32.6 | 30 | 45.2 | −28.1 |
| Oklahoma | 49 | 322.0 | −21.2 | 50 | 177.4 | −23.2 | 48 | 53.3 | −23.0 |
| Oregon | 14 | 228.8 | −29.6 | 8 | 99.2 | −40.2 | 36 | 48.0 | −38.8 |
| Pennsylvania | 35 | 268.8 | −29.9 | 32 | 136.0 | −37.4 | 24 | 43.6 | −30.0 |
| Puerto Rico | 6 | 219.4 | −27.5 | 10 | 106.6 | −23.7 | 26 | 43.9 | −25.0 |
| Rhode Island | 24 | 249.8 | −25.7 | 48 | 162.4 | −27.3 | 2 | 31.4 | −38.4 |
| South Carolina | 36 | 270.5 | −33.1 | 22 | 119.2 | −43.0 | 45 | 51.6 | −41.8 |
| South Dakota | 19 | 235.6 | −30.0 | 36 | 140.0 | −27.7 | 19 | 42.4 | −30.9 |
| Tennessee | 45 | 307.7 | −25.1 | 49 | 167.8 | −30.0 | 50 | 54.6 | −31.2 |
| Texas | 31 | 262.8 | −28.6 | 29 | 132.2 | −37.4 | 37 | 48.3 | −30.5 |
| Utah | 3 | 208.2 | −28.0 | 1 | 77.5 | −44.0 | 7 | 36.2 | −40.7 |
| Vermont | 15 | 229.3 | −33.0 | 26 | 124.5 | −37.8 | 12 | 37.8 | −39.7 |
| Virginia | 30 | 258.1 | −31.1 | 20 | 115.6 | −36.8 | 38 | 49.0 | −33.5 |
| Washington | 12 | 228.0 | −28.7 | 19 | 114.7 | −31.7 | 21 | 42.9 | −39.0 |
| West Virginia | 47 | 309.2 | −27.4 | 46 | 158.7 | −35.8 | 35 | 47.6 | −21.7 |
| Wisconsin | 21 | 241.8 | −30.9 | 16 | 113.9 | −39.2 | 27 | 44.3 | −38.9 |
| Wyoming | 25 | 250.1 | −26.6 | 11 | 107.1 | −36.5 | 32 | 45.4 | −37.2 |
| Total United States | 262.5 | −29.5 | 135.0 | −35.9 | 43.6 | −32.7 | |||
* Total cardiovascular disease (CVD) is defined by the 10th edition of the International Classification of Diseases (ICD-10) codes I00 to I99. Coronary heart disease (CHD) is defined here by the ICD-10 codes I20 to I25. Stroke is defined here by the ICD-10 codes I60 to I69.
Secular Trends in Mortality from Cardiovascular Disease
Mortality from CVD has been reduced substantially in most industrialized nations since the 1960s; this occurrence is congruent with changes in major CVD risk factors (discussed in the next section). Among 18 countries ( Figure 2-3 ), rates of mortality from CHD in men and women aged 35 to 74 declined in all countries from 1999 to 2004; these declines included a nearly 5% reduction per year in the United States.
Rates of mortality from stroke have also declined steadily. In 18 countries, stroke-related mortality was reduced annually among men aged 35 to 74 from 1999 to 2004 ( Figure 2-4 ). Reductions during this period were greatest among men in Australia and Norway and among women in Korea and Australia. In the United States, average annual reductions in stroke mortality during this period were 3% to 4%.
Table 2-2 shows changes in total CVD, CHD, and stroke mortality in all 50 U.S. states, Washington, D.C., and Puerto Rico from 1996 to 2006. In all states, CHD and stroke mortality declined substantially over the previous 10-year period, although there was a 7% increase in CHD in Washington, D.C. The percentage decreases were largest for CVD in Minnesota (−35.9%), for CHD in Utah and Nebraska (−44.0%) and for stroke in New Hampshire (−47.4%).
