Heart Disease and Stroke Statistics—2008 Update

Each year the American Heart Association, 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, 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, the lay public, and many others who seek the best national data available on disease and risk factor prevalence, disease incidence, and mortality rates in a single document. This year’s edition includes several areas not covered in previous editions. Below are a few highlights from this year’s Update in the areas of cardiovascular disease (CVD) mortality, control of risk factors, kidney disease, and medical care.

Death rates from CVD have declined, yet the burden of disease remains high.

• The 2004 overall death rate from CVD (International Classification of Diseases 10, I00–I99) was 288.0 per 100 000. The rates were 335.1 per 100 000 for white males, 454.0 per 100 000 for black males, 238.0 per 100 000 for white females, and 333.6 per 100 000 for black females. From 1994 to 2004, death rates from CVD (International Classification of Diseases 10, I00–I99) declined 24.7%. Preliminary mortality data from 2005 show that CVD (I00–I99; Q20–Q28) accounted for 35.2% (861 826) of all 2 447 910 deaths in 2005, or 1 of every 2.8 deaths in the United States.

• Nearly 2400 Americans die of CVD each day—an average of 1 death every 37 seconds. The 2005 overall preliminary death rate from CVD was 279.2. More than 148 000 Americans killed by CVD (I00–I99) in 2004 were <65 years of age. In 2004, 32% of deaths from CVD occurred before the age of 75 years, which is well before the average life expectancy of 77.9 years.

• Coronary heart disease caused 1 of every 5 deaths in the United States in 2004. Coronary heart disease mortality was 451 326. In 2008, an estimated 770 000 Americans will have a new coronary attack, and about 430 000 will have a recurrent attack. It is estimated that an additional 175 000 silent first myocardial infarctions occur each year. About every 26 seconds, an American will have a coronary event, and about every minute someone will die from one.

• Each year, about 780 000 people experience a new or recurrent stroke. About 600 000 of these are first attacks, and 180 000 are recurrent attacks. Preliminary data from 2005 indicate that stroke accounted for about 1 of every 17 deaths in the United States. On average, every 40 seconds someone in the United States has a stroke. From 1994 to 2004, the stroke death rate fell 24.2%, and the actual number of stroke deaths declined 6.8%.

• In 2004, 1 in 8 death certificates (284 365 deaths) in the United States mentions heart failure.

Control of risk factors remains an issue for many Americans.

• The age-adjusted prevalence of high low-density lipoprotein cholesterol in US adults was 26.6% in 1988–1994 and 25.3% in 1999–2004. Between 1988–1994 and 1999–2004, awareness increased from 39.2% to 63.0%, and use of pharmacological lipid-lowering treatment increased from 11.7% to 40.8%. Low-density lipoprotein cholesterol control increased from 4.0% to 25.1% among those with high low-density lipoprotein cholesterol.

• Overall, 62.0% of adults ≥18 years of age engaged in at least some vigorous and/or light-moderate leisure-time physical activity lasting ≥10 minutes per session. In 2002–2004, 40.2% of people ≥75 years of age (age adjusted) engaged in at least some regular leisure-time physical activity. Men were more likely (64.0%) to exercise than were women (60.2%).

• More than 9 million children and adolescents between 6 and 19 years of age are considered overweight on the basis of being in the 95th percentile or higher of body mass index values in the 2000 Centers for Disease Control and Prevention growth chart.

• On the basis of data from the National Health and Nutrition Examination Survey, the prevalence of overweight in children between 6 and 11 years of age increased from 4.0% in 1971–1974 to 17.5% in 2001–2004. The prevalence of overweight in adolescents between 12 and 19 years of age increased from 6.1% to 17.0%. In 2003–2004, 36% of women 65 to 74 years of age and 24% of women ≥75 years of age were obese. This is an increase from 1988–1994, when 27% of women 65 to 74 years of age and 19% of women ≥75 years of age were obese. For men, from 1988–1994, 24% of those 65 to 74 years of age and 13% of those ≥75 years of age were obese, compared with 33% of those 65 to 74 years of age and 23% of those ≥75 years of age in 2003–2004.

• One and a half million new cases of diabetes were diagnosed in people ≥20 years of age in 2005.

The 2008 Update expands data coverage of CVD-related kidney disease.

• End-stage renal disease and chronic kidney disease are conditions that are most commonly associated with diabetes and/or high blood pressure and occur when the kidneys can no longer function normally on their own.

• The incidence of reported end-stage renal disease has almost doubled in the past 10 years. In 2004, 104 364 new cases of end-stage renal disease were reported.

• The number of persons treated for end-stage renal disease increased from 68 757 in 1994 to 102 356 in 2004; this translates to 261.3 per million in 1994 to 348.6 per million in 2004.

• The US Renal Data System estimates that by 2010, 650 000 Americans will require treatment for kidney failure, which represents a 60% increase over the number who received such treatment in 2001.

• The prevalence of chronic kidney disease (stages I–V) is 16.8%. This represents an increase over the 14.5% prevalence estimate from the National Health and Nutrition Examination Survey 1988–1994.

• The prevalence of chronic kidney disease was greater among those with diabetes (40.2%), hypertension (24.6%), and CVD (28.2%) than among those without these chronic conditions.

Improvements in medical care are being made.

• Over a 3-year period from 2002 through 2004, among 159 168 patients admitted with heart failure at 285 hospitals, inotrope use decreased, and improvements were made in providing discharge instructions, smoking counseling, left ventricular assessment, and β-blocker prescription.

• During this same period of time, clinical outcomes improved, including the need for mechanical ventilation (5.3% to 3.4%), length of stay (mean, 6.3 days to 5.5 days), and in-hospital death rate (4.5% to 3.2%).

The American Heart Association, 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 2005 preliminary mortality data have been released, and although not included in this year’s Update, more information can be found at the National Center for Health Statistics Web site, http://www.cdc.gov/nchs/products/pubs/pubd/hestats/prelimdeaths05/prelimdeaths05.htm.

The American Heart Association (AHA) works with the Centers for Disease Control and Prevention’s National Center for Health Statistics (CDC/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 and an alphabetical list of abbreviations, see Chapter 21 of this document, the Glossary and Abbreviation Guide.

The surveys used are:

Disease Prevalence

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 (CVD). 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 of total CVD to include myocardial infarction (MI), AP, HF, stroke, and hypertension.

A major emphasis of this Update is to present the latest estimates of the number of persons in the United States who have specific conditions in order to provide a more realistic estimate of burden. Most estimates based on NHANES prevalence rates use data collected from 1999 to 2004 (in most cases, these are the latest published figures). These are applied to census population estimates for 2005. Differences in population estimates based on extrapolations of rates beyond the data collection period by using 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.

Risk Factor Prevalence

The NHANES 1999–2004 data are used in this Update to present estimates of the percentage of persons with high lipid values, diabetes, 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 Youth Risk Factor Surveillance System.

Incidence and Recurrent Attacks

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 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, the Cardiovascular Health Study (CHS) conducted by the NHLBI, and the Greater Cincinnati/Northern Kentucky Stroke Study (GCNKSS) 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 and Stroke Statistical Update (renamed the Heart Disease and Stroke Statistics Update). Doing so can lead to serious misinterpretation of time trends.

Mortality

Mortality data are grouped according to the underlying cause of death. “Total-mention” mortality is the number of death certificates in 2004 that mention the given disease classification either as the underlying cause or as a contributing cause. These were final 2004 data unless otherwise indicated. For many deaths classified as attributable to CVD, selection of the most likely single underlying cause can be difficult when several major comorbidities are present, as is often the case in the elderly population. It is, therefore, useful to know the extent of mortality from a given cause, regardless of whether it is the underlying cause or a contributing cause—ie, its “total mentions.” In all comparisons of deaths and death rates between 1994 and 2004, 1994 data were modified using appropriate comparability ratios.

The first text section for each disease listed in this Update mentions mortality information. This includes the number of deaths for which the disease is the underlying cause; this is referred to as “mortality.” That number is followed by “total-mention mortality.” All other numbers or rates of deaths in the Update refer to the given disease as the underlying cause. The one exception, heart failure, is explained in that section.

National and state mortality data presented according to the underlying cause of death are computed from the Data Warehouse mortality tables of the NCHS Web site or the compressed CDC file. Total-mention numbers of deaths are tabulated from the electronic mortality files of the NCHS Web site.

Population Estimates

In this publication, we have used national population estimates from the US Census Bureau for 2005 in the computation of morbidity data. Data for 2004 are used in the computation of death rates. The Census Bureau Web site contains these data as well as information on the file layout.¹

Hospital Discharges and Ambulatory Care Visits

Estimates of the numbers of hospital discharges and numbers of procedures performed are for inpatients discharged from short-stay hospitals. Discharges include those discharged alive, dead, or with unknown status. Unless otherwise specified, discharges are according to the first-listed (primary) diagnosis, and procedures are listed according to the all-listed diagnosis (primary plus secondary). These estimates are from the NHDS of the NCHS unless otherwise noted. Ambulatory care visits include patient visits to hospital emergency or outpatient departments and to physicians’ offices.

International Classification of Diseases

Morbidity (illness) and mortality (death) data in the United States use a standard classification system: the International Classification of Diseases (ICD). About every 10 to 20 years, the ICD codes are revised to reflect changes over time in medical technology, diagnosis, or terminology. Where necessary for comparability of mortality trends across the 9th and 10th ICD revisions, comparability ratios computed by NCHS are applied as noted.² Effective with mortality data for 1999, we are using the 10th revision (ICD-10). It will be a few more years before the 10th revision is used for hospital discharge data, which are based on the International Classification of Diseases, Clinical Modification, Ninth Revision (ICD-9-CM).³

Age Adjustment

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.⁴ International mortality data are age adjusted to the European standard.⁵ Unless otherwise stated, all death rates in this publication are age adjusted and are per 100 000 population.

Data Years for National Estimates

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 2005 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 2004. For disease and risk factor prevalence, most rates in this report are calculated from the 1999–2004 NHANES. Rates by age and sex are also applied to the US population in 2005 to estimate the numbers of persons 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 2005, recognizing that this probably underestimates 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 2005, as are many of the numbers of physician office visits and visits to hospital emergency and outpatient departments. Except as noted, economic cost estimates are projected to 2008.

Cardiovascular Disease

For data on hospitalizations, physician office visits, and mortality, CVD is defined according to ICD codes given in Chapter 21 of the present document. This definition includes all diseases of the circulatory system and congenital CVD. Unless so specified, an estimate for total CVD does not include congenital CVD.

Race

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.

Contacts

If you have questions about statistics or any points made in this Update, please contact the Biostatistics Program Coordinator at the American Heart Association National Center (e-mail [email protected], phone 214-706-1423). Direct all media inquiries to News Media Relations at [email protected] 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 Web site, http://www.americanheart.org/statistics, and in the journal Circulation.

See the Glossary for an explanation of terms.

ICD-9 390–459, 745–747, ICD-10 I00–I99, Q20–Q28; see Glossary (Chapter 21) for details and definitions. SeeTables 2-1 through 2-3andCharts 2-1 through 2-20.

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Prevalence

An estimated 80 700 000 American adults (1 in 3) have 1 or more types of CVD. Of these, 38 200 000 are estimated to be ≥60 years of age (extrapolated to 2005 from NCHS NHANES 1999–2004 data). (Total CVD includes diseases listed in the bullet points below except for congenital CVD.) Because of overlap, it is not possible to add these conditions to arrive at a total.

• High blood pressure (HBP)—73 000 000. (Defined as systolic pressure ≥140 mm Hg and/or diastolic pressure ≥90 mm Hg, taking antihypertensive medication, or being told at least twice by a physician or other health professional that one has HBP.)

• Coronary heart disease (CHD)—16 000 000.

  	— Myocardial infarction (MI) (heart attack)— 8 100 000.
  	— Angina pectoris (AP) (chest pain)—9 100 000.

• Heart failure (HF)—5 300 000.

• Stroke—5 800 000.

• Congenital cardiovascular defects—650 000 to 1 300 000 (see Chapter 6).

The following prevalence estimates are for people ≥18 years of age from NHIS, NCHS 2005.¹ Note: Hypertension estimates reflect only those aware that they have hypertension.)

Incidence

• On the basis of the NHLBI’s Framingham Heart Study (FHS) original and offspring cohort data from 1980 to 2003²:

  	— 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.
  	— Before 75 years of age, a higher proportion of CVD events due to CHD occur in men than in women, and a higher proportion of events due to stroke occur in women than in men.

• 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 1000.³

• Data from the FHS indicate that the lifetime risk for CVD is 2 in 3 for men and more than 1 in 2 for women at 40 years of age (personal communication, Donald Lloyd-Jones, MD, Northwestern University, Chicago, Ill).

Mortality

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’s disease; E10–E14 for diabetes; and V01–X59, Y85–Y86 for accidents.

• Mortality data show that CVD (I00–I99, Q20–Q28) as the underlying cause of death (includes congenital cardiovascular defects) accounted for 36.3% (869 724) of all 2 397 615 deaths in 2004, or 1 of every 2.8 deaths in the United States. CVD total mentions (1 357 000 deaths in 2004) constituted approximately 57% of all deaths that year.⁴

• In every year since 1900 except 1918, CVD accounted for more deaths than any other major cause of death in the United States.^5,6

• Nearly 2400 Americans die of CVD each day, an average of 1 death every 37 seconds. CVD claims approximately as many lives each year as cancer, CLRD, accidents, and diabetes mellitus combined.⁴

• The 2004 overall death rate due to CVD (I00–I99) was 288.0. The rates were 335.1 for white males, 454.0 for black males, 238.0 for white females, and 333.6 for black females. From 1994 to 2004, death rates due to CVD (ICD-10 I00–I99) declined 24.7%. In the same 10-year period, actual CVD deaths declined 8%.⁴

• Among other causes of death in 2004, cancer caused 553 888 deaths; accidents, 112 012; Alzheimer’s disease, 65 965; and HIV (human immunodeficiency virus)/AIDS (acquired immune deficiency syndrome), 13 063.⁴

• The 2004 CVD (I00–I99) death rates were 341.7 for males and 245.3 for females. Death rates for cancer (malignant neoplasms) were 227.7 for males and 157.4 for females. Breast cancer claimed the lives of 40 954 females in 2004; lung cancer claimed 68 461. Death rates for females were 24.4 for breast cancer and 41.6 for lung cancer. One in 30 female deaths was of breast cancer, whereas 1 in 6 was of CHD. For comparison, 1 in 4.6 females died of cancer, whereas 1 in 2.6 died of CVD. On the basis of 2004 mortality data, CVD caused approximately 1 death per minute among females, or approximately 460 000 female lives in 2004. That represents more female lives than were claimed by cancer, CLRD, Alzheimer’s disease, accidents, and diabetes mellitus combined.⁴

• More than 148 000 Americans killed by CVD (I00–I99) in 2004 were <65 years of age. In 2004, 32% of deaths due to CVD occurred before the age of 75 years, which is well before the average life expectancy of 77.9 years.⁴

• In 2004, death rates for diseases of the heart in American Indians or Alaska Natives were 182.7 for males and 119.9 for females; for Asians or Pacific Islanders, they were 146.5 for males and 96.1 for females; for Hispanics or Latinos, they were 193.9 for males and 130.0 for females.⁷

• 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 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 diabetes mellitus, and 0.7% for HIV.⁸

• In 2004, the leading causes of death in women ≥65 years of age were diseases of the heart (1), cancer (2), and stroke (3). In older men, they were diseases of the heart (1), cancer (2), CLRD (3), and stroke (4).⁹

• A recent study of the decrease in US deaths due to CHD from 1980 to 2000 suggests that approximately 47% of the decrease was attributed to evidence-based medical therapies and 44% to changes in risk factors in the population.¹⁰

Out-of-Hospital Cardiac Arrest

There is a wide variation in the reported incidence of and outcome for out-of-hospital cardiac arrest. These differences are due in part to differences in definition and ascertainment of cardiac arrest data, as well as differences in treatment after the onset of cardiac arrest.

Cardiac arrest is defined as cessation of cardiac mechanical activity and is confirmed by the absence of signs of circulation.¹¹ Available epidemiological databases do not adequately characterize cardiac arrest or the subset of cases that occur with sudden onset. The following information summarizes representative data from several sources in an attempt to characterize the incidence and outcome of out-of-hospital cardiac arrest.

• According to NCHS Data Warehouse mortality data, 310 000 CHD deaths occur out of hospital or in hospital emergency departments (EDs) annually (2004, ICD-10 codes I20–I25).¹²

• The annual incidence of out-of-hospital cardiac arrest in North America is approximately 0.55 per 1000 population.^13,14 With an estimated US population of 302 196 872 (www.census.gov, accessed June 27, 2007), this implies that approximately 166 200 out-of-hospital cardiac arrests occur annually.

• Approximately 60% of unexpected cardiac deaths are treated by emergency medical services (EMS).¹⁵

• In a population ≥20 years of age, the incidence of out-of-hospital cardiac arrest treated by EMS is from 36 to 81 per 100 000.^15,16

  — Of these, 20% to 38% have ventricular fibrillation or ventricular tachycardia as the first recorded rhythm.13,16

• The incidence of cardiac arrest with an initial rhythm of ventricular fibrillation is decreasing over time¹⁶; however, the incidence of cardiac arrest with any initial rhythm is not decreasing.¹⁶

• The median reported survival to discharge after out-of-hospital cardiac arrest with any first recorded rhythm is 6.4%.¹⁷

• The average proportion of cases of out-of-hospital cardiac arrest that receive bystander cardiopulmonary resuscitation is 27.4%.¹⁷

• The incidence of lay-responder defibrillation is low (2.05% in 2002) but increasing over time.¹⁸

• The reported incidences of out-of-hospital pediatric cardiac arrest vary widely (from 2.6 to 19.7 annual cases per 100 000).¹⁹

• In 2004, 5891 people died of unintentional choking or suffocation. Of these, 725 were <1 year of age (NCHS).

• For adults, the reported incidence of cardiac arrest in hospital was 0.17 (±0.09) per bed per year.²⁰

• The rates of survival to discharge after in-hospital cardiac arrest are 27% among children and 18% among adults.²¹

Pediatric/Children

• There are 72 293 812 individuals <18 years of age in the United States²²; this implies that there are from 1900 to 14 200 pediatric out-of-hospital cardiac arrests annually of all causes (including trauma, sudden infant death syndrome, respiratory causes, cardiovascular causes, and submersion).

