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Cardiovascular Epidemiology and PreventionNathan D. Wong, PhD, FACC, FAHAProfessor and Director, Heart Disease Prevention Program, Division of Cardiology, University of California, IrvinePresident, American Society of Preventive Cardiology

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Textbooks

Cardiovascular Epidemiology: Definitions, Concepts, Historical Perspectives and Statistics

*

Definitions

CORONARY ARTERY DISEASE (CAD) or CORONARY HEART DISEASE (CHD) (often broadly referred to as ISCHEMIC HEART DISEASE (IHD): primarily myocardial infarction and sudden coronary death, broader definition may include angina pectoris, atherosclerosis, positive angiogram, and revascularization (perceutaneous coronary interventions, or PCI such as angioplasty and stents)

CARDIOVASCULAR DISEASE or CVD includes CHD, cerebrovascular disease, peripheral vascular disease, and other cardiac conditions (congenital, arrhythmias, and congestive heart failure)

*

Definitions (cont.)

SURROGATE MEASURES include: carotid intimal medial thickness (IMT), coronary calcium, angiographic stenosis, brachial ultrasound flow mediated dilatation (FMD)

Hard endpoints include myocardial infarction, CHD death, and stroke

*

*

Hospital Specialty_FINAL ATS

*

*

Source: NCHS and NHLBI. A indicates CVD plus congenital CVD; B, cancer; C, accidents; D, CLRD; E, diabetes; and F, Alzheimer's disease.

2010 American Heart Association, Inc. All rights reserved.

Roger VL et al. Published online in Circulation Dec. 15, 2010

CVD and other major causes of death for all males and females (United States: 2007).

Trends in cardiovascular procedures, United States: 19792009

Note: Inpatient procedures only. Source: National Hospital Discharge Survey, NCHS, and NHLBI.



Direct and indirect costs (in billions of dollars)

of major cardiovascular diseases and stroke (United States: 2008)

Source: National Heart, Lung, and Blood Institute.



Projected Total Costs of CVD, 20152030 (in Billions 2008$) in the United States

Unpublished data tabulated by AHA using methods described in Circulation. 2011;123:933944.



CVD disease mortality trends for males and females(United States: 1979-2006). Source: NCHS and NHLBI.

Chart1

496.676466.361

506.154487.194

487.453495.286

444.763475.482

452.452503.139

440.175505.661

398.563432.709

Males

Females

Years

Deaths in Thousands

Sheet1

CVDCVDCardiovascular Disease Mortality Trends for Males and FemalesCVD *CVD*CVDCVD

MalesFemalesUnited States: 1979-2006MalesFemalesMalesFemales

795004697949746679497466

805104908050648780506487

8150048449748185487495

8249548449248190445475

8349849449549195452503

8449149348749100440506

854914988548749506399433

86481498478495

87475499472496

88476504473501

89456486453483

9044847890445475

91447479444477

92444479441477

93457500454498

94452498449496

9545550595452503

96453506451504

97450503448501

98446504Actual MortalityAdjusted Mortality*443502

99446513adjusted by 9-10 comparability ratio. (0.9981)445.024511.929446513

00440506440.175505.661439.339504.70000440506

01432499432.245498.863431.424497.915432499

Source: Final mortality data, NCHS.433.827493.69002433.003492.752434494

Numbers are in thousands.427.891483.37203427.078482.454428483

CVD including congenital CV disease.410.365461.15204409.585460.276411459

05410455

* - Since comparability ratio is so close to 1.00

it is not necessary to adjust. As per TT 9/26/06.

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Males

Females

Years

Deaths in Thousands

Hospital discharges for cardiovascular diseases. (United States: 1970-2006). Note: Hospital discharges include people discharged alive, dead and status unknown. Source: NCHS and NHLBI.

Chart1

3.34

4.418

5.14

5.47

5.161

5.83

6.294

6.161

Years

Discharges in Millions

CVD

CVD (390-459)Hdis.MalesFemalesHospital Discharges* for Cardiovascular Diseases as First listed Diagnosis

703.34United States: 1970-2006

3.543

3.86

4.11

4.304

754.418

4.585

4.758

4.766

4.907792.4712.436

805.14802.592.549

5.336812.6792.657

5.4882.7852.703

5.6542.8962.758

5.5932.8562.737

855.47852.7832.686

5.5632.8462.717

5.5722.8682.704

5.2962.7222.574

5.1972.672.527

905.161902.6682.493

5.3382.7282.611703.34

5.5972.8662.73754.418

5.6332.8852.747805.14

5.7792.9062.873855.47

955.83952.9732.857905.161

6.1073.1013.006955.83

6.0973.1163.03006.294

6.272983.1393.133066.161

6.344794.907

006.2943.1153.179805.14

6.2263.0583.168815.336

6.3733.2093.164825.488

6.4343,2393.196835.654

6.3633.2273.136845.593

056.1593.1363.023855.47

066.1613.1213.04865.563

875.572

885.296

895.197

905.161

915.338

925.597

935.633

945.779

955.83

966.107

976.097

NOTE: do not include congenital!986.272

996.344

006.294

Neoplams 140-4591.61.631

Endocrine System 240-2791.71.663

Musculoskeletal System 710-7392.01.969

Genitourinary System 580-6292.01.974

Mental 290-3192.42.419

External: Injuries, etc. 800-9993.02.968

Respiratory System 460-5193.53.485

Digestive System 520-5793.53.517

Obstetrical V274.14.127

Cardiovascular 340-4596.26.161

Chart 2-20. Hospital Discharges for the 10 Leading Diagnostic Groups

United States: 2006

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CVD

0

0

0

0

0

0

0

0

Years


stroke

Hospital Discharges Where Stroke Was the First Listed Diagnosis

United States: 1979 to Date

YearMalesFemalesTotal

79335411746

80371425796

368439807

388446834

407469876

420477897

85407499906

398491889

392503895

336448784

344447791

90355453808

371464835

376450826

387452839

407478885

95424501925

438518956

4615551017

4575531010

434527961

00428553981

391539931

432509942

455510965

416490906

05418477895

06404486889


United States: 1979-2006

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stroke

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

Males

Females

Years

Discharges in Thousands

CHF

Hospital Discharges for CHF

CHF Discharges

-----------In thousands------

MalesFemalesTotal

708074155

7986165

98102200

107111218

121113234

75122131253

123143267

143152296

157173330

174203377

80176224401

182240423

195243439

208255464

228303531

85247310557

274308582

269336605

277357634

304339643

90315386701

360405764

373449822

394481875

390484874

95378494872

377493870

431526957

438540978

430532962

00418581999

444551995

441529970

4715661,037

04

Hospital Discharges*for Congestive Heart Failure by Sex


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CHF

1

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#REF!