Table 2-3 shows the age-adjusted cause-specific mortality rates and the changes from 1972 to 2004 in the United States. Mortality from CHD overall was reduced 66% from 1972 (445.5 per 100,000 population) to 2004 (150.2 per 100,000 population). Similar reductions were observed in mortality from stroke during these time periods (66.1% reduction).
| Cause of Death | Deaths/100,000 Population | 1972-2004 Difference | Percentage Change | |
|---|---|---|---|---|
| 1972 | 2004 | |||
| All causes | 1214.8 | 800.8 | −414.0 | −34.1 |
| CVD * | 695.4 | 289.5 | −405.9 | −58.4 |
| CHD | 445.5 | 150.2 | −295.3 | −66.3 |
| Heart failure | 9.3 | 18.9 | 9.6 | 103.2 |
| Stroke | 147.3 | 50.0 | −97.3 | −66.1 |
| Other CVD | 93.3 | 70.4 | −22.9 | −24.5 |
| Non-CVD | 519.4 | 511.3 | −8.1 | −1.6 |
* Excluding congenital malformations of the circulatory system.
Rosamond and colleagues examined trends in heart disease incidence and mortality across four race/gender groups (white men and women, black men and women) in four U.S. communities (Forsyth County, N.C.; Jackson, Miss.; Minneapolis suburbs; and Washington County, Md.) from 1987 to 1994. Although CHD mortality was reduced in all four groups, the largest decreases in CHD mortality were observed among white men (average annual rate change, −4.7%), and the smallest decline in CHD mortality was observed for black men (average annual rate change, −2.5%). Average annual rates of hospitalization for a first myocardial infarction actually increased during this time period among black women (7.4%) and black men (2.9%) but remained essentially unchanged among white men (−0.3%) and decreased among white women (−2.5%). There was also evidence of an overall decrease in rates of recurrent myocardial infarction and improvement in survival after myocardial infarction.
In summary, although CVD mortality and morbidity were reduced significantly in most economically developed nations after the 1950s, CVD rates and the rates of reduction of CVD mortality were substantially heterogeneous between nations. In the United States, rates of CVD mortality and morbidity continue to decline, although there is still significant variation among regions (states) and among race/ethnic groups in the burden of CVD; African Americans bear the greatest burden from CVD. These data suggest which high-risk groups or regions have the greatest need for preventive efforts and programs.
Cardiovascular Disease Risk Factors: National and International Rates and Trends
Data on the prevalence and trends in selected CVD risk factors (i.e., high blood pressure, high cholesterol, cigarette smoking, obesity, and diabetes) in the United States and other countries are described as follows. These data are potential mediating factors for the previously discussed trends for CVD morbidity and mortality.
High Blood Pressure
Elevated systolic (≥140 mm Hg) and diastolic (≥90 mm Hg) blood pressure, or hypertension, greatly increases the risk of heart disease and stroke. In the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, an additional category of “pre-hypertension” (systolic blood pressure of 120 to 139 mm Hg or diastolic blood pressure of 80 to 89 mm Hg) was recognized in order to emphasize the role of increased risk of CVD associated with elevated blood pressure above 115/75 mm Hg.
International data indicate a great deal of geographic variation in blood pressure. Among adults aged 35 to 64 from WHO MONICA communities in the final wave of the survey, systolic blood pressure ranged, on average, from 121 mm Hg (Catalonia, Spain) to 142 mm Hg (North Karelia, Finland) among men and from 117 mm Hg (Toulouse, France) to 138.5 mm Hg (Kuopio Province, Finland) among women ( Table 2-4 ). During the approximately 10-year period from the initial to the final WHO MONICA surveys, systolic blood pressure was reduced in most participating communities. The downward trends were greater for women than for men: Nearly 75% of the communities demonstrated significant reductions for women (see Table 2-4 ). Only one of these communities (Halifax [Nova Scotia], Canada) demonstrated a significant increase in systolic blood pressure.