• Ventricular fibrillation is an uncommon cause of cardiac arrest in children but is observed in approximately 5% to 15% of children with out-of-hospital cardiac arrest.²³

• Studies that document voluntary reports of deaths among high school athletes suggest that the incidence of out-of-hospital cardiac arrest ranges from 0.28 to 1.0 deaths per 100 000 high school athletes annually nationwide.^24,25 Although incomplete, these numbers provide a basis for estimating the number of deaths in this age range.

• One report describes the incidence of nontraumatic pediatric cardiac arrest (among students ≥3 and ≤18 years of age) that occurs in schools and estimates rates (per 100 000 person-school-years) for elementary, middle, and high schools to be 0.18, 0.19, and 0.15, respectively, for the geographic area (King County, Washington) and time frame (January 1, 1990, to December 31, 2005) studied.²⁶

• The reported average rate of survival to discharge after pediatric out-of-hospital cardiac arrest is 6.7%.¹⁹

Awareness of Warning Signs and Risk Factors for CVD

• Surveys conducted by the American Heart Association in 1997, 2000, 2003, and 2006 to evaluate trends in women’s awareness, knowledge, and perceptions related to CVD found that in 2006, awareness of HD as the leading cause of death among women was 57%, significantly higher than in prior surveys. Awareness was lower among black and Hispanic women than among white women, and the racial/ethnic difference has not changed appreciably over time. More than twice as many women felt uninformed about stroke, compared with HD, in 2006. Hispanic women were more likely than white women to report that there is nothing they can do to keep themselves from getting CVD. The majority of respondents reported confusion related to basic CVD prevention strategies.²⁷

• Nearly 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, making 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 a substance abuse/use behavior, other than cigarettes, as the most important CVD risk behavior.²⁸

• A nationally representative sample of women were given a questionnaire about history of CVD risk factors, self-reported actions taken to reduce risk, and barriers to heart health. The rate of awareness of CVD as the leading cause of death has nearly doubled since 1997, was significantly greater for whites than for blacks and Hispanics, and was independently correlated with increased physical activity (PA) and weight loss in the previous year. Fewer than half of respondents were aware of healthy levels of risk factors. Awareness that their personal level was not healthy was positively associated with action. Most women took steps to lower risk in family members and themselves.²⁹

Risk Factors

• Data 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 increased among successive 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). Persons 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 persons (45.1%), unemployed adults (43.4%), homemakers (34.3%), and employed persons (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.³⁰

• Data from the BRFSS (CDC) showed that young women and men 18 to 24 years of age had comparatively poor health profiles and experienced adverse changes from 1990 to 2000. After adjustment for education and income, these young people had the highest prevalence of smoking (34% to 36% current smokers among whites), the largest increases in smoking (10% to 12% among whites and 9% among Hispanic women), and large increases in obesity (4% to 9% increase in all groups). All groups had high levels of sedentary behavior (approximately 20% to 30%) and low vegetable or fruit intake (approximately 35% to 50%). In contrast, older Hispanics and older black men (65 to 74 years of age) showed some of the most positive changes. They had the largest decreases in smoking (Hispanic women) and sedentary behavior (Hispanic women and black men) and the largest increases in vegetable or fruit intake (Hispanic women and black men).³¹

• Data from the Chicago Heart Association Detection Project (1967–1973, 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], diabetes, 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.^32,33

• Data from the BRFSS (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 approximately 5 years. CVD mortality at all ages tended to be highest in blacks.³⁴

• In respondents 18 to 74 years of age, data from the 2000 BRFSS (CDC) showed the prevalence of healthy lifestyle characteristics was as follows: no smoking, 76.0%; healthy weight, 40.1%; consumption of 5 fruits and vegetables per day, 23.3%; and regular PA, 22.2%. The overall prevalence of the healthy lifestyle indicators (ie, having all 4 healthy lifestyle characteristics) was only 3%, with little variation among subgroups.³⁵

• Analysis of 5 cross-sectional, nationally representative surveys from NHES 1960–1962 to NHANES 1999–2000 showed that the prevalence of key risk factors (ie, high cholesterol, HBP, current smoking, and total diabetes) decreased over time across all BMI groups, with the greatest reductions observed among overweight and obese groups. Total diabetes 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.³⁶

• Analysis of FHS data among participants free of CVD at the age of 50 years showed the lifetime risk for developing CVD was 51.7% for men and 39.2% for women. Median overall survival was 30 years for men and 36 years for women (see Table 2-4).³⁷

  Table 2-4. Remaining Risks for CVD and Other Diseases Among Men and Women Free of Disease at 40 and 70 Years of Age

  Diseases	Remaining Lifetime Risk at Age 40		Remaining Lifetime Risk at Age 70
  	Men	Women	Men	Women
  Ellipses (…) indicate not estimated; AF, atrial fibrillation.
  *Personal communication from Donald Lloyd-Jones, based on FHS data.
  †Age 55.
  ‡Age 65.
  Any CVD*	2 in 3	>1 in 2	>1 in 2	1 in 2
  CHD37	1 in 2	1 in 3	1 in 3	1 in 4
  AF38	1 in 4	1 in 4	1 in 4	1 in 4
  CHF39	1 in 5	1 in 5	1 in 5	1 in 5
  Stroke40	1 in 6†	1 in 5†	1 in 6	1 in 5
  Dementia40	…	…	1 in 7	1 in 5
  Hip fracture41	1 in 20	1 in 6	…	…
  Breast cancer42,43	1 in 1000	1 in 8	…	1 in 14
  Prostate cancer42	1 in 6	…	…	…
  Lung cancer42	1 in 12	1 in 17	…	…
  Colon cancer42	1 in 16	1 in 17	…	…
  Diabetes44	1 in 3	1 in 3	1 in 9	1 in 7
  Hypertension45	9 in 10†	9 in 10†	9 in 10†	9 in 10†
  Obesity46	1 in 3	1 in 3	…	…

• Analysis of >14 000 middle-aged subjects in the ARIC study of the NHLBI showed that >90% of CVD events in black subjects, compared with approximately 70% in white subjects, were 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 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. The primary prevention of elevated risk factors might largely eliminate the incidence of CVD, and these beneficial effects would be applicable not only for white but also for black subjects.³⁸

• Data from the Medical Expenditure Panel Survey (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 disease³⁹:

  	— 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%).
  	— 38.6% maintained a healthy weight. Among those told that they had HD, 33.9% had a healthy weight, as compared with 39.3% who had never been told they had HD.
  	— 78.8% do not currently smoke. Among those ever told that they had indicators of HD, 18.3% continued to smoke.
  	— More than 93% engaged in at least 1 recommended behavior for prevention of HD: 75.5% engaged in 1 or 2; 18% engaged in all 3; and 6.5% did not engage in any of the recommended behaviors.       ○Age-based variations          – Moderate to vigorous PA ≥3 times per week varied according to age. Younger people (18 to 44 years) were more likely (59.9%) than those who were older (45 to 64 and ≥65 years, 55.3% and 48.5%, respectively) to engage in regular PA.          – A greater percentage of those between 18 and 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).          – Those ≥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).       ○Race/ethnicity-based variations          – 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)          – Non-Hispanic whites were more likely to have maintained a healthy weight than were Hispanics or non-Hispanic blacks (39.8% versus 32.1% and 29.7%, respectively)          – Hispanics were more likely to be nonsmokers (84.2%) than were non-Hispanic whites and non-Hispanic blacks (77.8% and 76.3%, respectively).       ○Sex-based variations          – Men were more likely to have engaged in moderate to vigorous PA ≥3 times per week than women (60.3% versus 53.1%, respectively).          – Women were more likely than men to have maintained a healthy weight (45.1% versus 31.7%, respectively).          – 81.7% of women did not currently smoke, compared with 75.7% of men.       ○Variations based on education level          – 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).          – There was a greater percentage of nonsmokers among those with a college education (85.5%) than among those with a high school or less than high school education (73.8% and 69.9%, respectively).

• Forty-four percent of 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, not the direction, of association.⁴⁰

Impact of Healthy Lifestyle and Low Risk Factor Levels

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 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 improve healthy longevity.

• The lifetime risk for CVD and median survival were highly associated with risk factor 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 age 50 was defined as BP <120/80 mm Hg, total cholesterol <180 mg/dL, absence of diabetes, 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 diabetes. 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 50.³⁷

• 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 predicted overall survival and morbidity-free survival to the age of 85 years or longer.⁴¹

  	— Overall, 35.7% survived to the age of 85 years, and 22% survived to that age free of major morbidities.
  	— Factors associated with survival to the age of 85 years included female sex, lower systolic BP, lower total cholesterol, better glucose tolerance, absence of current smoking, and higher level of education attained. Factors associated with survival to the age of 85 years free of MI, unstable angina, HF, stroke, dementia, and cancer were nearly identical.
  	— When adverse levels of 4 of these factors were present in middle age, fewer than 5% of men and approximately 15% of women survived to age 85 years.

• A study of 366 000 men and women from the Multiple Risk Factor Intervention Trial (MRFIT) Study and Chicago cohorts defined low-risk status as follows: serum cholesterol level <200 mg/dL, untreated BP ≤120/80 mm Hg, absence of current smoking, absence of diabetes, 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 risk for CVD mortality, 40% to 60% lower total mortality rates, and 6 to 10 years’ greater life expectancy.³³

• A study of 84 129 women enrolled in the Nurses’ Health Study identified 5 healthy lifestyle factors, including absence of current smoking, drinking ½ glass or more of wine per day (or equivalent alcohol consumption), ½ hour or more per day of moderate or vigorous PA, BMI <25 kg/m², and dietary score in the top 40% (including 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, risk for CHD over a 14-year period was reduced by 57%; when 4 were present, risk was reduced by 66%; and when all 5 factors were present, risk was reduced by 83%.⁴²

• Among individuals 70 to 90 years of age, adherence to a Mediterranean-style diet and greater PA are associated with 65% to 73% lower rates of all-cause mortality, as well as lower mortality rates due to CHD, CVD, and cancer.⁴³

• Seventeen-year mortality data from the NHANES II Mortality Follow-Up Study indicated that the risk 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 estimated that 64% of all CHD deaths among women and 45% of CHD deaths in men could have been avoided.⁴⁴

• 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 (approximately 25 years later) and lower average annual Medicare costs at older ages.

  •    — The presence of a greater number of risk factors in middle age is associated with lower scores at older ages on assessment of social functioning, mental health, walking, and health perception in women, with similar findings in men.⁴⁵

  •    — Similarly, the existence of a greater number of risk factors in middle age is associated with higher average annual CVD-related and total Medicare costs (once Medicare eligibility is attained).⁴⁶

Hospital Discharges, Ambulatory Care Visits, and Nursing Home Visits

• From 1979 to 2005, the number of inpatient discharges from short-stay hospitals with CVD as the first-listed diagnosis increased 26% to 6 159 000 discharges (NCHS, NHDS). In 2005, CVD ranked highest among all disease categories in hospital discharges.⁴⁷

• In 2005, there were 81 836 000 physician office visits with a primary diagnosis of CVD (NCHS, NAMCS).⁴⁸

• In 2005, there were 4 036 000 visits to EDs with a primary diagnosis of CVD (NCHS, NHAMCS).⁴⁹

• In 1999, 23% of nursing home residents ≥65 years of age had a primary diagnosis of CVD at admission. This was the highest disease category for these residents (NCHS, NNHS).⁵⁰

• In 2005, there were 6 734 000 outpatient department visits with a primary diagnosis of CVD (NHAMCS).⁵¹ In 2005, approximately 1 of every 6 hospital stays, or almost 6 million, resulted from CVD. The total inpatient hospital cost for CVD was $71.2 billion, approximately one fourth of the total cost of hospital care in the United States. The average cost per hospitalization was approximately 41% higher than the average cost for all stays. Hospital admissions that originated in the ED accounted for 60.7% of all hospital stays for CVD. This was 41% higher than the overall rate of 43.1%; 3.3% of patients admitted to the hospital for CVD died in the hospital, which was significantly higher than the average in-hospital death rate of 2.1%.⁵²

• Coronary atherosclerosis involved 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 hospital charges for 695 000 hospital stays. The 1.1 million hospitalizations for CHF amounted to nearly $29 billion in hospital charges.⁵³

• In 2003, approximately 48.3% of 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, congestive HF, and stroke were for women. There was no difference between men and women in hospitalizations for cardiac dysrhythmias.⁵⁴

• Circulatory disorders were the most frequent reason for admission to the hospital through the ED, accounting for 26.3% of all admissions through the ED. After pneumonia, which was ranked first, the most common heart-related conditions were CHF (2), chest pain (3), hardening of the arteries (4), and heart attack (5), which together accounted for >15% of all admissions through the ED. Stroke and irregular heart beat ranked seventh and eighth, respectively.⁵⁵

Cost

• The estimated direct and indirect cost of CVD for 2008 is $448.5 billion.

• In 2003, $31.7 billion in program payments were made to Medicare beneficiaries discharged from short-stay hospitals with a principal diagnosis of CVD. That was an average of $8966 per discharge.⁵⁶

• A study of the 1987 National Medicaid Expenditure Survey and the 2000 MEPS, Household Component, showed the 15 most costly medical conditions and the estimated percentage increase in total healthcare spending for each condition from 1987 to 2000. The following are some of the top 15 conditions, in rank order, and their percentage impact on healthcare spending: heart disease (1), +8.06%; cancer (4), +5.36%; hypertension (5), +4.24%; cerebrovascular disease (7), +3.52%; diabetes (9), +2.37%; and kidney disease (15), +1.03%.⁵⁷

Operations and Procedures

• In 2005, an estimated 6 989 000 inpatient cardiovascular operations and procedures were performed in the United States; 4.1 million were performed on males, and 2.9 million were performed on females (NHDS, NCHS).⁴⁷

Coronary Heart Disease

ICD-9 410–414, 429.2; ICD-10 I20–I25; see Glossary (Chapter 21) for details and definitions. SeeTables 3-1 and 3-2. SeeCharts 3-1 through 3-8.

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Prevalence

• Data from 2005 from the BRFSS survey of the CDC showed that 6.5% of respondents reported a history of CHD. Men had a significantly higher prevalence of MI history than women (5.5% versus 2.9%), angina/CHD (5.5% versus 3.4%), and 1 or more of these conditions (8.2% versus 5.0%). Prevalence of these conditions increased with age and decreased with higher education. Of persons with less than a high school education, 9.8% reported a history of 1 or more of these conditions, nearly twice the proportion among college graduates, 5.0%. American Indians/Alaska Natives and multiracial persons had substantially higher prevalences of a history of MI, angina/CHD, and 1 or more of these conditions than did non-Hispanic whites. The prevalences of all of these conditions among whites and blacks were similar. The prevalence of respondents with a history of MI ranged from 2.1% in the US Virgin Islands to 6.1% in West Virginia. Puerto Rico (8.5%) and West Virginia (7.3%) had the highest prevalence of angina/CHD history; Colorado (2.8%) and the US Virgin Islands (2.2%) had the lowest.¹

• Combining the rates for possible and definite CHD shows that 17 to 25 of every 100 American Indian men 45 to 74 years of age have some evidence of heart disease.²

Incidence

• On the basis of unpublished data from the ARIC and CHS studies of the NHLBI:

  	— This year, an estimated 770 000 Americans will have a new coronary attack, and ≈430 000 will have a recurrent attack. It is estimated that an additional 190 000 silent first MIs occur each year.
  	— The estimated annual incidence of MI is 600 000 new attacks and 320 000 recurrent attacks.
  	— Average age at first MI is 64.5 years for men and 70.4 years for women.

• On the basis of the NHLBI’s FHS:

  	— CHD makes up more than half of all cardiovascular events in men and women <75 years of age.3
  	— The lifetime risk of developing CHD after 40 years of age is 49% for men and 32% for women.4
  	— The incidence of CHD in women lags behind men by 10 years for total CHD and by 20 years for more serious clinical events such as MI and sudden death.3

• In the NHLBI’s ARIC study, in participants 45 to 64 years of age, the average age-adjusted CHD incidence rates per 1000 person-years were as follows: white men, 12.5; black men, 10.6; white women, 4.0; and black women, 5.1. Incidence rates excluding revascularization procedures were as follows: white men, 7.9; black men, 9.2; white women, 2.9; and black women, 4.9. In a multivariable analysis, hypertension was a particularly strong risk factor in black women, with hazard rate ratios (95% CI) as follows: black women 4.8 (2.5 to 9.0); white women, 2.1 (1.6 to 2.9); black men, 2.0 (1.3 to 3.0); and white men, 1.6 (1.3 to 1.9). Diabetes mellitus was somewhat more predictive in white women than in other groups. Hazard rate ratios were as follows: black women, 1.8 (1.2 to 2.8); white women, 3.3 (2.4 to 4.6); black men, 1.6 (1.1 to 2.5); and white men, 2.0 (1.6 to 2.6).⁵

• The annual age-adjusted rates per 1000 population of first MI (1987–2001) in ARIC Surveillance (NHLBI) were 4.2 in black men, 3.9 in white men, 2.8 in black women, and 1.7 in white women.⁶

• Among American Indians 65 to 74 years of age, the annual rates per 1000 population of new and recurrent MIs were 7.6 for men and 4.9 for women.²

• Analysis of data from NHANES III and NHANES 1999–2002 (NCHS) showed that in adults 20 to 74 years of age, the overall distribution of 10-year risk of developing CHD changed little during this time. Among the 3 racial/ethnic groups, blacks had the highest proportion of participants in the high-risk group.⁷

Mortality

CHD caused 1 of every 5 deaths in the United States in 2004. CHD mortality was 451 326. CHD total mention mortality was 607 000. MI mortality was 156 816. MI total mention mortality was 196 000 (Vital Statistics of the United States, NCHS). CHD is the largest major killer of American males and females.⁸ About every 26 seconds, an American will suffer a coronary event, and about every minute, someone will die from one. About 38% of the people who experience a coronary attack in a given year will die from it (AHA computation).