HF

Hospital Discharge Code=428 FL (1970-2003) Heart Failure

MaleFemale

197011,07111,238

9,5199,157

10,4909,276

9,42910,090

8,9249,555

7510,3259,056

7,4888,974

6,2617,660

5,3346,539

MaleFemale

79185214

80190240

195252

207257Hospital discharges for Heart Failure by Sex

221276United States: 1979-2006MaleFemale

23731779185214

8525932680190240

28732885259326

28234790325397

28937595384497

31235100422586

9032539706523583

370417

384456

404491

395492

95384497

381496

436530

442547

434541

00422586

446554

443530

496597

05494590

06523583

Males

Females

Years


0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

HF

00

00

00

00

00

00

00

Male

Female

Years


HBP

Hospital Discharges Where HBP Was the First-Listed DiagnosisHospital Discharges Where HBP Was the All-Listed Diagnosis

United States: 1979 to Date (000)United States: 1979 to Date (000)

MalesFemalesTotalMalesFemalesTotal

19901221642851990163422303864

129190317178625204305

9215321336792200427834788

176208383223230235255

9415122137394234832505599

174200384244133605807

9617124641796262535486178

173250422277838596639

9817126643798295041967146

172267439319844367640

0018627145700330247328043

194292486396854059375

0222431253502396854059375

221299520424056419885

04230322551044500596510473

05215284499054648599910653

First-Listed Hospital Discharges for Hypertension by SexAll-Listed Hospital Discharges for Hypertension by Sex

United States 1990-2005United States 1990-2005

HBP

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

Males

Females

Years


chd

Hospital Discharges Where CHD Was the First Listed Diagnosis


(000)(000)

YearMalesFemales

70779597

851628

935693

982725

1030756

751043789

1087843

1111852

1110844

10147241738

801049737

1095765

1160841

1229852

1044840

851205846

1250889

1268901

1220830

1174819

901151795

1146806

1247886

1205872

1219899

9512698582127

1325933

1249840

1263915

1317945

001274892

1199891

1249875

1175834

11808011981

0511177111828

0610567041760

Hospital Discharges for Coronary Heart Diasease by SexYearMalesFemales

United States: 1970-200670779597

751043789

801107795

851226864sent by Maria Owings 9/19/08

901159806

951271865

001277896

061056706

Males

Females

Years


0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

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chd

00

00

00

00

00

00

00

00

Males

Females

Years


2

2

2.4

3.5

4.1

6.2

3

1.7

1.6

3.5

01234567

Neoplams 140-459

Endocrine System 240-279

Musculoskeletal System 710-739

Genitourinary System 580-629

Mental 290-319

External: Injuries, etc. 800-999

Respiratory System 460-519

Digestive System 520-579

Obstetrical V27

Cardiovascular 340-459


MBD0012E4D4.xls

Chart9

1.6

1.7

2

2

2.4

3

3.5

3.5

4.1

6.2


Sheet1

Neoplams 140-4591.61.631




Mental 290-3192.42.419







United States: 2006

Hemic and Lymphatic 40-410.40.371

Urinary System 55-591.01.025

Nervous System 01-051.21.155


Integumentary System 85-861.61.598

Female Genital Organs 65-712.01.957

Musculoskeletal 76-844.24.188



Obstetrical 72-757.17.076

Chart 18-3. Number of Surgical Procedures in the 10 Leading Diagnostic Groups

United States: 2006

Sheet1

1.6

1.7

2

2

2.4

3

3.5

3.5

4.1

6.2


Sheet2

Millions of Discharges

Hemic and Lymphatic 40-41

Urinary System 55-59

Nervous System 01-05


Integumentary System 85-86

Female Genital Organs 65-71

Musculoskeletal 76-84



Obstetrical 72-75

0.4

1

1.2

1.2

1.6

2

4.2

5.6

6.5

7.1

Sheet3

*

Source: NCHS and NHLBI. These data include CHD, HF, stroke, and hypertension.



Prevalence of CVD in adults 20 years of age by age and sex (NHANES: 20052008)



Deaths due to diseases of the heart (United States: 19002008)

Source: National Center for Health Statistics.

CVD deaths vs. cancer deaths by age.

(United States: 2006). Source: NCHS.

Chart1

25.05720.577

47.83950.334

81.456101.454

119.809137.554

241.95164.889

315.1685.08

831.272559.888

CVD

Cancer

Ages

Deaths in Thousands

Sheet1

CVD/can/age 2006 Final

CVDCancer

Source: NCHS and NHLBI. A indicates CVD plus congenital CVD; B, cancer; C, accidents; D, CLRD; E, diabetes; and F, Alzheimer's disease.



CVD and other major causes of death for all males and females (United States: 2008)

Source: NCHS and NHLBI.



Prevalence of stroke by age and sex (NHANES: 20052008)

Prevalence of stroke by age and sex (NHANES: 20052008).




Percentage breakdown of deaths from cardiovascular diseases (United States: 2006) * - Not a true underlying cause.Source: NCHS.

Chart1

51

17

7

7

4

14

PieCVD

2003CVD total mortality2004 CVD total mortality final2006 CVD total mortality

910,614PreliminaryPercentage Breakdown of Deaths From Cardiovascular DiseasesPercentage Breakdown of Deaths From Cardiovascular Diseases

479,304CHD52.6Coronary Heart Disease52451,32652United States:2004Coronary Heart Disease51425,42551.4United States:2006

157,803Stroke17.3Stroke17150,07417Stroke17137,11916.6

57,218HF6.3HF757,1207HF*760,3377.3

52,604Hyp.5.8High Blood Pressure654,7076High Blood Pressure756,5616.8

37,647Dis. of Arteries4.1Diseases of the Arteries435,5544Diseases of the Arteries431,1363.8

4,178Cong.HD0.5Congenital Cardiovascular Defects0.43,8610.4Other14117,16314.2

3,554RF/RHD0.4Rheumatic Fever/Rheumatic Heart Disease0.43,2540.4827,741100.0

118,306Other13.0Other13113,82813

910614100.0869724100.0

Note - CHD is 52 not 53.

Note: Try to arrange in descending order.

* Not a true underlying cause.

NOTE: May not add to 100 due to rounding.

Does not include congenital.