• A study of 1275 HMO enrollees 50 to 79 years of age who had cardiac arrest showed that the incidence of out-of-hospital cardiac arrest was 6.0/1000 subject-years in subjects with any clinically recognized heart disease, compared with 0.8/1000 subject-years in subjects without heart disease. In subgroups with heart disease, incidence was 13.6/1000 subject-years in subjects with prior MI and 21.9/1000 subject-years in subjects with HF.⁹

• An analysis of FHS data (NHLBI) from 1950–1999 showed that overall CHD death rates decreased by 59%. Nonsudden CHD death decreased by 64%, and sudden cardiac death fell by 49%. These trends were seen in men and women, in subjects with and without a prior history of CHD, and in smokers and nonsmokers.¹⁰

• From 1994 to 2004, the death rate from CHD declined 33%, but the actual number of deaths declined only 18%. In 2004, the overall CHD death rate was 150.2 per 100 000 population. The death rates were 194.2 for white males and 223.9 for black males; for white females, the rate was 114.7, and for black females it was 148.7.⁸

  — The 2004 death rates for CHD were 119.2 for Hispanics or Latinos, 106.5 for American Indians or Alaska Natives, and 84.1 for Asians or Pacific Islanders.11

• About 82% of people who die of CHD are ≥65 years of age (NCHS; AHA computation).

• The estimated average number of years of life lost because of an MI is 15.¹²

• On the basis of data from the FHS of the NHLBI³:

  •    — Fifty percent of men and 64% of women who die suddenly of CHD have no previous symptoms of this disease. Between 70% and 89% of sudden cardiac deaths occur in men, and the annual incidence is 3 to 4 times higher in men than in women. However, this disparity decreases with advancing age.

  •    — People who have had an MI have a sudden death rate 4 to 6 times that of the general population.

• According to data from the National Registry of Myocardial Infarction¹³:

  	— From 1990 to 1999, in-hospital acute MI mortality declined from 11.2% to 9.4%.
  	— Mortality increases for every 30 minutes that elapse before a patient with ST-segment elevation is recognized and treated.

• CHD death rates have fallen from 1968 to the present. Analysis of NHANES (NCHS) data compared CHD death rates between 1980 and 2000 to determine how much of the decline in deaths from CHD over that period could be explained by the use of medical and surgical treatments versus changes in CVD risk factors (resulting from lifestyle/behavior). After comparing 1980 and 2000, it was estimated that ≈47% of the decrease in CHD deaths was attributable to treatments, including¹⁴:

  	— secondary preventive therapies after MI or revascularization (11%),
  	— initial treatments for AMI or unstable angina (10%),
  	— treatments for HF (9%),
  	— revascularization for chronic angina (5%),
  	— and other therapies (12%), including antihypertensive and lipid-lowering primary prevention therapies.

• It was also estimated that a similar amount of the reduction in CHD deaths, ≈44%, was attributable to changes in risk factors, including¹⁴:

  	— lower total cholesterol (24%),
  	— lower systolic BP (20%),
  	— lower smoking prevalence (12%),
  	— and increased physical inactivity (5%).

However, these favorable improvements in risk factors were partially offset by increases in BMI and in diabetes prevalence, which accounted for an increased number of deaths (8% and 10%, respectively).

Risk Factors

• A study of men and women in 3 prospective cohort studies found that antecedent major CHD risk factor exposures were very common among those who developed CHD. About 90% of the CHD patients have prior exposure to at least 1 of these major risk factors, which include high total blood cholesterol levels or current medication with cholesterol-lowering drugs, hypertension or current medication with BP-lowering drugs, current cigarette use, and clinical report of diabetes.¹⁵

• According to a case-control study of 52 countries (INTERHEART), optimization of 9 easily measured and potentially modifiable risk factors could result in a 90% reduction in the risk of an initial acute MI. The effect of these risk factors is consistent in men and women across different geographic regions and by ethnic group, which makes the study applicable worldwide. These 9 risk factors include cigarette smoking, abnormal blood lipid levels, hypertension, diabetes, abdominal obesity, a lack of physical activity, low daily fruit and vegetable consumption, alcohol overconsumption, and psychosocial index.¹⁶

• A study of >3000 members of the FHS (NHLBI) offspring cohort without CHD showed that among men with 10-year predicted risk for CHD of 20%, both failure to reach target heart rate and ST-segment depression more than doubled the risk of an event, and each MET increment in exercise capacity reduced risk by 13%.¹⁷

• Low CHD risk is defined as BP <120/80 mm Hg, cholesterol <200 mg/dL, and absence of current smoking. Age-adjusted prevalence was estimated in nondiabetic persons without a history of MI participating in 4 NHANES (NCHS) surveys conducted in 1971–1975, 1976–1980, 1988–1994, and 1999–2000.¹⁸

  	— The prevalence of low risk rose from 6% in 1971–1975 to 17% in 1988–1994 and 1999–2000.
  	— Prevalence of low risk was about twice as high in women as in men throughout the period.
  	— Prevalence was initially higher in whites than in blacks (7% versus 3% in 1971–1975); it increased more with time in blacks (17% versus 15% in 1999–2000).
  	— Prevalence of low risk in 1999–2000 was lowest in those 65 to 74 years of age (3%) and was progressively greater at younger ages (29% at 25 to 34 years of age), with similar increases in prevalence over time across age groups.
  	— The greatest changes in the components of low risk from 1971 to 2000 were in prevalence of favorable diastolic BP (from 38% to 71%) compared with favorable systolic BP (from 32% to 47%), nonsmoking (from 60% to 79%), and favorable cholesterol (from 33% to 46%).

• A study of non-Hispanic white persons 35 to 74 years of age in the FHS (NHLBI) and the NHANES III (NCHS) studies showed that 26% of men and 41% of women had at least 1 borderline risk factor in NHANES III. It is estimated that >90% of CHD events will occur in individuals with at least 1 elevated risk factor and that approximately 8% will occur in people with only borderline levels of multiple risk factors. Absolute 10-year CHD risk exceeded 10% in men over 45 years of age who had 1 elevated risk factor and ≥4 borderline risk factors and in those who had ≥2 elevated risk factors. In women, absolute CHD risk exceeded 10% only in those over 55 years of age who had at least 3 elevated risk factors.¹⁹

• Analysis of data from the CHS study (NHLBI) among participants ≥65 years of age at entry into the study showed that subclinical CVD is very prevalent among older individuals, is independently associated with risk of CHD (even over a 10-year follow-up period), and substantially increases the risk of CHD among participants with hypertension or diabetes mellitus.²⁰

Awareness of Warning Signs and Risk Factors for Heart Disease

• Data from the Women Veteran Cohort showed that 42% of women ≥35 years of age were concerned about heart disease. Only 8% to 20% were aware that coronary artery disease is the major cause of death for women.²¹

• Data from the 2001 BRFSS (CDC) survey showed that 95% of respondents recognized chest pain as an MI symptom. However, only 11% correctly classified all symptoms and knew to call 9-1-1 when someone was having an MI. This random digit–dialed telephone survey was conducted in 17 states and the US Virgin Islands.²²

• A 2004 national study of physician awareness and adherence to CVD prevention guidelines showed that fewer than 1 in 5 physicians knew that more women than men die each year from CVD.²³

• A recent community surveillance study in 4 US communities reported that in 2000 the overall proportion of persons with delays of ≥4 hours from onset of acute MI symptoms to hospital arrival was 49.5%. The study also reported that from 1987 to 2000 there was no statistically significant change in the proportion of patients delaying ≥4 hours, which indicates that there has been little improvement in the speed at which patients with MI symptoms arrive at the hospital after onset. Although the proportion of MI patients who arrived at the hospital by EMS increased over this period, from 37% in 1987% to 55% in 2000, the total time between onset and hospital arrival did not change appreciably.²⁴

• A survey of over 500 internists and OB/GYNs attending presentations developed for the NY State Women and Heart Disease Physician Education Initiative found that 71.5% correctly responded to 13 questions assessing knowledge of coronary risk prevention. Of the attendees, 71.5% were internists, and 42.7% were women. Almost one third of internists and half of OB/GYNs did not know that tobacco use was the leading cause of MI in young women. For patients who smoked tobacco, only two thirds of internists and 55.4% of OB/GYNs reported suggesting a quit date.²⁵

• A study of the perceptions of susceptibility and seriousness of heart disease and the relationships between socioeconomic status, age, and knowledge of heart disease and its risk factors was conducted among 194 educated black women. Participants did not perceive themselves to be at high risk for developing heart disease, although they did perceive heart disease as serious. Black women who were older perceived heart disease to be more serious than their younger counterparts. Older women and those with higher socioeconomic status knew more about heart disease and risk factors. Neither socioeconomic status nor age moderated the relationship between knowledge and perceived susceptibility or seriousness.²⁶

• According to 2003 data from the BRFSS (CDC), 36.5% of all women surveyed had multiple risk factors for heart disease and stroke. The age-standardized prevalence of multiple risk factors was lowest in whites and Asians. After adjustment for age, income, education, and health coverage, the odds for multiple risk factors were greater in black and Native American women and lower for Hispanic women as compared with white women. Prevalence estimates and odds of multiple risk factors increased with age; decreased with education, income, and employment; and were lower in those with no health coverage. Smoking was more common in younger women, whereas older women were more likely to have medical conditions and to be physically inactive.²⁷

• In an effort to understand why women delay seeking treatment for symptoms of an acute MI, 30 interviews were conducted to determine black, Hispanic, and white women’s perceptions of heart disease risk and whether differences existed on the basis of the participants’ race or ethnicity. Perceptions of heart disease risk were similar between groups, with women generally believing that they were at risk for heart disease because of family history, diet, and obesity. Racial and ethnic differences were noted, however, in risk reduction and anticipated treatment-seeking behaviors.²⁸

Aftermath

• Depending on their gender and clinical outcome, people who survive the acute stage of an MI have a chance of illness and death 1.5 to 15 times higher than that of the general population. Among these people, the risk of another MI, sudden death, AP, HF, and stroke—for both men and women—is substantial (FHS, NHLBI).³

• A Mayo Clinic study found that cardiac rehabilitation after an MI is underused, particularly in women and the elderly. Women were 55% less likely than men to participate in cardiac rehabilitation, and older study patients were less likely than younger participants. Only 32% of men and women ≥70 years of age participated in cardiac rehabilitation, compared with 66% of 60- to 69-year-olds and 81% of those <60 years of age.²⁹

• On the basis of pooled data from the FHS, ARIC, and CHS studies of the NHLBI, within 1 year after a first MI:

  	— At ≥40 years of age, 18% of men and 23% of women will die.
  	— At 40 to 69 years of age, 8% of white men, 12% of white women, 14% of black men, and 11% of black women will die.
  	— At ≥70 years of age, 27% of white men, 32% of white women, 26% of black men, and 28% of black women will die.
  	— In part because women have MIs at older ages than men do, they are more likely to die from MIs within a few weeks.

• Within 5 years after a first MI:

  	— At ≥40 years of age, 33% of men and 43% of women will die.
  	— At 40 to 69 years of age, 15% of white men, 22% of white women, 27% of black men, and 32% of black women will die.
  	— At ≥70 years of age, 50% of white men, 56% of white women, 56% of black men, and 62% of black women will die.

• Of those who have a first MI, the percentage with a recurrent MI or fatal CHD within 5 years is:

  	— at 40 to 69 years of age, 16% of men and 22% of women.
  	— at 40 to 69 years of age, 14% of white men, 18% of white women, 27% of black men, and 29% of black women.
  	— at ≥70 years of age, 24% of white men and women, 30% of black men, and 32% of black women.

• The percentage of persons with a first MI who will have HF in 5 years is:

  	— at 40 to 69 years of age, 7% of men and 12% of women.
  	— at ≥70 years of age, 22% of men and 25% of women.
  	— at 40 to 69 years of age, 7% of white men, 11% of white women, 11% of black men, and 14% of black women.
  	— at ≥70 years of age, 21% of white men, 25% of white women, 29% of black men, and 24% of black women.

• The percentage of persons with a first MI who will have a stroke within 5 years is:

  	— at 40 to 69 years of age, 4% of men and 6% of women.
  	— at ≥70 years of age, 6% of men and 11% of women.
  	— at 40 to 69 years of age, 3% of white men, 5% of white women, 8% of black men, and 9% of black women.
  	— at ≥70 years of age, 6% of white men, 10% of white women, 7% of black men, and 17% of black women.

• The percentage of persons with a first MI who will experience sudden death in 5 years is:

  	— at 40 to 69 years of age, 1.1% of white men, 1.9% of white women, 2.5% of black men, and 1.4% of black women.
  	— at ≥70 years of age, 6.0% of white men, 3.5% of white women, 14.9% of black men, and 4.8% of black women.

• The median survival time (in years) after a first MI is:

  	— at 60 to 69 years of age, data not available for men and 7.4 for women.
  	— at 70 to 79 years of age, 7.4 for men and 10.4 for women.
  	— at ≥80 years of age, 2.0 for men and 6.4 for women.

Hospital Discharges and Ambulatory Care Visits

• From 1979 to 2005, the number of inpatient discharges from short-stay hospitals with CHD as the first-listed diagnosis increased 5% to 1 828 000 (NHDS, NCHS; AHA computation).

• Data from Ambulatory Care Visits to Physician Offices, Hospital Outpatient Departments, and Emergency Departments: United States, 2001 to 2002, showed the number of visits for CHD as 12.975 million (NAMCS, NHAMCS).³⁰

• Most hospitalized patients over 65 years of age are women. For MI, 28.4% of hospital stays for people 45 to 64 years of age were for women, but 63.7% of stays for those ≥85 years of age were for women. Similarly, for coronary atherosclerosis, 32.7% of stays were for women among people 45 to 64 years of age; this figure increased to 60.7% of stays among those ≥85 years of age. For nonspecific chest pain, women were more numerous than men among patients under 65 years of age. About 54.4% were for women 45 to 64 years of age. Women constituted 73.9% of nonspecific chest pain stays among patients ≥85 years of age—higher than for any other condition examined. For AMI, one third more women than men died in the hospital: 9.3% of women died in the hospital, compared with 6.2% of men.³¹

Cost

• The estimated direct and indirect cost of CHD for 2008 is $156.4 billion.

• In 2003, $12.2 billion was paid to Medicare beneficiaries for in-hospital costs when CHD was the principal diagnosis ($12 321 per discharge for acute MI, $11 783 per discharge for coronary atherosclerosis, and $5127 per discharge for other ischemic heart disease).³²

Operations and Procedures

• In 2005, an estimated 1 271 000 inpatient angioplasty procedures, 469 000 inpatient bypass procedures, 1 322 000 inpatient diagnostic cardiac catheterizations, 91 000 inpatient implantable defibrillators, and 180 000 pacemaker procedures were performed for inpatients in the United States (unpublished data from the NHDS 2005, NCHS; personal communication, July 2007).

Acute Coronary Syndrome

ICD-9 codes 410, 411.

The term “acute coronary syndrome” (ACS) is increasingly used to describe patients who present with either acute MI or unstable angina. (Unstable angina [UA] is chest pain or discomfort that is accelerating in frequency or severity and may occur while at rest but does not result in myocardial necrosis. The discomfort may be more severe and prolonged than typical AP or may be the first time a person has AP. Unstable angina, non–ST-elevation MI, and ST-elevation MI share common pathophysiological origins related to coronary plaque progression, instability, or rupture with or without luminal thrombosis and vasospasm.)

• A conservative estimate for the number of discharges with ACS from hospitals in 2005 is 772 000. Of these, an estimated 448 000 are male and 324 000 are female. This estimate is derived by adding the first-listed inpatient hospital discharges for MI (683 000) to those for UA (89 000) (NHDS, NCHS).

• When including secondary discharge diagnoses in 2005, the corresponding numbers of inpatient hospital discharges were 1 413 000 unique hospitalizations for ACS; 820 000 are male and 593 000 are female. Of the total, 838 000 were for MI alone, and 558 000 were for UA alone (17 000 hospitalizations received both diagnoses (NHDS, NCHS).

Decisions about medical and interventional treatments are based on specific findings noted when a patient presents with ACS. Such patients are classified clinically into 1 of 3 categories, according to the presence or absence of ST-segment elevation on the presenting ECG and abnormal (“positive”) elevations of myocardial biomarkers such as troponins as follows:

• ST-elevation MI

• non–ST-elevation MI

• unstable angina

The percentage of ACS or MI with ST elevation varies in different registries/databases and depends heavily on the age of patients included and the type of surveillance used. According to the National Registry of Myocardial Infarction 4 (NRMI-4), about 29% of MI patients are STEMI patients.³³ The AHA Get With The Guidelines project found that 32% of the MI patients in the CAD module are STEMI patients (AHA Get With The Guidelines Staff, personal communication, October 1, 2007). The study of the Global Registry of Acute Coronary Events (GRACE), which includes US patient populations, found that 38% of ACS patients have STEMI, whereas the second Euro Heart Survey on ACS (EHS-ACS-II) reported that about 47% of ACS patients have STEMI.³⁴

• Analysis of data from the GRACE multinational observational cohort study of patients with ACS found evidence of a change in practice for both pharmacological and interventional treatments in patients with either STEMI or NSTE ACS. These changes are accompanied by significant decreases in the rates of in-hospital death, cardiogenic shock, and new MI among patients with NSTE ACS. The use of evidence-based therapies and PCI interventions increased in the STEMI population. This increase was matched with a statistically significant decrease in the rates of death, cardiogenic shock, and HF or pulmonary edema.³⁵

• A study of patients with NSTE ACS treated at 350 US hospitals found that up to 25% of opportunities to provide ACC/AHA guideline–recommended care were missed in current practice. Composite guideline adherence rate was significantly associated with in-hospital mortality.³⁶

Angina Pectoris

ICD-9 413; ICD-10 I20. SeeTable 3-2andChart 3-5.

Prevalence

• A study of 4 national cross-sectional health examination studies found that among Americans 40 to 74 years of age, the age-adjusted prevalence of AP was higher among women than men. Increases in the prevalence of AP occurred for Mexican-American men and women and African-American women but were not statistically significant for the latter.³⁷

Incidence

• Only 18% of coronary attacks are preceded by long-standing AP (NHLBI computation of FHS follow-up since 1986).

• The annual rates per 1000 population of new episodes of AP for nonblack men are 28.3 for 65 to 74 years of age, 36.3 for 75 to 84 years of age, and 33.0 for those ≥85 years of age. For nonblack women in the same age groups, the rates are 14.1, 20.0, and 22.9, respectively. For black men, the rates are 22.4, 33.8, and 39.5; for black women, the rates are 15.3, 23.6, and 35.9, respectively (CHS, NHLBI).⁶

• On the basis of 1987–2001 data from the ARIC study of the NHLBI, the annual rates per 1000 population of new episodes of AP for nonblack men are 8.5 for those 45 to 54 years of age, 11.9 for those 55 to 64 years of age, and 13.7 for those 65 to 74 years of age. For nonblack women in the same age groups, the rates are 10.6, 11.2, and 13.1, respectively. For black men, the rates are 11.8, 10.6, and 8.8; for black women, the rates are 20.8, 19.3, and 10.0, respectively.⁶

Mortality

A small number of deaths resulting from CHD are coded as being from AP. These are included as a portion of total deaths from CHD.

Cost

For women with nonobstructive CHD enrolled in the Women’s Ischemia Syndrome Evaluation (WISE) study of the NHLBI, the average lifetime cost estimate was about $770 000 and ranged from $1.0 to $1.1 million for women with 1-vessel to 3-vessel CHD.³⁸

ICD-9 430-438, ICD-10 I60-I69. SeeTables 4-1 and 4-2andCharts 4-1 through 4-6.

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Prevalence

• Among American Indians/Alaska Natives ≥18 years of age, it is estimated that 5.8% have had a stroke (estimate considered unreliable). Among blacks, the rate was 3.4%; among whites, it was 2.3%; and among Asians, it was 2.0% (NHIS, NCHS).¹

• The 2005 BRFSS survey (CDC) found that many states with high stroke prevalence are concentrated in the Southeast, a region traditionally called the “stroke belt” because of its high rates of stroke mortality. However, certain states (Illinois, Michigan, Missouri, Nevada, Texas, and West Virginia) in other US regions also had prevalence estimates of 3.0% or higher, among the highest in the country. The overall prevalences of stroke among American Indians/Alaska Natives (6.0%), multiracial persons (4.6%), and blacks (4.0%) were higher than the prevalence among whites (2.3%). The prevalences of stroke among Asians/Pacific Islanders (1.6%; interpret with caution) and Hispanics (2.6%) were similar to the prevalence among whites.²

• The prevalence of silent cerebral infarction between 55 and 64 years of age is approximately 11%. This prevalence increases to 22% between 65 and 69 years of age, 28% between 70 and 74 years of age, 32% between 75 and 79 years of age, 40% between 80 and 85 years of age, and 43% above 85 years of age. The application of these rates to 1998 US population estimates results in an estimated 13 million people with prevalent silent stroke.^3,4

• The prevalence of stroke in American Indian men 45 to 74 years of age ranges from 0.2% to 1.4%. Among American Indian women in the same age group, the prevalence ranges from 0.2% to 0.7%.⁵

• The prevalence of stroke symptoms was found to be relatively high in a general population free of a prior diagnosis of stroke or transient ischemic attack. On the basis of data from 18 462 participants enrolled in a national cohort study, 17.8% of the population over 45 years of age reported at least 1 symptom. Stroke symptoms were more likely among blacks than whites, among those with lower income and less education, and among those with fair-to-poor perceived health status. Symptoms were also more likely in participants with higher Framingham Stroke Risk Score.⁶

• According to data from the 2005 BRFSS (CDC), 2.7% of men and 2.5% of women ≥18 years of age had a history of stroke. Among these, 2.3% were non-Hispanic white, 4.0% were non-Hispanic black, 1.6% were Asian/Pacific Islander (interpret with caution), 2.6% were Hispanic (might be of any race), 6.0% were American Indian/Alaska Native, and 4.6% were multiracial (see Table 4-2).²

Transient Ischemic Attack

• The prevalence of transient ischemic attack (TIA; a mini-stroke that lasts <24 hours) in men is estimated to be 2.7% for those 65 to 69 years of age and 3.6% for those 75 to 79 years of age. For women, TIA prevalence is estimated to be 1.6% for those 65 to 69 years of age and 4.1% for those 75 to 79 years of age.⁷

• Approximately 15% of all strokes are heralded by a TIA.⁸

• One third of spells characterized as TIAs according to the classic definition (focal neurological deficits that resolve within 24 hours) would be considered infarctions on the basis of diffusion-weighted magnetic resonance imaging findings.⁹

• In population-based studies, the age- and gender-adjusted incidence rates for TIA range from 68.2 to 83 per 100 000. Males and blacks have higher rates of TIA.^10,11

• Approximately half of all patients who experience a TIA fail to report it to their healthcare providers.^12,13

• After TIA, the 90-day risk of stroke is 3% to 17.3% and is highest within the first 30 days.^11,12,14,15

• Within 1 year of TIA, up to one fourth of patients will die.^11,16

• Individuals who have a TIA have a 10-year stroke risk of 18.8% and a combined 10-year stroke, MI, or vascular death risk of 42.8% (4% per year).¹⁷

• In the North American Symptomatic Carotid Endarterectomy Trial (NASCET) study, patients with a first-ever hemispheric TIA had a 90-day stroke risk of 20.1%. The risk of stroke after TIA exceeded the risk after hemispheric stroke.¹⁸

Incidence

• Each year, approximately 780 000 people experience a new or recurrent stroke. Approximately 600 000 of these are first attacks, and 180 000 are recurrent attacks (GCNKSS, NINDS and NHLBI; GCNKSS, NINDS data for 1999 provided August 1, 2007; US estimates compiled by NHLBI).

• On average, every 40 seconds, someone in the United States has a stroke (AHA computation based on latest available data).

• Each year, approximately 60 000 more women than men have a stroke (GCNKSS, NINDS).

• Men’s stroke incidence rates are greater than women’s at younger ages but not at older ages. The male/female incidence ratio (11/9) was 1.25 in those 55 to 64 years of age, 1.50 in those 65 to 74 years of age, 1.07 in those 75 to 84 years of age, and 0.76 in those ≥85 years of age (ARIC and CHS studies, NHLBI).¹⁹

• Data from the GCNKSS, NINDS show that the annual incidence of first-ever hospitalized stroke did not change significantly between study periods: 158 per 100 000 in both 1993–1994 and 1999. Blacks continue to have a higher stroke incidence than whites, especially among the young. Despite advances in stroke prevention treatments during the 1990s, the incidence of hospitalized stroke did not decrease within the population being studied. Case fatality also did not change between study periods. Excess stroke mortality rates seen in blacks nationally are likely the result of excess stroke incidence and not case fatality, and the racial disparity in stroke incidence did not change over time.²⁰

• Blacks have a risk of first-ever stroke that is almost twice that of whites. The age-adjusted stroke incidence rates in people 45 to 84 years of age are 6.6 per 1000 population in black males, 3.6 in white males, 4.9 in black females, and 2.3 in white females (ARIC, NHLBI).¹⁹ On the basis of 1987–2001 data from the ARIC study of the NHLBI, stroke/TIA incidence rates (per 1000 person-years) are 2.4 for white males 45 to 54 years of age, 6.1 for white males 55 to 64 years of age, and 12.2 for white males 65 to 74 years of age. For white women in the same age groups, the rates are 2.4, 4.8, and 9.8, respectively. For black men in the same age groups, the rates are 9.7, 13.1, and 16.2, and for black women, the rates are 7.2, 10.0, and 15.0, respectively.¹⁹

• Of all strokes, 87% are ischemic, 10% are intracerebral hemorrhage, and 3% are subarachnoid hemorrhage strokes (GCNKSS, NINDS 1999).¹⁹

• The Brain Attack Surveillance in Corpus Christi (BASIC, NINDS) project clearly demonstrated an increased incidence of stroke among Mexican Americans as compared with non-Hispanic whites in this community. The crude cumulative incidence was 168 per 10 000 in Mexican Americans and 136 per 10 000 in non-Hispanic whites. Specifically, Mexican Americans have a higher incidence of intracerebral hemorrhage and subarachnoid hemorrhage than that of non-Hispanic whites, adjusted for age, as well as a higher incidence of ischemic stroke and TIA at younger ages than non-Hispanic whites.²¹

• The age-adjusted annual incidence rate (per 1000) for total stroke in Japanese-American men has declined markedly from 5.1 to 2.4; for thromboembolic stroke, from 3.5 to 1.9; and for hemorrhagic stroke, from 1.1 to 0.6. The estimated average annual declines are 5% for total stroke, 3.5% for thromboembolic stroke, and 4.3% for hemorrhagic stroke. The decline in stroke mortality in the Honolulu Heart Program (HHP) target population was similar to that reported for US white males 60 to 69 years of age during the same period (during the 1969–1988 follow-up period of the HHP; NHLBI).

• Among American Indians 65 to 74 years of age, the annual rates per 1000 population of new and recurrent strokes are 6.1 for men and 6.6 for women.⁵

• The age-adjusted incidence of first ischemic stroke per 100 000 was 88 in whites, 191 in blacks, and 149 in Hispanics according to data from the Northern Manhattan Study (NOMAS, NINDS). Among blacks, compared with whites, the relative rate of intracranial atherosclerotic stroke was 5.85; extracranial atherosclerotic stroke, 3.18; lacunar stroke, 3.09; and cardioembolic stroke, 1.58. Among Hispanics, compared with whites, the relative rate of intracranial atherosclerotic stroke was 5.00; extracranial atherosclerotic stroke, 1.71; lacunar stroke, 2.32; and cardioembolic stroke, 1.42.²²

• Analysis of data from the FHS study of the NHLBI, from 1950 to 1977, 1978 to 1989, and 1990 to 2004, showed that the age-adjusted incidence of first stroke per 1000 person-years in each of the 3 periods was 7.6, 6.2, and 5.3 in men and 6.2, 5.8, and 5.1 in women, respectively. Lifetime risk at the age of 65 years decreased significantly, from 19.5% to 14.5% in men and from 18.0% to 16.1% in women. Age-adjusted stroke severity did not vary across periods; however, 30-day mortality decreased significantly in men (from 23% to 14%) but not in women (from 21% to 20%).²³

Mortality

Stroke accounted for approximately 1 of every 16 deaths in the United States in 2004. Approximately 54% of stroke deaths in 2004 occurred out of the hospital.²⁴

• Stroke mortality—150 074; total-mention mortality in 2004 was approximately 253 000.²⁴

• When considered separately from other CVDs, stroke ranks No. 3 among all causes of death, behind diseases of the heart and cancer (NCHS mortality data).

• On average, every 3 to 4 minutes, someone dies of a stroke (NCHS, NHLBI).

• Among persons 45 to 64 years of age, 8% to 12% of ischemic strokes and 37% to 38% of hemorrhagic strokes result in death within 30 days, according to the ARIC study of the NHLBI.²⁵

• In a study of persons ≥65 years of age recruited from a random sample of Health Care Financing Administration Medicare Part B eligibility lists in 4 US communities, the 1-month case fatality rate was 12.6% for all strokes, 8.1% for ischemic strokes, and 44.6% for hemorrhagic strokes.²⁶

• From 1994 to 2004, the stroke death rate fell 24.2%, and the actual number of stroke deaths declined 6.8%.²⁷

• Conclusions about changes in stroke death rates from 1983 to 2004:

  	— There was a greater decline in stroke death rates in males than in females, with a male/female ratio decreasing from 1.11 to 1.03 (age-adjusted).
  	— There were greater declines in stroke death rates at ≥65 years of age in men than in women compared with younger ages.27

• The 2004 overall death rate for stroke was 50.0 per 100 000. Death rates were 48.1 for white males, 74.9 for black males, 47.2 for white females, and 65.5 for black females.²⁷

• In 2004, death rates for stroke were 41.5 for Hispanic or Latino males and 35.4 for females; 44.2 for Asian or Pacific Islander males and 38.9 for females; and 35.0 for American Indian/Alaska Native males and 35.1 for females.²⁸

• Because women live longer than men, more women than men die of stroke each year. Women accounted for 61.0% of US stroke deaths in 2004 (AHA computation).

• From 1995 to 1998, age-standardized mortality rates for ischemic stroke, subarachnoid hemorrhage, and intracerebral hemorrhage were higher among blacks than whites. Death rates from intracerebral hemorrhage were also higher among Asians/Pacific Islanders than among whites. All minority populations had higher death rates from subarachnoid hemorrhage than did whites. Among adults 25 to 44 years of age, blacks and American Indians/Alaska Natives had higher risk ratios than did whites for all 3 stroke subtypes.²⁹

• In 2002, death certificate data showed that the mean age at stroke death was 79.6 years; however, males had a younger mean age at stroke death than females. Blacks, American Indians/Alaska Natives, and Asians/Pacific Islanders had younger mean ages than whites, and the mean age at stroke death was also younger among Hispanics than non-Hispanics.³⁰

• Age-adjusted stroke mortality rates began to level in the 1980s and stabilized in the 1990s for both men and women, according to the Minnesota Heart Study. Women had lower rates of stroke mortality than men did throughout the period. Some of the improvement in stroke mortality may be the result of improved acute stroke care, but most is thought to be the result of improved detection and treatment of hypertension.³¹

Stroke Risk Factors

• TIAs confer a substantial short-term risk of stroke, hospitalization for cardiovascular events, and death. Of 1707 TIA patients evaluated in the ED of a large healthcare plan, 180 patients, or 10%, developed stroke within 90 days. Ninety-one patients, or 5%, did so within 2 days. Predictors of stroke included age >60 years, having diabetes mellitus, focal symptoms of weakness or speech impairment, and TIA that lasted >10 minutes.³²

• The risk of ischemic stroke associated with cigarette smoking has been shown to be approximately double that of nonsmokers after adjustment for other risk factors (FHS, CHS, HHP, NHLBI). Atrial fibrillation (AF) is an independent risk factor for stroke, increasing risk approximately 5-fold.³³

• In adults >55 years of age, the lifetime risk for stroke is greater than 1 in 6. Women have a higher risk than men, perhaps because of women’s survival advantage. BP is a powerful determinant of stroke risk. Subjects with BP <120/80 mm Hg have approximately half the lifetime risk of stroke of subjects with hypertension.³⁴

• Ischemic stroke patients with diabetes are younger, more likely to be black, and more likely to have hypertension, MI, and high cholesterol than nondiabetic patients, according to data from the GCNKSS/NINDS study. Age-specific incidence rates and rate ratios show that diabetes increases ischemic stroke incidence at all ages, but this risk is most prominent before 55 years of age in blacks and before 65 years of age in whites. One-year case fatality rates after ischemic stroke are not different between patients with and without diabetes.³⁵

• A study of >37 000 women ≥45 years of age participating in the Women’s Health Study suggests that a healthy lifestyle that consists of abstinence from smoking, low BMI, moderate alcohol consumption, regular exercise, and a healthy diet was associated with a significantly reduced risk of total and ischemic stroke but not of hemorrhagic stroke.³⁶

• In a recent ARIC/NHLBI study of a biracial population 45 to 64 years of age, with an average follow-up of 13.4 years, researchers found that blacks had a 3-fold higher multivariate-adjusted risk ratio of lacunar stroke than whites, whereas no difference in nonlacunar strokes was found after adjustment for prevalent risk factors between these 2 groups. The top 3 risk factors based on the population-attributable fraction for lacunar stroke were hypertension (population-attributable fraction 33.9%), diabetes mellitus (26.3%), and current smoking (22.0%). The top 3 risk factors for nonlacunar stroke were hypertension (35.3%), current smoking (11.4%), and diabetes mellitus (11.3%).³⁷

• In the Women’s Health Initiative trial, among 10 739 women with hysterectomy, it was found that conjugate equine estrogen alone increased risk of ischemic stroke by 55%, and there was no significant effect on hemorrhagic stroke. The excess risk of total stroke conferred by estrogen alone was 12 additional strokes per 10 000 person-years.³⁸

• In the FHS of the NHLBI, in participants <65 years of age, the risk of developing stroke/TIA was 4.21 times greater in those with symptoms of depression. After adjustment for components of the Framingham Stroke Risk Profile and education, similar results were obtained. In subjects ≥65 years of age, use of antidepressant medications did not alter the risk associated with depressive symptoms. Identification of depressive symptoms at younger ages may have an impact on the primary prevention of stroke.³⁹

• High BP is the biggest risk factor for stroke.⁴⁰

• Data from the HHP/NHLBI found that in Japanese men 71 to 93 years of age, low concentrations of high-density lipoprotein (HDL) cholesterol were more likely to be associated with a future risk of thromboembolic stroke than were high concentrations.⁴¹

Pregnancy as a Risk Factor for Stroke

• The risk of ischemic stroke or intracerebral hemorrhage during pregnancy and the first 6 weeks postpartum was 2.4 times greater than for nonpregnant women of similar age and race, according to the Baltimore-Washington Cooperative Young Stroke Study. The risk of ischemic stroke during pregnancy was not increased during pregnancy per se but was increased 8.7-fold during the 6 weeks postpartum. Intracerebral hemorrhage showed a small relative risk (RR) of 2.5 during pregnancy but increased dramatically to an RR of 28.3 in the 6 weeks postpartum. The excess risk of stroke (all types except subarachnoid hemorrhage) attributable to the combined pregnancy/postpregnancy period was 8.1 per 100 000 pregnancies.⁴²

• With Swedish administrative data, it was found that ischemic stroke and intracerebral hemorrhage, including subarachnoid hemorrhage, are increased in association with pregnancy. Compared with the risk of stroke among women who were not pregnant or who were in early pregnancy (up to the first 27 gestational weeks), women in the peripartum (from 2 days before to 1 day after delivery) and the puerperium (from 2 days before to 6 complete weeks after delivery) periods were at increased risk for all 3 major stroke types. The 3 days surrounding delivery were the time of highest risk.⁴³

• In the US Nationwide Inpatient Sample from 2000 to 2001, the rate of events per 100 000 pregnancies was 9.2 for ischemic stroke, 8.5 for intracerebral hemorrhage, 0.6 for cerebral venous thrombosis, and 15.9 for the ill-defined category of pregnancy-related cerebrovascular events, or a total rate of 34.2 per 100 000, not including subarachnoid hemorrhage. The risk was increased in blacks and among older women. Death occurred during hospitalization in 4.1% of women with these events and in 22% of survivors after discharge to a facility other than home.⁴⁴