959,368Percentage Breakdown of Deaths From Cardiovascular Diseases

529659CHD55.2Coronary Heart Disease54502,18954United States:1980

167,366Stroke17.4Stroke18163,53818

54,920CHF38.9Congestive Heart Failure652,8286

42,997Hyp.4.5High Blood Pressure546,7655

14,979Dis. of Arteries1.6Diseases of the Arteries439,4044

3,676RF/RHD0.4Rheumatic Fever/Rheumatic Heart Disease0.43,4890.4

4657Cong.HD0.5Congenital Cardiovascular Defects0.44,1090.4

141114Other15.5Other13118,78613

959368134.0100.8931,108100.0

1990 CVD total mortality1990CVD total mortality

959,368Percentage Breakdown of Deaths From Cardiovascular Diseases

529659CHD55.2Coronary Heart Disease54502,18954United States:1990

167,366Stroke17.4Stroke18163,53818

54,920CHF38.9Congestive Heart Failure652,8286

42,997Hyp.4.5High Blood Pressure546,7655

14,979Dis. of Arteries1.6Diseases of the Arteries439,4044

3,676RF/RHD0.4Rheumatic Fever/Rheumatic Heart Disease0.43,4890.4

4657Cong.HD0.5Congenital Cardiovascular Defects0.44,1090.4

141114Other15.5Other13118,78613

959368134.0100.8931,108100.0

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PieCVD

53%

LCDAIAN

LCD AM. INDIAN M/F, 2003

Diseases of the Heart and Stroke and other Major Causes of Death for American Indian/Alaska Native Males and Femlaes

MALESFEMALESUnited States: 2003

Diseases of the Heart, and StrokeA24.9Diseases of the Heart, and StrokeA24.7

CancerB15.4CancerB17.6

AccidentsC14.7AccidentsC8.8

Diabetes MellitusD5.2DiabetesD6.9

Chronic Liver Disease and CirrhosisE4.5Chronic Liver Disease and CirrhosisE4.2

Diseases of the Heart and Stroke and other Major Causes of Death for American Indian/Alaska Native Males and Femlaes

United States: 2003

Females

Males

MALES

Diseases of the Heart, and Stroke23.6FEMALES

Cancer17.4Diseases of the Heart, and Stroke25.0

Accidents14.2Cancer19.2

Diabetes Mellitus5.1Accidents8.5

Chronic Liver Disease and Cirrhosis4.5Diabetes Mellitus6.4

Chronic Liver Disease and Cirrhosis4.2

Diseases of the Heart and Stroke and other Major Causes of Death for American Indian/Alaska Native Males and FemlaesDiseases of the Heart and Stroke and other Major Causes of Death for American Indian/Alaska Native Males and Femlaes

United States: 2004United States: 2004

MALESFEMALES

CVD (I00-I99)A24.4CVD (I00-I99)A25.8



Diabetes MellitusD4.7DiabetesD7.0

Chronic Liver Disease and CirrhosisE4.3CLRDF4.3

ABCDEABCDF

Males24.416.015.54.74.3

Females25.819.28.17.04.3

CVD and Other Major Causes of Death for American Indian or Alaska Native Males and Females

United States: 2006

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LCDAIAN

MALES

Percent of Total Deaths

LCDWHITEMF

CVD and Other Major Causes of Death for White Females

LCD WHITE M/F, 2004 finalUnited States: 2004

10072661049377

MALESFEMALES

CVD+cong.A35.1CVD+cong.A37.7


AccidentsC6.1Chronic LRDD5.7

Chronic LRDD5.3Alzheimer'sF4.1

DiabetesE2.8AccidentsC3.3

CVD and Other Major Causes of Death for White Males

United States:2004

Females

Males

LCD WHITE M/F, 2006

MALESFEMALES



AccidentsC6.5Chronic LRDD5.8

Chronic LRDD5.3Alzheimer'sF4.5


ABCDEABDFC

Males33.324.56.55.32.8

Females35.322.05.84.53.5

CVD and Other Major Causes of Death for White Males and Females

United States:2006

`

FEMALES




Males

Females


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LCDWHITEMF

MALES


LCDMF

LCD MALES AND FEMALES, 2004 (Final)CVD and Other Major Causes of Death for All Males and Females

United States: 2004

MALESFEMALES

CVD+cong.A410,628CVD+cong.A459,096

CancerB286,830CancerB267,058

AccidentsC72,050Chronic LRDD63,341

Chronic LRDD58,646Alzheimer'sF46,991

DiabetesE35,267DiabetesE37,871

CVD and Other Major Causes of Death for All Males and Females

United States: 2004

Females

Males

LCD, 2002

Total CVD433,825

Cancer288,768

Accidents69,257

Chronic Lower Respiratory Disease60,713

Diabetes Mellitus34,301

Leading Causes of Death

United States: 2002

LCD MALES AND FEMALES, 2005

MALESFEMALES

CVD+cong.A398,563CVD+cong.A432,709

CancerB290,069CancerB269,819

AccidentsC78,941Chronic LRDD65,323

Chronic LRDD59,260Alzheimer'sF51,281

DiabetesE36,006AccidentsC42,658

ABCDEABDFC

Males398,563290,06978,94159,26036,006

Females432,709269,81965,32351,28142,658

CVD and Other Major Causes of Death for All Males and Females

United States: 2006

FEMALES


Males

Females


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LCDMF

MALES

Deaths in Thousands

LCDBLKMF

LCD BLACK M/F, 2004 final

CVD and Other Major Causes of Death for Black Males and Females

MALESFEMALESUnited States: 2004



AccidentsC5.9DiabetesE5.1

Assault(Homicide)D4.7Nephritis, etc.F3.0



United States: 2004

Females

Males

LCD BLACK M/F, 2006

MALESFEMALES



AccidentsC6.5DiabetesE5.0

Assault(Homicide)D5.2Nephritis, etc.F3.2


ABCDEABEFC

Males32.321.96.55.23.9

Females35.921.65.03.23.1


United States: 2006

FEMALES

Deaths in Thousands

Deaths in Thousands

Males

Females

Deaths

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LCDBLKMF

MALES


LCDAPI

MalesFemales

Diseases of Heart and StrokeA34.0Diseases of Heart and StrokeA34.7



Chronic Lower Respiratory DiseaseD3.8Diabetes MellitusE3.9

DiabetesE3.3Influenza and PneumoniaF3.0

Diseases of the Heart and Stroke and Other Major Causes of Death for Asian/Pacific Islander Males and FemalesDiseases of the Heart and Stroke and Other Major Causes of Death for Asian/Pacific Islander Males and Females