Postmenopause as a Risk Factor for Stroke

• Stroke is a major health issue for women, particularly for postmenopausal women, which raises the question of whether increased incidence is due to aging or to hormone status and whether hormone therapy affects risk.⁴⁵

• Among postmenopausal women who were generally healthy, the Women’s Health Initiative, a randomized trial of 16 608 women (95% of whom had no preexisting CVD), found that estrogen plus progestin increased ischemic stroke risk by 44%, with no effect on hemorrhagic stroke. The excess risk was apparent in all age groups, in all categories of baseline stroke risk, and in women with and without hypertension or prior history of CVD.⁴⁶

• In postmenopausal women with known CHD, the Heart and Estrogen/progestin Replacement Study (HERS), a secondary CHD prevention trial, found that a combination of estrogen plus progestin (conjugated equine estrogen [0.625 mg] and medroxyprogesterone acetate [2.5 mg]) hormone therapy did not reduce stroke risk.⁴⁷

• The Women’s Estrogen for Stroke Trial (WEST) found that estrogen alone (1 mg of 17B-estradiol) in women with a mean age of 71 years also had no significant overall effect on recurrent stroke or fatality, but there was an increased rate of fatal stroke and an early rise in overall stroke rate in the first 6 months.⁴⁸

• Clinical trial data indicate that the use of estrogen plus progestin, as well as estrogen alone, increases stroke risk in postmenopausal, generally healthy women and provides no protection for women with established heart disease.^46,49

Physical Inactivity as a Risk Factor for Stroke

• PA reduces stroke risk. Results from the Physicians’ Health Study showed a lower stroke risk associated with vigorous exercise among men (total stroke RR=0.86 for exercise ≥5 times per week).⁵⁰ The Harvard Alumni Study showed a decrease in total stroke risk in men who were highly physically active (RR=0.82).⁵¹ More recently, a clear inverse relationship between stroke incidence and increasing levels of combined work and leisure activity were shown in the EPIC-Norfolk study of 22 602 men and women, with a nearly 40% risk reduction in the most active category. In sex-stratified analysis, the trend was not significant in women.⁵²

• For women in the Nurses’ Health Study, RRs for total stroke from the lowest to the highest PA levels were 1.00, 0.98, 0.82, 0.74, and 0.66, respectively.⁵³

• NOMAS (NINDS), which included white, black, and Hispanic men and women in an urban setting, showed a decrease in ischemic stroke risk associated with PA levels across all racial/ethnic and age groups and for each gender (odds ratio [OR] 0.37).⁵⁴

• PA—be it in sports, during leisure time, or at work—was related to reduced risk of ischemic stroke according to a follow-up of the ARIC/NHLBI cohort.⁵⁵

• The association between type of PA and stroke risk has been investigated in several studies. In an evaluation of walking and sports participation in a cohort of 73 265 men and women in Japan, risk of stroke death in the highest category of walking and sports participation was reduced by 29% and 20%, respectively.⁵⁶ In a study of 47 721 men and women in Finland, the effect of leisure-time, occupational, and commuting PA on incident stroke was investigated. Significant trends toward lower stroke risk were associated with moderate and high levels of leisure-time activity and active commuting, with the strongest trend seen for ischemic stroke; a smaller but still significant benefit was seen with occupational activity.⁵⁷ A meta-analysis of reports of 31 observational studies conducted mainly in the United States and Europe found that moderate and high levels of leisure-time and occupational PA protected against total stroke, hemorrhagic stroke, and ischemic stroke.⁵⁸

Awareness of Stroke Warning Signs and Risk Factors

• 2001 data from the BRFSS (CDC) survey in 17 states and the US Virgin Islands showed that public awareness of the major stroke warning signs was high⁵⁹:

  	— Sudden numbness or weakness of the face, arm, or leg—94.1%;
  	— Sudden confusion, trouble speaking, or trouble understanding—87.9%.
  	— Sudden trouble walking, dizziness, or loss of balance or coordination—85%.
  	— Sudden trouble seeing in 1 or both eyes—68.1%.
  	— Sudden severe headache with no known cause—61.3%.

• Of the respondents, 37.8% incorrectly reported sudden chest pain as a sign of stroke.⁵⁹

• A study was conducted of patients admitted to an ED with possible stroke to determine their knowledge of the signs, symptoms, and risk factors of stroke. Of the 163 patients able to respond, 39% did not know a single sign or symptom. Patients >65 years of age were less likely than those <65 years old to know a sign or symptom of stroke (28% versus 47%), and 43% did not know a single risk factor. Overall, almost 40% of patients did not know the signs, symptoms, and risk factors of stroke.⁶⁰

• A study of >2100 respondents to a random-digit telephone survey in Cincinnati, Ohio, in 2000 showed that 70% of respondents correctly named at least 1 established stroke warning sign (versus 57% in 1995), and 72% correctly named at least 1 established risk factor (versus 68% in 1995).^61,62 In the 1995 survey,⁶² respondents ≥75 years of age were less likely to correctly list 1 warning sign and to list 1 risk factor.

• Only 17.2% of adults overall correctly classified all stroke symptoms and indicated that they would call 9-1-1 if they thought someone was having a stroke, according to 2001 BRFSS/CDC data from >61 000 adults.⁶³

• Among patients recruited from the Academic Medical Center Consortium, the CHS, and United HealthCare, only 41% were aware of their increased risk for stroke. Approximately 74% recalled being told of their increased stroke risk by a physician, compared with 28% who did not recall this. Younger patients, depressed patients, those in poor current health, and those with a history of TIA were most likely to be aware of their risk.⁶⁴

• An AHA-sponsored random-digit dialing telephone survey was conducted in mid-2003. Only 26% of women over 65 years of age reported being well informed about stroke. Correct identification of the warning signs of stroke was low among all racial/ethnic and age groups.⁶⁵

• Among participants in a study by the National Stroke Association, 2.3% reported having been told by a physician that they had had a TIA. Of those with a TIA, only 64% saw a physician within 24 hours of the event, only 8.2% correctly related the definition of TIA, and 8.6% could identify a typical symptom. Men, nonwhites, and those with lower income and fewer years of education were less likely to be knowledgeable about TIA.¹⁰

• Participants in the 1999 World Senior Games received 1 or more free screening tests and completed an awareness questionnaire. Results indicate that stroke education should be targeted at the very elderly, those who have less than a college education, and those who do not have a history of chronic disease. It also may be effectively directed toward those with higher cholesterol.⁶⁶

• Insufficient awareness persists in the general medical community with regard to risk factors, warning signs, and prevention strategies for stroke. A survey of 308 internal medicine residency programs showed only 46% required the study of neurology, and 97% required the study of cardiology. Underrepresentation of neurology in internal medicine residency programs may contribute to stroke outcome.⁶⁷

• In 2004, 800 adults ≥45 years of age were surveyed to assess their perceived risk for stroke and their history of stroke risk factors. Overall, 39% perceived themselves to be at risk. Younger age, current smoking, a history of diabetes, high BP, high cholesterol, heart disease, and stroke/TIA were independently associated with perceived risk for stroke. Respondents with AF were no more likely to report being at risk than were respondents without AF. Perceived risk for stroke increased as the number of risk factors increased; however, 46% of those with ≥3 risk factors did not perceive themselves to be at risk.⁶⁸

• A telephone survey of adults ≥45 years of age in 2 Montana counties showed that >70% were able to correctly name ≥2 warning signs for stroke. More than 45% were able to name ≥2 risk factors. Respondents 45 to 64 years of age, women, those with ≥12 years of education, and those with high cholesterol were more likely to correctly identify ≥2 warning signs than were those without these characteristics. Women and respondents 45 to 64 years of age were also more likely than men or older respondents to correctly identify ≥2 stroke risk factors.⁶⁹

• A study of patients who have had a stroke found that only 60.5% were able to accurately identify 1 stroke risk factor, and 55.3% were able to identify 1 stroke symptom. Patients’ median delay time from onset of symptoms to admission in the ED was 16 hours, and only 31.6% accessed the ED in <2 hours. Analysis showed that the appearance of nonmotor symptoms as the primary symptom and nonuse of the 9-1-1 system were significant predictors of delay >2 hours. Someone other than the patient made the decision to seek treatment in 66% of the cases.⁷⁰

• Research confirms that first- and second-generation Hispanic adolescents and young adults continue to demonstrate increased levels of smoking, physical inactivity, and obesity. When educational material is presented in a familiar environment and offers lifestyle options that are culturally realistic, there is an increase in knowledge and compliance with lifestyle changes.⁷¹

• Spanish-speaking Hispanics are far less likely to know all heart attack symptoms and less likely to know all stroke symptoms than English-speaking Hispanics, non-Hispanic blacks, and non-Hispanic whites. Lack of English proficiency is strongly associated with lack of heart attack and stroke knowledge among Hispanics. This highlights the need for educational intervention about cardiovascular emergencies targeted to Spanish-speaking communities.⁷²

• In the REasons for Geographic And Racial Differences in Stroke study (REGARDS), black participants were more aware than whites of their hypertension and more likely to be undergoing treatment if aware of their diagnosis, but among those treated for hypertension, they were less likely than whites to have their BP controlled. There was no evidence of a difference between the stroke belt and other regions in awareness of hypertension, but there was a trend for better treatment and control in the stroke belt region. The lack of substantial geographic differences in hypertension awareness and the trend toward better treatment and control in the stroke belt suggest that differences in hypertension management may not be a major contributor to the geographic disparity in stroke mortality.⁷³

Aftermath

Stroke is a leading cause of serious, long-term disability in the United States (Survey of Income and Program Participation [SIPP]; a survey of the US Bureau of the Census).⁷⁴

• The median time from stroke onset to arrival in an ED is between 3 and 6 hours, according to a study of at least 48 unique reports of prehospital delay time for patients with stroke, TIA, or strokelike symptoms. The study included data from 17 countries, including the United States. Improved clinical outcome at 3 months was seen for patients with acute ischemic stroke when intravenous thrombolytic treatment was started within 3 hours of the onset of symptoms.⁷⁵

• Data from the Paul Coverdell National Acute Stroke Registry were analyzed from the 142 hospitals that participated in the 4 registry states. Among the >17 600 patients in the study, 66.1% were ≥65 years of age. Women were older than men, and whites were older than blacks. Ischemic stroke (65%) was the most common subtype, followed by TIA (24%) and hemorrhagic stroke (9.7%). More patients were transported by ambulance than by other means (43.6%). Time of stroke symptom onset was recorded for 44.8% of the patients. Among these patients, 48% arrived at the ED within 2 hours of symptom onset. Significantly fewer blacks (42.4%) arrived within 2 hours of symptom onset than did whites (49.5%), and significantly fewer nonambulance patients (36.2%) arrived within 2 hours of symptom onset than did patients transported by ambulance (58.6%). The median arrival time for all patients with known time of onset was 2.0 hours. Sixty-five percent of patients who arrived at the ED within 2 hours of onset received imaging within 1 hour of ED arrival. Significantly fewer women (62%) received imaging within 1 hour of ED arrival than men.⁷⁶

• Data from the BRFSS (CDC) 2005 survey on stroke survivors in 21 states and the District of Columbia found that 30.7% of stroke survivors received outpatient rehabilitation. The findings indicated that the prevalence of stroke survivors receiving outpatient stroke rehabilitation was lower than would be expected if clinical practice guideline recommendations for all stroke patients had been followed. Increasing the number of stroke survivors who receive needed outpatient rehabilitation might lead to better functional status and quality of life in this population.⁷⁷

• In 1999, more than 1 100 000 American adults reported difficulty with such things as functional limitations and activities of daily living as a result of stroke (SIPP).⁷⁴

• On the basis of pooled data from the FHS, ARIC, and CHS studies of the NHLBI:

  	— The percentages dead 1 year after a first stroke were as follows:       ○At ≥40 years of age, 21% of men and 24% of women.       ○At 40 to 69 years of age: 14% of white men, 20% of white women, 19% of black men, and 19% of black women.       ○At ≥70 years of age: 24% of white men, 27% of white women, 25% of black men, and 22% of black women.
  	— The percentages dead within 5 years after a first stroke were as follows:       ○At ≥40 years of age: 47% of men and 51% of women.       ○At 40 to 69 years of age: 32% of white men, 32% of white women, 34% of black men, and 42% of black women.       ○At ≥70 years of age: 58% of white men, 58% of white women, 49% of black men, and 54% of black women.
  	— Of those who have a first stroke, the percentages with a recurrent stroke in 5 years are as follows:       ○At 40 to 69 years of age: 13% of men and 22% of women.       ○At ≥70 years of age: 23% of men and 28% of women.       ○At 40 to 69 years of age: 15% of white men, 17% of white women, 10% of black men, and 27% of black women.       ○At ≥70 years of age: 23% of white men, 27% of white women, 16% of black men, and 32% of black women.
  	The median survival times (in years) after a first stroke are:       ○At 60 to 69 years of age: 6.8 for men and 7.4 for women.       ○At 70 to 79 years of age: 5.4 for men and 6.4 for women.       ○At ≥80 years of age: 1.8 for men and 3.1 for women.

• The length of time to recover from a stroke depends on its severity. From 50% to 70% of stroke survivors regain functional independence, but 15% to 30% are permanently disabled, and 20% require institutional care at 3 months after onset.⁷⁸

• In the NHLBI’s FHS, among ischemic stroke survivors who were at least 65 years of age, these disabilities were observed at 6 months after stroke⁷⁹:

  	— 50% had some hemiparesis.
  	— 30% were unable to walk without some assistance.
  	— 26% were dependent in activities of daily living.
  	— 19% had aphasia.
  	— 35% had depressive symptoms.
  	— 26% were institutionalized in a nursing home.

• Black stroke survivors had greater activity limitations than did white stroke survivors, according to data from the NHIS (2000–2001, NHCS), as analyzed by the CDC.⁸⁰

• Of patients with ischemic stroke in the California Acute Stroke Pilot Registry, 23.5% arrived at the ED within 3 hours of symptom onset, and 4.3% received thrombolysis. If all patients had called 9-1-1 immediately, the expected overall rate of thrombolytic treatment within 3 hours would have increased to 28.6%. If all patients with known onset had arrived within 1 hour and had been optimally treated, 57% could have received thrombolytic treatment.⁸¹

• Patients with a discharge diagnosis of ischemic stroke were identified in 7 California hospitals participating in the California Acute Stroke Pilot Registry. Six points of care were tracked: thrombolysis, receipt of antithrombotic medications within 48 hours, prophylaxis for deep vein thrombosis, smoking cessation counseling, and prescription of lipid-lowering and antithrombotic medications at discharge. Overall, rates of optimal treatment improved for patients treated in year 2 versus year 1, with 63% receiving a perfect score in year 2 versus 44% in year 1. Rates improved significantly in 4 of the 6 hospitals and for 4 of the 6 interventions. A seventh hospital that participated in the registry but did not implement standardized orders showed no improvement in optimal treatment.⁸²

• A population-based study performed in a biracial population of 1.3 million in Ohio in 1993 and 1994 showed that 8% of all ischemic stroke patients presented to an ED within 3 hours and met other eligibility criteria for treatment with recombinant tissue plasminogen activator (rtPA). Even if time were not an exclusion criterion for use of rtPA, only 29% of all ischemic strokes in the population would have otherwise been eligible for rtPA.⁸³

Hospital Discharges/Ambulatory Care Visits

From 1979 to 2005, the number of inpatient discharges from short-stay hospitals with stroke as the first listed diagnosis increased 20%, to 895 000 (NHDS, NCHS; AHA computation).

• 2005 data from the Hospital Discharge Survey of the NCHS showed the average length of stay for discharges with stroke as the first-listed diagnosis was 5.2 days.⁸⁴

• Between 1980 and 1999, hospital discharge rates for stroke increased for blacks and whites; in-hospital mortality rates decreased for both black and white patients. Generally, the risk of stroke hospitalization was more than 70% greater for blacks than for whites. Both groups were similar in terms of in-hospital mortality rates.⁸⁵ Note: Estimates by race, especially time trends, are affected by the increasing underreporting of race in the NHDS/NCHS.⁸⁶

• In 1999–2000, the number of ambulatory care visits for stroke was 3.0 million (NAMCS, NHAMCS/NCHS).⁸⁷

• In 2003, men and women accounted for roughly the same number of hospital stays for stroke in the 18- to 44-year-old age group. After 65 years of age, women were the majority. Among 65- to 84-year-olds, 54.5% of stroke patients were women, whereas among the oldest age group, women constituted 69.7% of all stroke patients.⁸⁸

Cost

The estimated direct and indirect cost of stroke for 2008 is $65.5 billion.

• In 2003, $3.7 billion ($6363 per discharge) was paid to Medicare beneficiaries discharged from short-stay hospitals for stroke.⁸⁹

• The mean lifetime cost of ischemic stroke in the United States is estimated at $140 048. This includes inpatient care, rehabilitation, and follow-up care necessary for lasting deficits. (All numbers were converted to 1999 dollars by use of the medical component of the Consumer Price Index.)⁹⁰

• In a population study of stroke costs within 30 days of an acute event, the average cost was $13 019 for mild ischemic strokes and $20 346 for severe ischemic strokes (4 or 5 on the Rankin Disability Scale).⁹¹

• Inpatient hospital costs for an acute stroke event account for 70% of first-year poststroke costs.⁹⁰

• The largest components of acute-care costs were room charges (50%), medical management (21%), and diagnostic costs (19%).⁹²

• Death within 7 days, subarachnoid hemorrhage, and stroke while hospitalized for another condition are associated with higher costs in the first year. Lower costs are associated with mild cerebral infarctions or residence in a nursing home before the stroke.⁹¹

• Demographic variables (age, sex, and insurance status) are not associated with stroke cost. Severe strokes (NIHSS score >20) cost twice as much as mild strokes, despite similar diagnostic testing. Comorbidities such as ischemic heart disease and AF predict higher costs.^92,93 The total cost of stroke from 2005 to 2050, in 2005 dollars, is projected to be $1.52 trillion for non-Hispanic whites, $313 billion for Hispanics, and $379 billion for blacks. The per capita cost of stroke estimates are highest in blacks ($25 782), followed by Hispanics ($17 201) and non-Hispanic whites ($15 597). Loss of earnings is expected to be the highest cost contributor in each race-ethnic group.⁹⁴

Operations and Procedures

In 2005, an estimated 103 000 inpatient endarterectomy procedures were performed in the United States. Carotid endarterectomy is the most frequently performed surgical procedure to prevent stroke (NHDS, NCHS).

Stroke in Children

• Stroke in children peaks in the perinatal period. In the NHDS/NCHS, from 1980 to 1998, the rate of stroke for infants <30 days old (per 100 000 live births per year) was 26.4, with rates of 6.7 for hemorrhagic stroke and 17.8 for ischemic stroke.⁹⁵

• A history of infertility, preeclampsia, prolonged rupture of membranes, and chorioamnionitis were found to be independent risk factors for radiologically confirmed perinatal arterial ischemic stroke in the Kaiser Permanente Medical Care Program. The risk of perinatal stroke increased approximately 25-fold, with an absolute risk of 1 per 200 deliveries, when ≥3 of the following antenatally determined risk factors were present: infertility, preeclampsia, chorioamnionitis, prolonged rupture of membranes, primiparity, oligohydramnios, decreased fetal movement, prolonged second stage of labor, and fetal heart rate abnormalities.⁹⁶

• The overall incidence rate of all strokes in children under 15 years of age was 6.4 per 100 000 in 1999, a nonsignificant increase compared with 1988. The 30-day case fatality rates were 18% in 1988–1989, 9% in 1993–1994, and 9% in 1999. The incidence of stroke in children has been stable over the past 10 years. The previously reported nationwide decrease in overall stroke mortality in children might be due to decreasing case fatality after stroke and not decreasing stroke incidence. It was conservatively estimated that approximately 3000 children and adults younger than 20 years of age would have a stroke in the United States in 2004.⁹⁷

• Stroke in childhood and young adulthood has a disproportionate impact on the affected patients, their families, and society compared with stroke at older ages. Outcome of childhood stroke was a moderate or severe deficit in 42% of cases.⁹⁸

• Compared with the stroke risk of white children, black children have a higher RR of 2.12, Hispanics have a lower RR of 0.76, and Asians have a similar risk. Boys have a 1.28-fold higher risk of stroke than girls. There are no ethnic differences in stroke severity or case fatality, but boys have a higher case-fatality rate for ischemic stroke. The increased risk among blacks is not fully explained by the presence of sickle cell disease, nor is the excess risk among boys fully explained by trauma.⁹⁹

• Despite current treatment, 1 of 10 children with ischemic stroke will have a recurrence within 5 years.¹⁰⁰

• Cerebrovascular disorders are among the top 10 causes of death in children, with rates highest in the first year of life. Stroke mortality in children <1 year of age has remained the same over the past 40 years.⁹⁴

• From 1979 to 1998 in the United States, childhood mortality due to stroke declined by 58% overall, with reductions in all major subtypes.¹⁰¹

  	— Ischemic stroke decreased by 19%, subarachnoid hemorrhage by 79%, and intracerebral hemorrhage by 54%.
  	— Black ethnicity was a risk factor for death due to all stroke types.
  	— Male sex was a risk factor for death due to subarachnoid hemorrhage and intracerebral hemorrhage but not for death due to ischemic stroke.

• Sickle cell disease is the most important cause of ischemic stroke among black children. The Stroke Prevention Trial in Sickle Cell Anemia (STOP) demonstrated the efficacy of blood transfusions for primary stroke prevention in high-risk children with sickle cell disease in 1998. First-admission rates for stroke in California among persons under age 20 years with sickle cell disease showed a dramatic decline subsequent to the publication of the STOP study. For the study years 1991–1998, 93 children with sickle cell disease were admitted to California hospitals with a first stroke; 92.5% of these strokes were ischemic, and 7.5% were hemorrhagic. The first-stroke rate was 0.88 per 100 person-years during 1991–1998, compared with 0.50 in 1999 and 0.17 in 2000 (P<0.005 for trend).¹⁰²

ICD-9 401–404, ICD-10 I10-I15. SeeTable 5-1andCharts 5-1 through 5-4.

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Prevalence

• HBP is defined as:

  	— systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg or taking antihypertensive medicine
  	— or having been told at least twice by a physician or other health professional that one has HBP.

• One in 3 US adults has HBP.¹

• A higher percentage of men than women have HBP until 45 years of age. From 45 to 54 years of age, the percentages of men and women with HBP are similar. After that, a much higher percentage of women have HBP than do men.²

• HBP is 2 to 3 times more common in women taking oral contraceptives, especially in obese and older women, than in women not taking them.³

Older Adults

• Age-adjusted estimates show that in 2004–2005, diagnosed chronic conditions that were more prevalent among older women than men included hypertension (51% for women, 45% for men). Ever-diagnosed conditions that were more prevalent among older men than older women included heart disease (33% for men, 26% for women) and diabetes (17% for men, 15% for women).⁴

• The age-adjusted prevalence of hypertension (both diagnosed and undiagnosed) in 1999–2002 was 78% for older women and 64% for older men on the basis of data from NHANES/NCHS.⁴

Children and Adolescents

• Analysis of NHES, HHANES, and NHANES/NCHS surveys of the NCHS (1963–2002) found that the BP, pre-HBP, and HBP trends in children and adolescents 8 to 17 years of age were downward from 1963 to 1988 and upward thereafter. Pre-HBP and HBP increased 2.3% and 1%, respectively, between 1988 and 1999. Increased obesity (more so abdominal obesity than general obesity) partially explained the HBP and pre-HBP rise from 1988 to 1999. Blood pressure and HBP reversed their downward trends 10 years after the increase in the prevalence of obesity. In addition, an ethnic and gender gap appeared in 1988 for pre-HBP and in 1999 for HBP; non-Hispanic blacks and Mexican Americans had a greater prevalence of HBP and pre-HBP than non-Hispanic whites, and the prevalence was greater in males than in females. In this study, HBP in children and adolescents is defined as SBP and/or DBP that is, on repeated measurement, equal to or greater than the 95th percentile.⁵

• A study in Ohio of >14 000 children and adolescents 3 to 18 years of age observed at least 3 times between 1999 and 2006 found that 3.6% had hypertension. Of these, 26% had been diagnosed and 74% were undiagnosed. In addition, 3% of those with hypertension had stage 2 hypertension, and 41% of those with stage 2 were undiagnosed. Criteria for prehypertension were met by 485 children. Of these, 11% were diagnosed. In this study, HBP in children and adolescents is defined as systolic BP and/or diastolic BP that is, on repeated measurement, equal to or greater than the 95th percentile.⁶

• A study from 1988–1994 to 1999–2000 of children and adolescents 8 to 17 years of age showed that among non-Hispanic blacks, mean systolic BP levels increased by 1.6 mm Hg among girls and 2.9 mm Hg among boys compared with non-Hispanic whites. Among Mexican Americans, girls’ systolic BP increased 1.0 mm Hg and boys’ systolic BP increased 2.7 mm Hg compared with non-Hispanic whites.⁷

Race/Ethnicity and HBP

• The prevalence of hypertension in blacks in the United States is among the highest in the world, and it is increasing. From 1988–1994 to 1999–2002, the prevalence of HBP in adults increased from 35.8% to 41.4% among blacks, and it was particularly high among black women, at 44.0%. Prevalence among whites also increased, from 24.3% to 28.1%.⁸

• Compared with whites, blacks develop HBP earlier in life, and their average BPs are much higher. As a result, compared with whites, blacks have a 1.3-times greater rate of nonfatal stroke, a 1.8-times greater rate of fatal stroke, a 1.5-times greater rate of heart disease death, and a 4.2-times greater rate of end-stage kidney disease (Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure [JNC] 5 and 6).

• Within the African American community, rates of hypertension vary substantially.^8,9

  	— Those with the highest rates are more likely to be middle aged or older, less educated, overweight or obese, and physically inactive and are more likely to have diabetes.
  	— Those with the lowest rates are more likely to be younger but also overweight or obese.
  	— Those with uncontrolled HBP who are not on antihypertensive medication tend to be male, to be younger, and to have infrequent contact with a physician.

• Analysis from the REGARDS study of the NINDS suggests that efforts to raise awareness of prevalent hypertension among African Americans have apparently been successful (31% greater odds in African Americans relative to whites), and efforts to communicate the importance of receiving treatment for hypertension have been successful (69% greater odds among African Americans relative to whites); however, substantial racial disparities remain in the control of BP (systolic BP <140 mm Hg, diastolic BP <90 mm Hg), with the odds of control 27% lower in African Americans relative to whites. In contrast, geographic disparities in hypertension awareness, treatment, and control were minimal.¹⁰

• Data from the 2005 NHIS survey showed that American Indian/Alaska Native adults age ≥18 years were less likely (25.5%) than black adults (31.2%) and more likely than white adults (21.0%) and Asian adults (19.4%) to have been told on ≥2 occasions that they had hypertension.¹¹

• The CDC analyzed death certificate data from 1995 to 2002. The results indicated that Puerto Rican Americans had consistently higher hypertension-related mortality than all other Hispanic subpopulations and non-Hispanic whites. The age-standardized hypertension-related mortality rate was 127.2 per 100 000 population for all Hispanics, similar to that of non-Hispanic whites (135.9). The age-standardized rate for Hispanic women (118.3) was substantially lower than that observed for Hispanic men (135.9). Male hypertension-related mortality rates were higher than female rates for all Hispanic subpopulations. Puerto Rican Americans had the highest hypertension-related death rate among all Hispanic subpopulations (154.0); Cuban Americans had the lowest (82.5).¹²

• Some studies suggest that Hispanic Americans have rates of HBP similar to or lower than those of non-Hispanic white Americans. Findings from a new analysis of combined data from the NHIS surveys of 2000 to 2002 point to a health disparity between black and white adults of Hispanic descent. Black Hispanics were at slightly greater risk than white Hispanics, although non-Hispanic black adults had by far the highest rate of HBP. The racial disparity among Hispanics also was evident in the fact that higher-income, better-educated black Hispanics still had a higher rate of HBP than lower-income, less-educated white Hispanics.¹³ Data from the NHLBI’s ARIC study found that hypertension was a particularly powerful risk factor for CHD in black persons, especially in black women.¹⁴

• Data from the Multi-Ethnic Study of Atherosclerosis (MESA) found that being born outside the United States, speaking a language other than English at home, and living fewer years in the United States were associated with a decreased prevalence of hypertension.¹⁵

Mortality

HBP mortality—54 707. Total-mention mortality in 2004 was about 300 000.

• From 1994 to 2004, the death rate from HBP increased 26.6%, and the actual number of deaths rose 56.1% (NCHS and NHLBI; 1994 rate modified by appropriate comparability ratio).

• The 2004 overall death rate from HBP was 18.1. Death rates were 15.7 for white males, 51.0 for black males, 14.5 for white females, and 40.9 for black females.¹⁶

Risk Factors

• Numerous risk factors and markers for development of hypertension have been identified, including age, ethnicity, family history of hypertension and genetic factors, lower education and socioeconomic status, greater weight, lower physical activity, psychosocial stressors, sleep apnea, and dietary factors (including dietary fats, higher sodium intake, lower potassium intake, and excessive alcohol intake) (personal communication with Donald Lloyd-Jones, July 30, 2007).

• A study of related individuals in the NHLBI’s FHS estimated that when measured at a single examination, BP levels are approximately 40% heritable; when measured across multiple examinations, long-term BP trends are approximately 55% heritable.¹⁷

Aftermath

• About 69% of people who have a first heart attack, 77% who have a first stroke, and 74% who have CHF have BP higher than 140/90 mm Hg (NHLBI unpublished estimates from ARIC, CHS, and FHS Cohort and Offspring Studies).

• Data from FHS/NHLBI indicate that recent (within the past 10 years) and remote antecedent BP levels may be an important determinant of risk over and above current BP level.¹⁸

• Data from the FHS/NHLBI indicate that hypertension is associated with shorter overall life expectancy, shorter life expectancy free of CVD, and more years lived with CVD.¹⁹

  	— Total life expectancy was 5.1 years longer for normotensive men and 4.9 years longer for normotensive women than for hypertensives of the same sex at 50 years of age.
  	— Compared with hypertensive men at 50 years of age, men with untreated BP <140/90 mm Hg survived on average 7.2 years longer without CVD and spent 2.1 fewer years of life with CVD. Similar results were observed for women.

Hospital Discharges/Ambulatory Care Visits

• Data from Ambulatory Care Visits to Physician Offices, Hospital Outpatient Departments, and Emergency Departments: US, 2001–2002, showed the number of visits for essential hypertension was 45.3 million.²⁰

• In 2005, there were 301 000 hospitalizations with a first-listed diagnosis of essential hypertension (ICD-9–CM code 401), but essential hypertension was listed as either a primary or secondary diagnosis 9 003 000 times for hospitalized inpatients.²¹

Awareness, Treatment, and Control

• Data from NHANES/NCHS 1999–2004 showed that of those with hypertension ≥18 years of age, 71.8% were aware of their condition, 61.4% were under current treatment, 35.1% had it under control, and 64.9% did not have it controlled (NCHS and NHLBI).

• Analysis of NHANES/NCHS data from 1999–2004 found that there were no significant increases in the overall prevalence, awareness, and treatment rates of hypertension. The control rates increased significantly in both sexes, non-Hispanic blacks, and Mexican Americans. Among the group ≥60 years of age, the awareness, treatment, and control rates of hypertension had all increased significantly.²²

• Data from the 2005 BRFSS/CDC survey indicate that overall 25.5% of adults ≥18 years of age had been told that they had HBP. The highest percentage was in Mississippi (33.3%), and the lowest was in Utah (18.4%).²³

• In NHANES/NCHS 2003–2004, rates of control were lower in Mexican Americans (26.5%) than in non-Hispanic whites (35.4%) and non-Hispanic blacks (28.9%).²²

• The awareness, treatment, and control of HBP among those ≥65 years of age in the CHS/NHLBI improved during the 1990s. The percentages of those aware of and treated for HBP were higher among blacks than among whites. Prevalences with HBP under control were similar. For both groups combined, the control of BP to <140/90 mm Hg increased from 37% in 1990 to 49% in 1999. Improved control was achieved by an increase in antihypertensive medications per person and by an increase in the proportion of the CHS population treated for hypertension from 34.5% to 51.1%.²⁴

• Data from the FHS study of the NHLBI show that:

  — Among those ≥80 years of age, only 38% of men and 23% of women had BPs that met targets set forth in the National High Blood Pressure Education Program’s clinical guidelines. Control rates in men <60, 60 to 79, and ≥80 years of age were 38%, 36%, and 38%, respectively; for women in the same age groups, they were 38%, 28%, and 23%, respectively.25

• Data from the Women’s Health Initiative Observational Study of nearly 100 000 postmenopausal women across the country enrolled between 1994 and 1998 indicate that although prevalence rates ranged from 27% of women between 50 and 59 years of age to 41% of women between 60 and 69 years of age and 53% of women between 70 and 79 years of age, treatment rates were similar across age groups, being 64%, 65%, and 63%, respectively. Despite similar treatment rates, hypertension control is especially poor in older women, with only 29% of hypertensive women 70 to 79 years of age having clinic BPs <140/90 mm Hg, compared with 41% and 37% of those 50 to 59 and 60 to 69 years of age, respectively.²⁶

• A study of >300 women in Wisconsin showed a need for significant improvement in BP and low-density lipoprotein (LDL) levels. Of the screened participants, 35% were not at BP goal, 32.4% were not at LDL goal, and 53.5% were not at both goals.²⁷

• In 2005, a survey of people in 20 states conducted by the BRFSS of the CDC found that 19.4% of respondents on ≥2 visits to a health professional had been told they had HBP. Of these, 70.9% reported changing their eating habits; 79.5% reduced the use of or are not using salt; 79.2% reduced the use of or eliminated alcohol; 68.8% are exercising; and 73.4% are taking antihypertensive medication.²⁸

Cost

• The estimated direct and indirect cost of HBP for 2008 is $69.4 billion.

Prehypertension

• “Prehypertension” is untreated systolic BP of 120 to 139 mm Hg or untreated diastolic BP of 80 to 89 mm Hg and not having been told on 2 occasions by a doctor or other health professional that one has hypertension.

• It is estimated that 37.4% of the US population ≥20 years of age has prehypertension, including 41 900 000 men and 27 800 000 women.²⁹

• Follow-up of 9845 men and women in the FHS/NHLBI who attended examinations from 1978 to 1994 revealed that at 35 to 64 years of age, the 4-year incidence of hypertension was 5.3% for those with baseline BP <120/80 mm Hg, 17.6% for those with systolic BP of 120 to 129 mm Hg or diastolic BP of 80 to 84 mm Hg, and 37.3% for those with systolic BP of 130 to 139 mm Hg or diastolic BP of 85 to 89 mm Hg. At 65 to 94 years of age, the 4-year incidences of hypertension were 16.0%, 25.5%, and 49.5% for these BP categories, respectively.³⁰

• Data from FHS/NHLBI also reveal that prehypertension is associated with elevated relative and absolute risks for CVD outcomes across the age spectrum. Compared with normal BP (<120/80 mm Hg), prehypertension was associated with a 1.5- to 2-fold risk for major CVD events in those under 60, between 60 and 79, and ≥80 years of age. Absolute risks for major CVD associated with prehypertension increased markedly with age: 6-year event rates for major CVD were 1.5% in prehypertensives under 60 years of age, 4.9% in those 60 to 79 years of age, and 19.8% in those ≥80 years of age.²⁵

• In a study of NHANES 1999–2000 (NCHS), people with prehypertension were more likely than those with normal BP levels to have above-normal cholesterol levels, overweight/obesity, and diabetes mellitus, whereas the probability of currently smoking was lower. Persons with prehypertension were 1.65 times more likely to have at least 1 of these adverse risk factors than were those with normal blood pressure.³¹

  Abbreviations Used in Chapter 5

  ARIC	Atherosclerosis Risk in Communities Study
  BMI	body mass index
  BP	blood pressure
  BRFSS	Behavior Risk Factor Surveillance System
  CDC	Centers for Disease Control and Prevention
  CHD	coronary heart disease
  CHF	congestive heart failure
  CHS	Cardiovascular Health Study
  CVD	cardiovascular disease
  FHS	Framingham Heart Study
  HBP	high blood pressure
  HHANES	Hispanic Health and Nutrition Examination Survey
  ICD	International Classification of Diseases
  JNC	Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure
  LDL	low-density lipoprotein
  MESA	Multi-Ethnic Study of Atherosclerosis
  mm Hg	millimeter of mercury
  NCHS	National Center for Health Statistics
  NH	non-Hispanic
  NHANES	National Health and Nutrition Examination Survey
  NHES	National Health Examination Survey
  NHDS	National Hospital Discharge Survey
  NHIS	National Health Interview Survey
  NHLBI	National Heart, Lung, and Blood Institute
  NINDS	National Institute of Neurological Disorders and Stroke
  REGARDS	Reasons for Geographic and Racial Differences in Stroke

ICD-9 745–747, ICD-10 Q20–Q28. SeeTables 6-1 through 6-4.