United States: 2003United States: 2003

MalesFemales

Diseases of Heart and Stroke34.7

Diseases of Heart and Stroke32.9Cancer27.1

Cancer26.7Accidents4.1

Accidents5.5Diabetes Mellitus3.9

Chronic Lower Respiratory Disease3.5Influenza and Pneumonia3.0

Diabetes Mellitus3.3

Diseases of the Heart and Stroke and Other Major Causes of Death for Asian/Pacific Islander Males and Females

Diseases of the Heart and Stroke and Other Major Causes of Death for Asian/Pacific Islander Males and FemalesUnited States: 2003

United States: 2004

MalesFemales

MalesFemales

CVD (I00-I99)A34.5CVD (I00-I99)A34.8



Chronic Lower Respiratory DiseaseD3.6Diabetes MellitusE3.8

DiabetesE3.5Influenza and PneumoniaF3.0

ABCDEABCEF

Males34.525.55.63.63.5

Females34.827.23.83.83.0

CVD and Other Major Causes of Death for Asian/Pacific Islander Males and Females

United States: 2006

FEMALES


Males

Females


LCDAPI

Females


lcdkids

LCD MALE AND FEMALE Children Age

Prevalence of heart failure by age and sex (NHANES: 2005-2006). Source: NCHS and NHLBI.

Chart1

0.10.2

2.21.2

9.34.8

13.812.2

Men

Women

Percent of Population

DEATHSCHF

Deaths From CHF, United States: 1979-98 (428.0)

(000)Congestive

Ht. Failuremalesfemaleswmwfbmbf

197920

8022

8123

8225

83271116101411411712511573

84291217109011532913031708

85321319114801684914181841

86341420124511812714591989

87351421125571916114661949

88371522132872014115672109

89341321119031870014082056

90341321118251871613971931

91351422121191963713331999

92361422124682030013351963

93421626142322351814772246

94421626141492354614192119

95431627145952436714652217

96441727

97451728

98471829comp. Ratio

9951193248,8221.041

0052193249,516

0153203350,747

Deaths From Congestive Heart Failure


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DEATHSCHF

Congestive Ht. Failure

Years

Deaths in Thousands

PCTCHGCHF

Congestive Heart Failure % Increase in Deaths

CHF

7919.936

8021.804

8123.297

8225.09

8327.274

8429.429

8531.807

8634.271

8735.387

8837.371

8934.348

9034.156

9135.393

9236.387

9341.819

9441.601

9543.01

9643.837

119.8886436597

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HFPREV

HF PREVALENCE

MenWomen

20-390.10.2

40-592.21.2

60-799.34.8

80+13.812.2

Prevalence of Heart Failure by Age and Sex


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HFPREV

Men

Women


*

Note: Hospital discharges include people discharged alive, dead and status unknown.

Hospital discharges for heart failure by sex.

(United States: 1979-2006). Source: NHDS/NCHS and NHLBI.

Chart1

185.303214.49

190.125240.37

258.645326.377

324.63397.288

383.917496.515

421.896585.791

523583

Male

Female

Years


CVD

CVD (390-459)Hdis.MalesFemalesHospital Discharges* for Cardiovascular Diseases as First listed Diagnosis

703.34United States: 1970-2006

3.543

3.86

4.11

4.304

754.418

4.585

4.758

4.766

4.907792.4712.436

805.14802.592.549

5.336812.6792.657

5.4882.7852.703

5.6542.8962.758

5.5932.8562.737

855.47852.7832.686

5.5632.8462.717

5.5722.8682.704

5.2962.7222.574

5.1972.672.527

905.161902.6682.493

5.3382.7282.611703.34

5.5972.8662.73754.418

5.6332.8852.747805.14

5.7792.9062.873855.47

955.83952.9732.857905.161

6.1073.1013.006955.83

6.0973.1163.03006.294

6.272983.1393.133066.161

6.344794.907

006.2943.1153.179805.14

6.2263.0583.168815.336

6.3733.2093.164825.488

6.4343,2393.196835.654

6.3633.2273.136845.593

056.1593.1363.023855.47

066.1613.1213.04865.563

875.572

885.296

895.197

905.161

915.338

925.597

935.633

945.779

955.83

966.107

976.097

NOTE: do not include congenital!986.272

996.344

006.294

Neoplams 140-4591.61.631




Mental 290-3192.42.419







United States: 2006

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CVD

0

0

0

0

0

0

0

0

Years


stroke


United States: 1979 to Date

YearMalesFemalesTotal

79335411746

80371425796

368439807

388446834

407469876

420477897

85407499906

398491889

392503895

336448784

344447791

90355453808

371464835

376450826

387452839

407478885

95424501925

438518956

4615551017

4575531010

434527961

00428553981

391539931

432509942

455510965

416490906

05418477895

06404486889



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stroke

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

Males

Females

Years


CHF

Hospital Discharges for CHF

CHF Discharges

-----------In thousands------

MalesFemalesTotal

708074155

7986165

98102200

107111218

121113234

75122131253

123143267

143152296

157173330

174203377

80176224401

182240423

195243439

208255464

228303531

85247310557

274308582

269336605

277357634

304339643

90315386701

360405764

373449822

394481875

390484874

95378494872

377493870

431526957

438540978

430532962

00418581999

444551995

441529970

4715661,037

04

Hospital Discharges*for Congestive Heart Failure by Sex


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1

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#REF!


HF

Hospital Discharge Code=428 FL (1970-2003) Heart Failure

MaleFemale

197011,07111,238

9,5199,157

10,4909,276

9,42910,090

8,9249,555

7510,3259,056

7,4888,974

6,2617,660

5,3346,539

MaleFemale

79185214

80190240

195252

207257Hospital discharges for Heart Failure by Sex

221276United States: 1979-2006MaleFemale

23731779185214

8525932680190240

28732885259326

28234790325397

28937595384497

31235100422586

9032539706523583

370417

384456

404491

395492

95384497

381496

436530

442547

434541

00422586

446554

443530

496597

05494590

06523583

Males

Females

Years


0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

HF

00

00

00

00

00

00

00

Male

Female

Years


HBP

Hospital Discharges Where HBP Was the First-Listed DiagnosisHospital Discharges Where HBP Was the All-Listed Diagnosis

United States: 1979 to Date (000)United States: 1979 to Date (000)