Congenital cardiovascular defects, also known as congenital heart defects, are structural problems arising from abnormal formation of the heart or major blood vessels. At least 15 distinct types of congenital defects are recognized, with many additional anatomic variations.

Defects range in severity from tiny pinholes between chambers, which are nearly irrelevant and often resolve spontaneously, to major malformations that result in fetal loss or death in infancy or childhood. The common complex defects include:

• tetralogy of Fallot (9% to 14%)

• transposition of the great arteries (10% to 11%)

• atrioventricular septal defects (4% to 10%)

• coarctation of the aorta (8% to 11%)

• hypoplastic left heart syndrome (4% to 8%)

• ventricular septal defects (VSDs)

VSD is the most common defect. Many close spontaneously, but VSDs still account for 14% to 16% of defects requiring an invasive procedure within the first year of life.¹

Prevalence

As of 2002, the prevalence of congenital cardiovascular defects in the United States was estimated to range from 650 000 to 1.3 million.² Almost as many people with congenital cardiovascular defects are <25 years of age as are over that age, but the proportions differ among disease types. Using available data to estimate the expected numbers of infants with each type of congenital cardiovascular defect at birth, the authors estimate their survival to 2002 assuming no treatment (the low estimate) and full treatment (the high estimate). Of the 1.3 million defects, 750 000 are simple lesions, 400 000 are of moderate complexity, and 180 000 are complex. An estimated 3 million more people have bicuspid aortic valve: 2 million adults and 1 million children. On the basis of the tabulations in Hoffman et al,² prevalence was calculated by type of lesion, excluding bicuspid aortic valve (Table 6-3). We assumed that prevalence is two thirds of the way between the estimated high and low ranges, representing a total of approximately 1 million persons with congenital heart disease. The most common types are VSD, 199 000 people; atrial septal defect (ASD), 187 000 people; patent ductus arteriosus, 144 000 people; and valvular pulmonary stenosis, 134 000 people.²

Incidence

Major defects are usually apparent in the neonatal period, but minor defects may not be detected until adulthood. Thus, true measures of incidence for congenital heart disease would need to record new cases of defects presenting any time in fetal life through adulthood. However, estimates are only available for new cases detected between birth and 30 days of life, known as birth prevalence, or for new cases detected in the first year of life only. Both of these are typically reported as cases per 1000 live births per year and do not distinguish between tiny defects that resolve without treatment and major malformations. To distinguish more serious defects, some studies also report new cases of sufficient severity to require an invasive procedure or that result in death within the first year of life. Despite the absence of true incidence figures, some data are available and are shown in Table 6-2.

• According to the CDC, 1 in every 110 infants in the metropolitan Atlanta, Ga, area is born with a congenital heart defect, including some infants with tiny defects that resolved without treatment. Some defects occur more commonly in males or females or in whites or blacks.³

• Nine (9.0) defects per 1000 live births are expected, or 36 000 infants per year, in the United States. Of these, several studies suggest that 9200, or 2.3 per 1000 live births, require invasive treatment or result in death in the first year of life.⁴

• Estimates are also available for bicuspid aortic valves, occurring in 13.7 per 1000 people; these defects may not require treatment in infancy but can cause problems later in adulthood.^5,6

• Some studies suggest that as many as 5% of newborns, or 200 000 per year, are born with tiny muscular VSDs, almost all of which close spontaneously.^7,8 These defects nearly never require treatment, so they are not included in Table 6-2.

• Data collected by the National Birth Defects Prevention Network from 11 states from 1999 to 2001 showed the average prevalence of 18 selected major birth defects. These data indicated that there are >6500 estimated annual cases of 5 cardiovascular defects: truncus arteriosus, transposition of the great arteries, tetralogy of Fallot, atrioventricular septal defect, and hypoplastic left heart syndrome.⁹

Mortality

Cardiovascular defects mortality—3861. Total-mention mortality in 2004 was 5810.

• Congenital cardiovascular defects are the most common cause of infant death from birth defects; >29% of infants who die from a birth defect have a heart defect (National Vital Statistics System, Final Data for 2004).

• The 2004 overall death rate for congenital cardiovascular defects was 1.3. Death rates were 1.4 for white males, 1.8 for black males, 1.2 for white females, and 1.4 for black females. Crude infant death rates (<1 year of age) were 38.3 for white infants and 56.0 for black infants.¹⁰

• In 2004, 195 000 life-years were lost before the age of 55 years because of deaths from congenital cardiovascular defects. This is more than the life-years lost from leukemia, prostate cancer, and Alzheimer’s disease combined.¹¹

• The mortality rate from congenital defects has been declining. From 1979 to 1997, age-adjusted death rates from all defects declined 39%, and deaths tended to occur at progressively older ages. Nevertheless, 43% of deaths still occurred in infants <1 year of age. Mortality rate varies considerably according to type of defect.¹²

• From 1994 to 2004, death rates for congenital cardiovascular defects declined 31.6%, whereas the actual number of deaths declined 25.4%.

Hospitalizations

In 2004, birth defects accounted for >139 000 hospitalizations, representing 47.4 stays per 100 000 persons. Cardiac and circulatory congenital anomalies, which include ASDs and VSDs, accounted for more than one third of all hospital stays for birth defects and had the highest in-hospital mortality rate. Between 1997 and 2004, hospitalization rates increased by 28.5% for cardiac and circulatory congenital anomalies. For almost 86 300 hospitalizations, ASD was noted as the principal reason for the hospital stay or as a coexisting or secondary condition.¹³

Cost

• On the basis of 2003 data from the Healthcare Cost and Utilization Project 2003 Kids’ Inpatient Database (KID) and 35 birth defects from the 45 defect categories included in the Congenital Malformations Surveillance Report, it was found that the most expensive average neonatal hospital charges were for 2 congenital heart defects: hypoplastic left heart ($199 597) and common truncus arteriosus ($192 781). Two other cardiac defects, coarctation of the aorta and transposition of the great arteries, were associated with average hospital charges in excess of $150 000. For the 11 selected cardiovascular congenital defects, there were 11 578 hospitalizations in 2003 and 1550 in-hospital deaths (13.4%). Estimated total hospital charges for these 11 conditions were $1.4 billion.¹⁴

• In 2004, hospital costs for congenital cardiovascular defects conditions totaled $2.6 billion. The highest aggregate costs were for stays related to cardiac and circulatory congenital anomalies, which accounted for approximately $1.4 billion—more than half of all hospital costs for birth defects.¹³

ICD-9 428, ICD-10 I50. SeeTable 7-1andCharts 7-1 through 7-3.

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Incidence

• Data from the NHLBI’s FHS¹ indicate that:

  	— HF incidence approaches 10 per 1000 population after 65 years of age.
  	— Seventy-five percent of HF cases have antecedent hypertension.
  	— At 40 years of age, the lifetime risk of developing HF for both men and women is 1 in 5.
  	— At 40 years of age, the lifetime risk of HF occurring without antecedent MI is 1 in 9 for men and 1 in 6 for women.
  	— The lifetime risk for people with BP >160/90 mm Hg is double that of those with BP <140/90 mm Hg.

• The annual rates per 1000 population of new HF events for white men are 15.2 for those between 65 and 74 years of age, 31.7 for those between 75 and 84 years of age, and 65.2 for those ≥85 years of age. For white women in the same age groups, the rates are 8.2, 19.8, and 45.6, respectively. For black men, the rates are 16.9, 25.5, and 50.6,* and for black women, the rates are 14.2, 25.5, and 44.0,* respectively (CHS, NHLBI).²

• In Olmsted County, Minn, the incidence of HF (ICD-9 428) has not declined during 2 decades, but survival improved overall, with less improvement, however, among women and elderly persons.³

Risk Factors

• In the FHS (NHLBI), hypertension is a common risk factor for HF that contributed to a large proportion of HF cases.⁴

• Among women with CHD, diabetes was the strongest risk factor for HF. Diabetic women with elevated BMI or reduced creatinine clearance were at highest risk, with annual incidence rates of 7% and 13%, respectively. Among nondiabetic women with no risk factors, the annual incidence of HF was 0.4%. HF incidence increases with each additional risk factor, and nondiabetic women with ≥3 risk factors had an annual incidence of 3.4%. Among diabetic persons with no additional risk factors, the annual incidence of HF was 3.0%, compared with 8.2% among diabetics with ≥3 additional risk factors.⁵

• The prevalence of diabetes is increasing among older persons with HF, and diabetes is a risk factor for death in these individuals. Mayo Clinic data indicate that the prevalence of diabetes increased 3.8% every year. The odds of having diabetes for those first diagnosed with HF in 1999 were nearly 4 times higher than those diagnosed 20 years earlier. The 5-year survival rate was 46% for those with HF alone but only 37% for those with HF and diabetes mellitus.⁶

Left Ventricular Function

• Data from Olmsted County, Minn, indicate that:

  	— Among asymptomatic individuals, the prevalence of left ventricular diastolic dysfunction was 21% for mild diastolic dysfunction and 7% for moderate or severe diastolic dysfunction. Altogether, 6% had moderate or severe diastolic dysfunction with normal ejection fraction (EF). The prevalence of systolic dysfunction was 6%. The presence of any left ventricular dysfunction (systolic or diastolic) was associated with an increased risk of HF, and diastolic dysfunction was predictive of all-cause death.7
  	— Among individuals with symptomatic HF, the prevalence of left ventricular diastolic dysfunction was 6% for mild diastolic dysfunction and 75% for moderate or severe diastolic dysfunction. Isolated diastolic dysfunction (diastolic dysfunction with preserved EF) was present in 44% of persons presenting with HF. The prevalence of systolic dysfunction was 45%.8
  	— The proportion of persons with HF and preserved EF increased over time. Survival improved over time among individuals with reduced EF but not among those with preserved EF.9

Mortality

In 2004, HF total-mention mortality was 284 365. HF was mentioned on 284 365 US death certificates and was selected as the “underlying cause” in 57 120 of those deaths.¹⁰ Unlike other cardiovascular diseases, HF is the end stage of a cardiac disease. It is most often a consequence of hypertension, CHD, valve deformity, diabetes, or cardiomyopathy. There are other less common causes of HF as well. For each of the 57 120 deaths, the true underlying cause—ie, the “etiology” of HF—is not known. The certifier of the cause of death either failed to report the underlying cause or had insufficient information to do so. In those cases, HF must be nominally coded as the underlying cause. Table 7-1 contains the total-mention numbers of deaths from HF, with a footnote giving the numbers of these deaths that are coded to HF as the “underlying cause.”

• The 2004 overall total-mention death rate for HF was 52.0. Total-mention death rates were 63.2 for white males, 78.8 for black males, 43.5 for white females, and 58.7 for black females (NCHS, NHLBI).

• One in 8 deaths has HF mentioned on the death certificates (NCHS, NHLBI).

• The number of total-mention deaths from HF was as high in 1994 (284 087) as it was in 2004 (NCHS, NHLBI).

• On the basis of the 44-year follow-up of the original FHS cohort (NHLBI) and 20-year follow-up of the offspring cohort:

  	— Eighty percent of men and 70% of women <65 years of age who have HF will die within 8 years.
  	— After HF is diagnosed, survival rate is lower in men than in women, but fewer than 15% of women survive more than 8 to 12 years. The 1-year mortality rate is high, with 1 in 5 dying.
  	— In people diagnosed with HF, sudden cardiac death occurs at 6 to 9 times the rate of the general population.11

Hospital Discharges

• Hospital discharges for HF rose from 400 000 in 1979 to 1 084 000 in 2005, an increase of 171% (NHDS, NHLBI).

• Data from Ambulatory Care Visits to Physician Offices, Hospital Outpatient Departments, and Emergency Departments: US, 1999 to 2000, showed the number of visits for HF was 3.4 million.¹²

Cost

• The estimated direct and indirect cost of HF in the United States for 2008 is $34.8 billion. (See Chapter 19.) In 2003, $4.4 billion ($6577 per discharge) was paid to Medicare beneficiaries for HF.¹³

  Abbreviations Used in Chapter 7

  BMI	body mass index
  BP	blood pressure
  CHD	coronary heart disease
  CHS	Cardiovascular Health Study
  EF	ejection fraction
  FHS	Framingham Heart Study
  HF	heart failure
  ICD	International Classification of Diseases
  MI	myocardial infarction
  mm Hg	millimeters of mercury
  NCHS	National Center for Health Statistics
  NH	non-Hispanic
  NHANES	National Health and Nutrition Examination Survey
  NHDS	National Hospital Discharge Survey
  NHLBI	National Heart, Lung, and Blood Institute

SeeTable 8-1.

Mortality and total mentions in this section are for 2004. “Mortality” is the number of deaths in 2004 for the given underlying cause. Prevalence data are for 2005. Hospital discharge data are from the NHDS/NCHS; data include inpatients discharged alive, dead, or status unknown. Hospital discharge data for 2005 are based on ICD-9 codes.

Arrhythmias (Disorders of Heart Rhythm)

ICD-9 426, 427; ICD-10 I46-I49.

Mortality—37 001. Total-mention mortality—458 800. Hospital discharges—829 000.

In 2003, $3.1 billion ($7312 per discharge) was paid to Medicare beneficiaries for cardiac dysrhythmias.^1,2

Atrial Fibrillation and Flutter

ICD-9 427.3; ICD-10 I48.

Mortality—10 610. Total-mention mortality—80 770. Prevalence—>2 200 000.³ Incidence—>75 000.⁴ Hospital discharges—454 000.

• Participants in the FHS study of the NHLBI were followed up from 1968 to 1999. At 40 years of age, remaining lifetime risks for AF were 26.0% for men and 23.0% for women. At 80 years of age, lifetime risks for AF were 22.7% for men and 21.6% for women. In further analysis, counting only those who had development of AF without prior or concurrent HF or MI, lifetime risk for AF was approximately 16%.⁵

• Data from a large community-based population suggest that AF is less prevalent in blacks than in whites, both overall and in the setting of CHF.^3,6

• Data from the NHDS/NCHS (1996–2001) on cases that included AF as a primary discharge diagnosis found that⁷:

  	— Approximately 44.8% of patients were men.
  	— The mean age for men was 66.8 years, versus 74.6 years for women.
  	— The racial breakdown for admissions was 71.2% white, 5.6% black, and 2.0% other races (20.8% were not specified).
  	— Black patients were much younger than patients of other races.
  	— The incidence in men ranged from 20.58/100 000 persons per year for patients between 15 and 44 years of age to 1077.39/100 000 persons per year for patients ≥85 years of age. In women, the incidence ranged from 6.64/100 000 persons per year for patients between 15 and 44 years of age to 1203.7/100 000 persons per year for those ≥85 years of age.
  	— From 1996 to 2001, hospitalizations with AF as the first-listed diagnosis increased 34%.

• Age-adjusted death rates for AF were highest among whites (25.7) and blacks (16.4) and higher for men (34.7) than women (22.8).⁸

• In 1999, the CDC analyzed data from national and state multiple-cause mortality statistics and Medicare hospital claims for persons with AF. The most common disease listed as the primary diagnosis for persons hospitalized with AF was HF (11.8%), followed by AF (10.9%), CHD (9.9%), and stroke (4.9%).⁸

• Paroxysmal, persistent, and permanent AF all appear to increase the risk of stroke to a similar degree.⁹

• AF is responsible for about 15% to 20% of all strokes.³

• AF is also an independent risk factor for stroke recurrence and stroke severity. A recent report showed that people who had AF and were not treated with anticoagulants had a 2.1-fold increase in risk for recurrent stroke and a 2.4-fold increase in risk for recurrent severe stroke.¹⁰

• People who have strokes caused by AF have been reported as 2.23 times more likely to be bedridden than those who have strokes from other causes.¹¹

• In Olmsted County, Minn, the age-adjusted incidence of AF increased by 12.6% between 1980 and 2000.^12,13

  	— The incidence of AF was greater in men (incidence ratio for men over women, 1.86) and increased markedly with age.12
  	— According to US population projections by the Census Bureau, the projected number of persons with AF may exceed 10 million by 2050.12

• Chronic atrial flutter is uncommon but is associated with a high risk of developing AF,¹⁴ and data from a sample of 191 patients with chronic atrial flutter revealed a risk of stroke that was similar to that for AF.¹⁵

• A study of >4600 patients diagnosed with first AF showed that mortality within the first 4 months was high. The most common causes of CVD death were CAD, HF, and ischemic stroke, accounting for 22%, 14%, and 10% respectively, of the early deaths (within the first 4 months) and 15%, 16%, and 7%, respectively, of the late deaths.¹³

• Among Medicare patients ≥65 years of age, AF prevalence increased from 3.2% in 1992 to 6.0% in 2002, with higher prevalence in older subsets of the study population. Stroke rates per 1000 patient-years declined from 46.7 in 1992 to 19.5 in 2002 for ischemic stroke but remained fairly steady for hemorrhagic stroke (1.6 to 2.9).¹⁶

Other Arrhythmias

Tachycardia

ICD-9 427.0, 1, 2; ICD-10 I47.0, 1, 2, 9.

Mortality—587. Total-mention mortality—6400. Hospital discharges—87 000.

Paroxysmal Supraventricular Tachycardia

ICD-9 427.0; ICD-10 I47.1.

Mortality—141. Total-mention mortality—1341. Hospital discharges—28 000.

Ventricular Fibrillation

ICD-9 427.4; ICD-10 I49.0.

Mortality—1166. Total-mention mortality—11 100. Hospital discharges—8000.

Ventricular fibrillation is listed as the cause of relatively few deaths, but the overwhelming majority of sudden cardiac deaths from coronary disease (estimated at about 325 000 per year) are thought to be from ventricular fibrillation.