MalesFemalesTotalMalesFemalesTotal

19901221642851990163422303864

129190317178625204305

9215321336792200427834788

176208383223230235255

9415122137394234832505599

174200384244133605807

9617124641796262535486178

173250422277838596639

9817126643798295041967146

172267439319844367640

0018627145700330247328043

194292486396854059375

0222431253502396854059375

221299520424056419885

04230322551044500596510473

05215284499054648599910653

First-Listed Hospital Discharges for Hypertension by SexAll-Listed Hospital Discharges for Hypertension by Sex

United States 1990-2005United States 1990-2005

HBP

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

00

Males

Females

Years


chd

Hospital Discharges Where CHD Was the First Listed Diagnosis


(000)(000)

YearMalesFemales

70779597

851628

935693

982725

1030756

751043789

1087843

1111852

1110844

10147241738

801049737

1095765

1160841

1229852

1044840

851205846

1250889

1268901

1220830

1174819

901151795

1146806

1247886

1205872

1219899

9512698582127

1325933

1249840

1263915

1317945

001274892

1199891

1249875

1175834

11808011981

0511177111828

0610567041760

Hospital Discharges for Coronary Heart Diasease by SexYearMalesFemales

United States: 1970-200670779597

751043789

801107795

851226864sent by Maria Owings 9/19/08

901159806

951271865

001277896

061056706

Males

Females

Years


0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

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chd

00

00

00

00

00

00

00

00

Males

Females

Years


2

2

2.4

3.5

4.1

6.2

3

1.7

1.6

3.5

01234567

Neoplams 140-459

Endocrine System 240-279

Musculoskeletal System 710-739

Genitourinary System 580-629

Mental 290-319

External: Injuries, etc. 800-999



Obstetrical V27



MBD0012E4D4.xls

Chart9

1.6

1.7

2

2

2.4

3

3.5

3.5

4.1

6.2


Sheet1

Neoplams 140-4591.61.631




Mental 290-3192.42.419







United States: 2006

Hemic and Lymphatic 40-410.40.371

Urinary System 55-591.01.025

Nervous System 01-051.21.155


Integumentary System 85-861.61.598

Female Genital Organs 65-712.01.957

Musculoskeletal 76-844.24.188



Obstetrical 72-757.17.076

Chart 18-3. Number of Surgical Procedures in the 10 Leading Diagnostic Groups

United States: 2006

Sheet1

1.6

1.7

2

2

2.4

3

3.5

3.5

4.1

6.2


Sheet2

Millions of Discharges

Hemic and Lymphatic 40-41

Urinary System 55-59

Nervous System 01-05


Integumentary System 85-86

Female Genital Organs 65-71

Musculoskeletal 76-84



Obstetrical 72-75

0.4

1

1.2

1.2

1.6

2

4.2

5.6

6.5

7.1

Sheet3

*

Development of Atherosclerotic Plaques

Normal

Fatty streak

Foam cells

Lipid-rich plaque

Lipid core

Fibrous cap

Thrombus

Ross R. Nature. 1993;362:801-809.

*

2.03

PDAY: Percentage of Right Coronary Artery Intimal Surface Affected With Early Atherosclerosis

PDAY= Pathobiological Determinants of Atherosclerosis in Youth.

Strong JP, et al. JAMA. 1999;281:727-735.

Fatty streaks

Raised lesions

White

15-19

20-24

25-29

30-34

0

10

20

30

Women

0

10

20

30

15-19

20-24

25-29

30-34

Black

Age (y)

0

10

20

30

White

15-19

20-24

25-29

30-34

Men

Black

Intimalsurface(%)

*

Most Myocardial Infarctions Are Causedby Low-Grade Stenoses

Pooled data from 4 studies: Ambrose et al, 1988; Little et al, 1988; Nobuyoshi et al, 1991; and Giroud et al, 1992.(Adapted from Falk et al.)

Falk E et al, Circulation, 1995.

*

(Adapted from Glagov et al.)

Coronary Remodeling

Normal

vessel

Minimal

CAD

Progression

Compensatory expansion

maintains constant lumen

Expansion overcome:

lumen narrows

Severe

CAD

Moderate

CAD

Glagov et al, N Engl J Med, 1987.

*

Intraluminal thrombus

Growth of thrombus

Intraplaque thrombus

Lipid pool

Blood Flow

Atherosclerotic Plaque Rupture and Thrombus Formation

Adapted from Weissberg PL. Eur Heart J Supplements 1999:1:T1318

*

Rupture of atherosclerotic plaque and subsequent thrombosis of the vessel is responsible for the development of acute ischemic coronary syndromes. A lipid-rich core (particularly in the shoulder regions of lesions), abundance of inflammatory cells, a thin fibrous cap and dysfunctional overlying endothelium characterize plaques that are prone to rupture.

Reference

Weissberg PL. Eur Heart J Supplements 1999:1:T1318.

Eccentric, lipid-richFragile fibrous capPrior luminal obstruction < 50%Visible rupture and thrombus

Constantinides P. Am J Cardiol. 1990;66:37G-40G.

Features of a Ruptured Atherosclerotic Plaque

*

2.07

Libby P. Circulation. 1995;91:2844-2850.

Vulnerable Plaque

Thin fibrous capInflammatory cell infiltrates:

proteolytic activity

Lipid-rich plaque

Lumen

Lipid

Core

Fibrous Cap

Thick fibrous capSmooth muscle cells: more extracellular matrixLipid-poor plaque

Stable Plaque

Lumen

Lipid

Core

Fibrous Cap

Vulnerable Versus Stable Atherosclerotic Plaques

*

2.05

Correlation of CT angiography of the coronary arteries with intravascular ultrasound illustrates the ability of MDCT to demonstrate calcified and non-calcified coronary plaques (Becker et al., Eur J Radiol 2000)

Non-calcified, soft, lipid-rich plaque in left anterior descending artery (arrow) (Somatom Sensation 4, 120 ml Imeron 400). The plaque was confirmed by intravascular ultrasound (Kopp et al., Radiology 2004)

*

Concept of cardiovascular risk factors

Kannel et al, Ann Intern Med 1961

Age, sex, hypertension, hyperlipidemia, smoking, diabetes, (family history), (obesity)

Major Risk Factors
Cigarette smoking (passive smoking?)Elevated total or LDL-cholesterolHypertension (BP 140/90 mmHg or on antihypertensive medication)Low HDL cholesterol (

Other Recognized Risk Factors

Obesity: Body Mass Index (BMI)Weight (kg)/height (m2)Weight (lb)/height (in2) x 703 Obesity BMI >30 kg/m2 with overweight defined as 25-40 in. in men, >35 in. in womenPhysical inactivity: most experts recommend at least 30 minutes moderate activity at least 4-5 days/week

*

Prevalence (unadjusted) estimates for poor, intermediate and ideal cardiovascular health

for each of the 7 metrics of cardiovascular health in the AHA 2020 goals,

US children aged 12-19 years, NHANES 2007-2008



Chart1

16.3432357623083.6567642377

18.557141708518.958640651362.4842176401

7.197208724753.851620601138.9511706742

91.4571719338.5428280670

4.644661785720.218780189775.1365580246

2.020390993215.673607204982.3060018019

1.015740366822.783806840876.2004527924

Poor

Intermediate

Ideal

Percentage

Sheet1

PoorIntermediateIdeal

Current Smoking16.30.083.7

Body Mass Index18.619.062.5

Physical Activity7.253.939.0

Healthy Diet Score91.58.50.0

Total Cholesterol4.620.275.1

Blood Pressure2.015.782.3

Fasting Plasma Glucose1.022.876.2

Age-standardized prevalence for poor, intermediate and ideal cardiovascular health for each of the 7 metrics of cardiovascular health in the AHA 2020 goals,

among US adults >20 years of age, NHANES 2007-2008



Chart1

24.08999792152.972269053172.9377330254

34.148680074433.991188490431.8601314352

47.536894565112.98933610739.473769328

79.047116047520.6916590980.2612248545

13.998799066939.234183767346.7670171658

14.189211528841.988455761843.8223327094

7.92913667840.084754553551.9861087686

Poor

Intermediate

Ideal

Percentage

Sheet1

PoorIntermediateIdeal

Current Smoking24.13.072.9

Body Mass Index34.134.031.9

Physical Activity47.513.039.5

Healthy Diet Score79.020.70.3

Total Cholesterol14.039.246.8

Blood Pressure14.242.043.8

Fasting Plasma Glucose7.940.152.0

Lifetime Risk of Coronary Heart Disease in the Framingham Study

Men Women

At age 40 years:48.6%31.7%

At age 70 years:34.9%24.2%

Lloyd-Jones et al. Lancet 1999; 353:89-92

____________________________________________________________

______________________________________________________________

_________________________________________________________________

*

First Coronary Events: Framingham Study

Percent as Specified Event

MyocardialAngina Sudden

InfarctionPectoris Death

AgeMen Women Men Women Men Women

35-64 43%28% 41% 59% 9% 4%

65-8455%44% 28% 41% 11% 7.4%

Framingham Study 44 year follow-up.

____________________________________________________________

________________________________________________________

____________________________________________________________

*

Estimated 10-Year CHD Risk in

55-Year-Old Adults According to Levels of Various Risk Factors

Framingham Heart Study

A B C D

Blood Pressure (mm Hg)120/80140/90140/90140/90

Total Cholesterol (mg/dL) 200 240 240 240

HDL Cholesterol (mg/dL) 50 50 40 40

Diabetes No No Yes Yes

Cigarettes No No No Yes

mm Hg = millimeters of mercury

mg/dL = milligrams per deciliter of blood

Source:Circulation 1998;97:1837-1847.

Chart15

55

138

2520

3727

Men

Women

Estimated 10-Year Rate (%)

Sheet1

CVDCVD2001 CVD total mortalityLCD BLACK M/F, 2001LCD AM. INDIAN M/F, 2001AgesMenWomenMenWomenNHES IIINHANES INHANES III

MalesFemales145,908141,80125-442.02.8A2.61.1Non-Hispanic WhitesNon-Hispanic BlacksMexican AmericansWhite Males163163155% of Men using PA to lose weight% of Men meeting PA guidelines% of Women using PA to lose weight% of Women meeting PA guidelinesNumber of TransplantsEST. COST OF CV DISEASES 2004

1979500469MALESFEMALESMALESFEMALES45-546.75.5B4.02.0Black Males171165166Whites66.522.863.520.1196823

80510490Coronary Heart Disease54502,18954CVD+cong.A33.5CVD+cong.A40.1D of H/St.A24.4D of H/St.A25.455-6413.18.4C5.43.5Awareness69.573.957.8White Females170166163Blacks70.122.662.816.9197010Heart Disease238.6

81500484Stroke18163,53818CancerB22.4CancerB20.8CancerB17.1CancerB19.165-7417.711.1D8.46.3Treatment60.163.040.3Black Females172174168Hispanics63.817.152.714.3197522Coronary Heart Disease133.2

82495484Congestive Heart Failure652,8286AccidentsC5.9DiabetesF5.1Acc.C14.0Acc.C8.275+18.616.1E14.819.1Control, Treated55.644.644.0Others68.423.063.520.6198057Stroke53.6

83498494High Blood Pressure546,7655Assault(Homicide)D4.6Nephritis, etc.G2.9C. Liver D.D4.8DiabetesE6.7F22.427.0Control, All Hypertensives33.428.117.7Trends in Mean Total Blood Cholesterol Among Adolescents Ages 12-17 by Sex and Race and Survey1985719Hypertensive Disease55.5

84491493Diseases of the Arteries439,4044HIV(Aids)E3.7AccidentsC2.8DiabetesE4.3C. Lower res.D.F4.1Prevalence of Coronary Heart Disease by Age and SexNHES III, NHANES I, NHANES III: 1966-70, 1971-74 and 1988-94Leisure-time Physical Activity (PA) Patterns Among Overweight Adults by Race/Ethnicity and Sex19902,107Congestive Heart Failure28.8

85491498Rheumatic Fever/Rheumatic Heart Disease0.43,4890.4NHANES III: 1988-94Estimated 10 Year Stroke Risk in 55 Year Old AdultsBRFSS: 199819952,363Total CVD*368.4

86481498Congenital Cardiovascular Defects0.44,1090.4Leading Causes of Death for Black or African American Males and FemalesLeading Causes of Death for American Indian/Alaska Native Males and FemlaesAccording to Levels of Various Risk FactorsExtent of Awareness, Treatment and Control of High Blood Pressure by Race/Ethnicity20002,199

87475499Other13118,78613United States: 2001United States: 2001Framingham Heart StudyNHANES IV: 1999-200020022,154Estimated Direct and Indirect Costs (in Billions of Dollars) of Cardiovascular Diseases and Stroke

88476504100.8931,108100.0United States: 2004

89456486Trend in Heart Transplants

90448478Percentage Breakdown of Deaths From Cardiovascular DiseasesUnitedStates: 1968-2002