Arteries, Diseases of

ICD-9 440 to 448; ICD-10 I70-I79. Includes peripheral arterial disease (PAD).

Mortality—35 554. Total-mention mortality—104 700. Hospital discharges—286 000.

Aortic Aneurysm

ICD-9 441; ICD-10 I71.

Mortality—13 753. Total-mention mortality—19 300. Hospital discharges—63 000.

• Although the definition varies somewhat by age and body-surface area, generally, an abdominal aortic aneurysm (AAA) is considered to be present when the anteroposterior diameter of the aorta reaches 3.0 cm.¹⁷

• The prevalence of AAAs 2.9 to 4.9 cm in diameter ranges from 1.3% in men 45 to 54 years of age to 12.5% in men 75 to 84 years of age. For women, the prevalence ranges from 0% in the youngest to 5.2% in the oldest age groups.¹⁷

• Factors associated with increased prevalence of AAA include older age, male sex, family history of AAA, tobacco use, hypertension, dyslipidemia, and manifest atherosclerotic disease in other vascular beds.¹⁷

• Large AAAs tend to expand more rapidly than small AAAs, and large AAAs are at substantially higher risk for rupture.¹⁷

  	— Average annual expansion rates are approximately 1 to 4 mm for aneurysms <4.0 cm in diameter, 4 to 5 mm for AAAs 4.0 to 6.0 cm in diameter, and as much as 7 to 8 mm for AAAs >6.0 cm in diameter.
  	— Absolute risk for eventual rupture is approximately 20% for AAAs >5.0 cm, approximately 40% for AAAs >6.0 cm, and >50% for AAAs >7.0 cm in diameter.
  	— Rupture of an AAA may be associated with death rates as high as 90%.

Atherosclerosis

ICD-9 440; ICD-10 I70.

Mortality—11 861. Total-mention mortality—75 400. Hospital discharges—126 000.

Atherosclerosis is a process that leads to a group of diseases characterized by a thickening of artery walls. Atherosclerosis causes many deaths from heart attack and stroke and accounts for nearly three fourths of all deaths from CVD (FHS, NHLBI).

Analysis of data from the REACH Registry¹⁹ showed that atherothrombosis (CAD, CVD, and PAD) is associated with the main causes of death on a worldwide scale. Despite decreases in age-adjusted death rates, the absolute number of deaths from these conditions continues to increase, and prevalence is increasing sharply in other parts of the world. Atherothrombotic diseases are currently and are projected to be the leading cause of death worldwide by 2020. In the REACH study, outpatients with established atherosclerotic arterial disease, or at risk of atherothrombosis, experienced relatively high annual cardiovascular event rates. Multiple disease locations increased the 1-year risk of cardiovascular events.¹⁸

Other Diseases of Arteries

ICD-9 442 to 448; ICD-10 I72-I78.

Mortality—9940. Total-mention mortality—32 566. Hospital discharges—97 000.

Kawasaki Disease

ICD-9 446.1; ICD-10 M30.3.

Mortality—8. Total-mention mortality—12. Hospital discharges—9000, primary plus secondary diagnoses.

An estimated 5300 cases of Kawasaki disease (KD) were diagnosed in 2003. KD occurs more often among boys (63%) and among those of Asian ancestry¹⁹ (personal communication with Jane W. Newburger and Kimberlee Gauvreau of Children’s Hospital of Boston, August 15, 2007).

• An estimated 4248 hospitalizations for KD occurred in the United States in 2000, with a median patient age of 2 years. Race-specific incidence rates indicate that KD is most common among Americans of Asian and Pacific Island descent (32.5/100 000 children <5 years of age), occurs with intermediate frequency in non-Hispanic blacks (16.9/100 000 children <5 years old) and Hispanics (11.1/100 000 children <5 years of age), and is least common in whites (9.1/100 000 children <5 years of age).²⁰ In the United States, KD is more common during the winter and early spring months; boys outnumber girls by approximately 1.5:1 to 1.7:1; and 76% of children are <5 years of age.²¹

• The incidence of KD in the United States did not increase between 1988 and 1997.²¹

Peripheral Arterial Disease

PAD affects approximately 8 million Americans and is associated with significant morbidity and mortality.²² Recently published data from multiple epidemiological studies demonstrate that approximately 8 million men and women ≥40 years of age have PAD.²³ Prevalence increases dramatically with age, and PAD disproportionately affects blacks.²⁴

• PAD affects 12% to 20% of Americans ≥65 years of age.²⁵ Despite its prevalence and cardiovascular risk implications, only about 25% of PAD patients are undergoing treatment.²⁶

• In the general population, only about 10% of persons with PAD have the classic symptom of intermittent claudication. About 40% do not complain of leg pain, whereas the remaining 50% have a variety of leg symptoms different from classic claudication.^22,27 In an older, disabled population of women, however, as many as two thirds of individuals with PAD had no exertional leg symptoms.²⁸

• Intermittent claudication is present in fewer than 1% of individuals <50 years of age and approximately 5% or more of those >80 years of age.¹⁷

• In the FHS (NHLBI), the incidence of PAD was based on symptoms of intermittent claudication in subjects 29 to 62 years of age. Annual incidence of intermittent claudication per 10 000 subjects at risk rose from 6 in men and 3 in women between the ages of 30 and 44 years to 61 in men and 54 in women between the ages of 65 and 74 years. The incidence of intermittent claudication has declined since 1950, but survival among persons with intermittent claudication has remained low.²⁹

• The risk factors for PAD are similar to those for CHD, although diabetes and cigarette smoking are particularly strong risk factors for PAD.^17,30 Most studies suggest that the prevalence of PAD is similar in men and women.³¹

• Persons with PAD have impaired function and quality of life. This is true even for persons who do not report leg symptoms. Furthermore, PAD patients, including those who are asymptomatic, experience a significant decline in lower-extremity functioning over time.^32,33

• Pooled data from 11 studies in 6 countries found that PAD is a marker for systemic atherosclerotic disease. The age- and sex-adjusted relative risk (RR) of all-cause death was 2.35; for CVD mortality, 3.34; and for CHD fatal and nonfatal events combined, 2.13. The findings for stroke were slightly weaker, but still significant, with a pooled RR of 1.86 for fatal and nonfatal events combined.³⁴

• Data from NHANES 1999–2000 (NCHS) show that high blood levels of lead and cadmium may increase the risk of PAD. Exposure to these 2 metals can occur through cigarette smoke. The risk was 2.8 for high levels of cadmium and 2.9 for high levels of lead. The OR of PAD for current smokers was 4.13, as compared with people who had never smoked.³⁵

• Results from NHANES 1999–2000 (NCHS) showed a remarkably high prevalence of PAD among patients with renal insufficiency. Accurate identification of patients with renal insufficiency, combined with routine ankle brachial index measurement in this group, would greatly enhance efforts to detect subclinical PAD.³⁶

• Available evidence suggests that the prevalence of PAD in persons of Hispanic origin is similar to or slightly higher than that in non-Hispanic whites.^23,37

• Recent studies indicate an association of elevated ankle brachial index levels with increased risk of all-cause and cardiovascular death.³⁸

• Among patients with established PAD, higher physical activity levels during daily life are associated with better overall survival rate and a lower risk of death from CVD.³⁹

• A cross-sectional, population-based telephone survey of >2500 adults ≥50 years of age, with oversampling of blacks and Hispanics, found that 26% expressed familiarity with PAD. Of these, half were not aware that diabetes and smoking increase the risk of PAD. One in 4 knew that PAD is associated with increased risk of heart attack and stroke, and only 14% were aware that PAD could lead to amputation. All knowledge domains were lower in individuals with lower income and education levels.⁴⁰

Bacterial Endocarditis

ICD-9 421.0; ICD-10 I33.0.

Total-mention mortality—2438. Hospital discharges—30 000, primary plus secondary diagnoses.

• The 2007 AHA Guidelines on Prevention of Infective Endocarditis⁴¹ state that infective endocarditis (IE) is thought to result from the following sequence of events: (1) formation of nonbacterial thrombotic endocarditis on the surface of a cardiac valve or elsewhere that endothelial damage occurs; (2) bacteremia; and (3) adherence of the bacteria in the bloodstream to nonbacterial thrombotic endocarditis and proliferation of bacteria within a vegetation.

• Viridans group streptococci are part of the normal skin, oral, respiratory, and gastrointestinal tract flora, and they cause ≥50% of cases of community-acquired native valve IE not associated with intravenous drug use.⁴²

• Transient bacteremia is common with manipulation of the teeth and periodontal tissues, and reported frequencies of bacteremia due to dental procedures vary widely: tooth extraction (10% to 100%), periodontal surgery (36% to 88%), scaling and root planing (8% to 80%), teeth cleaning (up to 40%), rubber dam matrix/wedge placement (9% to 32%), and endodontic procedures (up to 20%). Transient bacteremia also occurs frequently during routine daily activities unrelated to dental procedures: tooth brushing and flossing (20% to 68%), use of wooden toothpicks (20% to 40%), use of water irrigation devices (7% to 50%), and chewing food (7% to 51%). Considering that the average person living in the United States has fewer than 2 dental visits per year, the frequency of bacteremia from routine daily activities is far greater than that associated with dental procedures.⁴¹

• Although the absolute risk for IE from a dental procedure is impossible to measure precisely, the best available estimates are as follows: If dental treatment causes 1% of all cases of viridans group streptococcal IE annually in the United States, the overall risk in the general population is estimated to be as low as 1 case of IE per 14 million dental procedures. The estimated absolute risk rates for IE from a dental procedure in patients with underlying cardiac conditions are⁴¹:

  	— Mitral valve prolapse: 1 per 1.1 million procedures;
  	— CHD: 1 per 475 000;
  	— Rheumatic heart disease: 1 per 142 000;
  	— Presence of a prosthetic cardiac valve: 1 per 114 000; and
  	— Previous IE: 1 per 95 000 dental procedures.

Although these calculations of risk are estimates, it is likely that the number of cases of IE that results from a dental procedure is exceedingly small. Therefore, the number of cases that could be prevented by antibiotic prophylaxis, even if prophylaxis were 100% effective, is similarly small. One would not expect antibiotic prophylaxis to be near 100% effective, however, because of the nature of the organisms and choice of antibiotics.⁴¹

Cardiomyopathy

ICD-9 425; ICD-10 I42.

Mortality—25 580. Total-mention mortality—51 100. Hospital discharges—41 000.

• Mortality from cardiomyopathy is highest in older persons, men, and blacks (FHS, NHLBI).

• Tachycardia-induced cardiomyopathy develops slowly and appears reversible, but recurrent tachycardia causes rapid decline in left ventricular function and development of HF. Sudden death is possible.⁴³

• Since 1996, the NHLBI’s Pediatric Cardiomyopathy Registry has collected data on all children with newly diagnosed cardiomyopathy in New England and the Central Southwest (Texas, Oklahoma, and Arkansas).⁴⁴<

  	— The overall incidence of cardiomyopathy is 1.13 cases per 100 000 in children <18 years of age.
  	— In children <1 year of age, the incidence is 8.34, and in children between 1 and 18 years of age it is 0.70 per 100 000.
  	— The annual incidence is lower in white than in black children, higher in boys than in girls, and higher in New England (1.44 per 100 000) than in the Central Southwest (0.98 per 100 000).

• Studies show that 36% of young athletes who die suddenly have probable or definite hypertrophic cardiomyopathy.⁴⁵

• Hypertrophic cardiomyopathy is the leading cause of sudden cardiac death in young people, including trained athletes. Hypertrophic cardiomyopathy is the most common inherited heart defect, occurring in 1 of 500 individuals. In the United States, some 500 000 people have hypertrophic cardiomyopathy, yet most are unaware of it.⁴⁶

Rheumatic Fever/Rheumatic Heart Disease

ICD-9 390 to 398; ICD-10 I00-I09. SeeTable 8-1.

Mortality—3254. Total-mention mortality—6020.

• The incidence of rheumatic fever remains high in African Americans, Puerto Ricans, Mexican Americans, and American Indians.⁴⁷

• In 1950, approximately 15 000 Americans (adjusted for changes in ICD codes) died of rheumatic fever/rheumatic heart disease, compared with approximately 3200 today.

• From 1994 to 2004, the death rate from rheumatic fever/rheumatic heart disease fell 42.1%, while actual deaths declined 31.8%.

• The 2004 overall death rate for rheumatic fever/rheumatic heart disease was 1.1. Death rates were 0.8 for white males, 0.6 for black males, 1.3 for white females, and 1.0 for black females.

Valvular Heart Disease

ICD-9 424; ICD-10 I34-I38.

Mortality—20 260. Total-mention mortality—43 100. Hospital discharges—100 000.

Aortic Valve Disorders

ICD-9 424.1; ICD-10 I35.

Mortality—12 665. Total-mention mortality—26 660. Hospital discharges—51 000.

Mitral Valve Disorders

ICD-9 424.0; ICD-10 I34.

Mortality—2554. Total-mention mortality—about 6200. Hospital discharges—43 000.

• The NHLBI’s FHS reports that among people 26 to 84 years of age, prevalence of mitral valve disorders is about 1% to 2% and equal between women and men.⁴⁸

Pulmonary Valve Disorders

ICD-9 424.3; ICD-10 I37.

Mortality—13. Total-mention mortality—42.

Tricuspid Valve Disorders

ICD-9 424.2; ICD-10 I36.

Mortality—10. Total-mention mortality—89.

Endocarditis, Valve Unspecified

ICD-9 424.9; ICD-10 I38.

Mortality—5018. Total mention mortality—10 116. Hospital discharges—5000.

Venous Thromboembolism

• Venous thromboembolism (VTE) occurs for the first time in about 100 per 100 000 persons each year in the United States. About one third of patients with symptomatic VTE manifest pulmonary embolism (PE), whereas two thirds manifest deep vein thrombosis (DVT) alone.⁴⁹

• Whites and blacks have a significantly higher incidence than Hispanics and Asians or Pacific Islanders.⁴⁹

• In studies in Worcester, Mass, and Olmsted County, Minn, the incidence of VTE was about 1 in 1000. In both studies, VTE was more common in men; for each 10-year increase in age, the incidence doubled. By extrapolation, it is estimated that >250 000 patients are hospitalized annually with VTE.⁵⁰

• The crude incidence rate per 1000 person-years was 0.80 in the ARIC study, 2.15 in the CHS, and 1.08 in the combined cohort. Half of the participants who developed incident VTE were women, and 72% were white.⁵¹

• More than 200 000 new cases of VTE occur annually. Of these, 30% die within 30 days, one fifth suffer sudden death due to PE, and about 30% develop recurrent VTE within 10 years. Independent predictors for recurrence include increasing age, obesity, malignant neoplasm, and extremity paresis.⁵²

• Data from the ARIC study of the NHLBI showed that the 28-day fatality rate from DVT is 9%; from PE, 15%; from idiopathic DVT or PE, 5%; from secondary non–cancer-related DVT or PE, 7%; and from secondary cancer-related DVT or PE, 25%.⁵³

• The RR of VTE among pregnant or postpartum women was 4.29%, and the overall incidence of VTE (absolute risk) was 199.7 per 100 000 woman-years. The annual incidence was 5 times higher among postpartum women than pregnant women, and the incidence of DVT was 3 times higher than that of PE. PE was relatively uncommon during pregnancy versus the postpartum period. Over the 30-year period, the incidence of VTE during pregnancy remained relatively constant, whereas the postpartum incidence of PE decreased >2-fold.⁵⁴

• On the basis of a prospective study of black and white middle-aged adults in the ARIC study of the NHLBI, it was found that consumption of ≥4 servings of fruit and vegetables per day or ≥1 serving of fish per week was associated with lower incidence of VTE. In a comparison of the highest quintile of intake with the lowest, red and processed meat and a Western diet pattern were positively associated with incident VTE.⁵⁵

• Results from phase I of the WHO Research Into Global Hazards of Travel (WRIGHT) project found that the risk of developing VTE approximately doubles after travel lasting 4 hours or more. However, the absolute risk of developing VTE if seated and immobile for more than 4 hours remains relatively low, at about 1 in 6000. Other risk factors that increase the risk of VTE during travel are obesity, being very tall or very short, use of oral contraceptives, and inherited blood disorders that lead to increased clotting tendency. One study within the project examining flights in particular found that those taking multiple flights over a short period of time are also at higher risk.⁵⁶ This is because the risk of VTE remains elevated for about 4 weeks.

Deep Vein Thrombosis

ICD-9 451.1; ICD-10 I80.2.

Mortality—2843. Total-mention mortality—11 190. Hospital discharges—6300.

• A review of 9 studies conducted in the United States and Sweden showed that the mean incidence of first DVT in the general population was 5.04 per 10 000 person-years. The incidence was similar in males and females and increased dramatically with age from about 2 to 3 per 10 000 person-years at 30 to 49 years of age to 20 at 70 to 79 years of age.⁵⁷

• Death occurs in about 6% of DVT cases within 1 month of diagnosis.⁴⁹

Pulmonary Embolism

ICD-9 415.1; ICD-10 I26.

Mortality—8113. Total-mention mortality—26 540. Hospital discharges—140 000.

• In the Nurses’ Health Study, nurses ≥60 years of age in the highest BMI quintile had the highest rates of PE. Heavy cigarette smoking and HBP were also identified as risk factors for PE.⁵⁰

• Death occurs in about 12% of PE cases within 1 month of diagnosis.⁴⁹

• A study of Medicare recipients ≥65 years of age reported 30-day case fatality rates in patients with PE. Overall, men had higher fatality rates than women (13.7% versus 12.8%), and blacks had higher fatality rates than whites (16.1% versus 12.9%).⁵⁰

• In the International Cooperative Pulmonary Embolism Registry, the 3-month mortality rate was 17.5%. In contrast, the overall 3-month mortality rate in the Prospective Investigation of Pulmonary Embolism Diagnosis was 15%, but only 10% of deaths during 1 year of follow-up were ascribed to PE.⁵⁰

• The age-adjusted rate of deaths from pulmonary thromboembolism decreased from 191 per million in 1979 to 94 per million in 1998 overall, decreasing 56% for men and 46% for women. During this time, the age-adjusted mortality rates for blacks were consistently 50% higher than those for whites, and those for whites were 50% higher than those for people of other races (Asian, American Indian, etc). Within racial strata, mortality rates were consistently 20% to 30% higher among men than among women.⁵⁸