91447479United States:2001

92444479

93457500

94452498

95455505

96453506

97450503

98446504

99446513

00439507Non-Hispanic WhitesNon-Hispanic BlacksMexican Americans

01432499YearMalesFemales12% of high school students who participated in vigorous or moderate physical physical activity in past 7 daysMen5.47.68.1

70779597Whites76.644.218.2Women4.79.511.4

Cardiovascular Disease Mortality Trends for Males and FemalesMales71851628Blacks26.724.116.4Non-Hispanic White MalesNon-Hispanic White FemalesNon-Hispanic Black MalesNon-Hispanic Black FemalesHispanic MalesHispanic FemalesMalesFemales

United States: 1979-2001Males72935693ABCDEFCHF PREVALENCEMexican Americans34.317.317.5Vigorous73.759.872.447.868.852.4Non-Hispanic Whites12.45.3Prevalence of Age-Adjusted (2000) Physician-Diagnosed Diabetes in Americans Age 20 and Older by Sex and Race/Ethnicity

73982725Blood Pressure*95-105138-148138-148138-148138-148138-148MalesFemalesModerate29.824.723.716.525.918.5Non-Hispanic Blacks17.514.6NHANES III: 1988-94 NHANES III

741030756DiabetesNoNoYesYesYesYes20-240.10.1Prevalence of Current Smoking for Men Ages 18-24 by Education and Race/EthnicityHispanics21.38.8

751043789Cigarette SmokingNoNoNoYesYesYes25-340.10.1NHANES III: 1988-94Prevalence of Students in Grades 9-12 Who Participated in Sufficient Vigorousu.s. 1979-00

Prevalence of CVD, U.S. 1988-94 NHANES III761087843Prior AFNoNoNoNoYesYes35-440.70.5or Moderate Physical Activity During the Past 7 Days by Race/Ethnicity and SexPercentage of Overweight Among Students in Grades 9-12 by Sex and Race/EthnicityCatheterizationsOpen-HeartBypassPTCAEndarterectomyPacemakers

771111852Prior CVDNoNoNoNoNoYes45-541.81.3United States: 2001United States: 200119792991721145442

AgeMalesFemales78111084455-646.23.4803501971375544

20-245.54.6791014724* - Closest ranges for women are : 95-104 and 115-124.65-746.86.6814162221597326

25-3410.44.280104973775+9.89.7824732401708231

35-4417.413.6811095765MenWomen835122601919525

45-5434.228.982116084120-349.80.0Prevalence of Congestive Heart Failure by Age and Sex8457627820210339

55-6451.048.183122985235-4417.116.0NHANES III: 1988-948569030823010740

65-7465.265.284104484045-5432.330.5867863702848332

75+70.779.085120584655-6444.153.0878794093321568189

86125088965-7459.970.38894445735321170120

Females87126890175+68.884.18999846836824370107

Prevalence of Cardiovascular Diseases in Americans Age 20 and Older by Age and SexFemales8812208309010465013922666897

NHANES III :1988-94MenWomen891174819Prevalence of High Blood Pressure in Americans Age 20 and Over by Age and Sex91105751840730367121

DR FOR WOMEN, CV AND CANCER 2001A55901151795United States: 1999-200092108459046836791113

LCD HISPANIC M/F, 2001B138911146806WhitesBlacksMexican Americans93107860648536989123

White FemalesBlack Females63,31747,082C252092124788612

Estimated 10-Year Stroke Risk in 55-Year-Old Adults According to Levels of Various Risk Factors Framingham Heart Study

ABCDEF

Systolic BP*95-105130-148130-148130-148130-148130-148

DiabetesNoNoYesYesYesYes

CigarettesNoNoNoYesYesYes

Prior Atrial Fib.NoNoNoNoYes Yes

Prior CVDNoNoNoNoNoYes

Source: Stroke 1991;22:312-318.

*BP in millimeters of mercury (mmHg)

Chart2

2.61.1

42

5.43.5

8.46.3

14.819.1

22.427

Men

Women

Estimated 10-Year Rate (%)

Sheet1

CVDCVD2001 CVD total mortalityLCD BLACK M/F, 2001LCD AM. INDIAN M/F, 2001AgesMenWomenMenWomenNHES IIINHANES INHANES III

MalesFemales145,908141,80125-442.02.8A2.61.1Non-Hispanic WhitesNon-Hispanic BlacksMexican AmericansWhite Males163163155% of Men using PA to lose weight% of Men meeting PA guidelines% of Women using PA to lose weight% of Women meeting PA guidelinesNumber of TransplantsEST. COST OF CV DISEASES 2004

1979500469MALESFEMALESMALESFEMALES45-546.75.5B4.02.0Black Males171165166Whites66.522.863.520.1196823

80510490Coronary Heart Disease54502,18954CVD+cong.A33.5CVD+cong.A40.1D of H/St.A24.4D of H/St.A25.455-6413.18.4C5.43.5Awareness69.573.957.8White Females170166163Blacks70.122.662.816.9197010Heart Disease238.6

81500484Stroke18163,53818CancerB22.4CancerB20.8CancerB17.1CancerB19.165-7417.711.1D8.46.3Treatment60.163.040.3Black Females172174168Hispanics63.817.152.714.3197522Coronary Heart Disease133.2

82495484Congestive Heart Failure652,8286AccidentsC5.9DiabetesF5.1Acc.C14.0Acc.C8.275+18.616.1E14.819.1Control, Treated55.644.644.0Others68.423.063.520.6198057Stroke53.6

83498494High Blood Pressure546,7655Assault(Homicide)D4.6Nephritis, etc.G2.9C. Liver D.D4.8DiabetesE6.7F22.427.0Control, All Hypertensives33.428.117.7Trends in Mean Total Blood Cholesterol Among Adolescents Ages 12-17 by Sex and Race and Survey1985719Hypertensive Disease55.5

84491493Diseases of the Arteries439,4044HIV(Aids)E3.7AccidentsC2.8DiabetesE4.3C. Lower res.D.F4.1Prevalence of Coronary Heart Disease by Age and SexNHES III, NHANES I, NHANES III: 1966-70, 1971-74 and 1988-94Leisure-time Physical Activity (PA) Patterns Among Overweight Adults by Race/Ethnicity and Sex19902,107Congestive Heart Failure28.8

85491498Rheumatic Fever/Rheumatic Heart Disease0.43,4890.4NHANES III: 1988-94Estimated 10 Year Stroke Risk in 55 Year Old AdultsBRFSS: 199819952,363Total CVD*368.4

86481498Congenital Cardiovascular Defects0.44,1090.4Leading Causes of Death for Black or African American Males and FemalesLeading Causes of Death for American Indian/Alaska Native Males and FemlaesAccording to Levels of Various Risk FactorsExtent of Awareness, Treatment and Control of High Blood Pressure by Race/Ethnicity20002,199

87475499Other13118,78613United States: 2001United States: 2001Framingham Heart StudyNHANES IV: 1999-200020022,154Estimated Direct and Indirect Costs (in Billions of Dollars) of Cardiovascular Diseases and Stroke

88476504100.8931,108100.0United States: 2004

89456486Trend in Heart Transplants

90448478Percentage Breakdown of Deaths From Cardiovascular DiseasesUnitedStates: 1968-2002

91447479United States:2001

92444479

93457500

94452498

95455505

96453506

97450503

98446504

99446513

00439507Non-Hispanic WhitesNon-Hispanic BlacksMexican Americans

01432499YearMalesFemales12% of high school students who participated in vigorous or moderate physical physical activity in past 7 daysMen5.47.68.1

70779597Whites76.644.218.2Women4.79.511.4

Cardiovascular Disease Mortality Trends for Males and FemalesMales71851628Blacks26.724.116.4Non-Hispanic White MalesNon-Hispanic White FemalesNon-Hispanic Black MalesNon-Hispanic Black FemalesHispanic MalesHispanic FemalesMalesFemales

United States: 1979-2001Males72935693ABCDEFCHF PREVALENCEMexican Americans34.317.317.5Vigorous73.759.872.447.868.852.4Non-Hispanic Whites12.45.3Prevalence of Age-Adjusted (2000) Physician-Diagnosed Diabetes in Americans Age 20 and Older by Sex and Race/Ethnicity

73982725Blood Pressure*95-105138-148138-148138-148138-148138-148MalesFemalesModerate29.824.723.716.525.918.5Non-Hispanic Blacks17.514.6NHANES III: 1988-94 NHANES III

741030756DiabetesNoNoYesYesYesYes20-240.10.1Prevalence of Current Smoking for Men Ages 18-24 by Education and Race/EthnicityHispanics21.38.8

751043789Cigarette SmokingNoNoNoYesYesYes25-340.10.1NHANES III: 1988-94Prevalence of Students in Grades 9-12 Who Participated in Sufficient Vigorousu.s. 1979-00

Prevalence of CVD, U.S. 1988-94 NHANES III761087843Prior AFNoNoNoNoYesYes35-440.70.5or Moderate Physical Activity During the Past 7 Days by Race/Ethnicity and SexPercentage of Overweight Among Students in Grades 9-12 by Sex and Race/EthnicityCatheterizationsOpen-HeartBypassPTCAEndarterectomyPacemakers

771111852Prior CVDNoNoNoNoNoYes45-541.81.3United States: 2001United States: 200119792991721145442

AgeMalesFemales78111084455-646.23.4803501971375544

20-245.54.6791014724* - Closest ranges for women are : 95-104 and 115-124.65-746.86.6814162221597326

25-3410.44.280104973775+9.89.7824732401708231

35-4417.413.6811095765MenWomen835122601919525

45-5434.228.982116084120-349.80.0Prevalence of Congestive Heart Failure by Age and Sex8457627820210339

55-6451.048.183122985235-4417.116.0NHANES III: 1988-948569030823010740

65-7465.265.284104484045-5432.330.5867863702848332

75+70.779.085120584655-6444.153.0878794093321568189

86125088965-7459.970.38894445735321170120

Females87126890175+68.884.18999846836824370107

Prevalence of Cardiovascular Diseases in Americans Age 20 and Older by Age and SexFemales8812208309010465013922666897

NHANES III :1988-94MenWomen891174819Prevalence of High Blood Pressure in Americans Age 20 and Over by Age and Sex91105751840730367121

DR FOR WOMEN, CV AND CANCER 2001A55901151795United States: 1999-200092108459046836791113

LCD HISPANIC M/F, 2001B138911146806WhitesBlacksMexican Americans93107860648536989123

White FemalesBlack Females63,31747,082C252092124788612

Offspring CVD Risk by Parental CVD Status: Framingham Study

Risk Ratio

2.5

2

1.5

1

0.5

0

Men

Women

1.0

1.7

2.2

1.0

1.7

1.7

Adjusted for: age, total/HDL Chol. ratio, SBP, smoking, diabetes, BMI

Parental CVD

Multivariable Risk

Risk imposed by a strong family history of heart attacks varies widely depending on the burden of modifiable risk factors

*

9

Doubts about cholesterol as late as 1989

*

Lifetime Risk of CHD Increases with Serum Cholesterol

Framingham Study: Subjects age 40 years

DM Lloyd-Jones et al Arch Intern Med 2003; 1966-1972

34

44

57

19

29

33

Cholesterol

___________________________________________________________________________

_______________________________________________________________________________

*

Q = serum cholesterol quintile.

Kannel WB et al. Am Heart J. 1986;112:825-836.

Multiple Risk Factor Intervention Trial (MRFIT) N=325,346

Correlation Between Serum Cholesterol and CVD Mortality

6-Year CVD Death Rate Per 1000

0

5

10

15

20

25

30

Q1

(244)

35-39 years

40-44 years

45-49 years

50-54 years

55-57 years

Serum Cholesterol Quintile (mg/dL)

Untreated Patients

*

Source: NCHS and NHLBI. NH indicates non-Hispanic. Mex. Am. indicates Mexican American.

* Data for Mexican Americans not available.



Trends in mean total serum cholesterol among adolescents 1217 years of age by race, sex, and survey year (NHANES: 19881994*, 19992004 and 2005-2008).

Source: NCHS and NHLBI. NH indicates non-Hispanic.



Trends in mean total serum cholesterol among adults ages 20 by race and survey year, (NHANES: 19881994, 19992004 and 20052008).

CK Friedberg on Hypertension: Diseases of the Heart 1996

There is a lack of correlation in most cases between the severity and duration of hypertension and development of cardiac complications.

___________________________________________________________

________________________________________________________

_______________________________________________________________

*

Relation of Non-Hypertensive Blood Pressure to Cardiovascular DiseaseVasan R, et al. N Engl J Med 2001; 345:1291-1297

10-year Age- Adjusted Cumulative Incidence

Hazard Ratio*

SBPWomenMen

Source: NCHS and NHLBI. Hypertension is defined as SBP 140 mm Hg or DBP 90 mmHg, taking antihypertensive medication, or being told twice by a physician or other professional that one has hypertension.



Prevalence of High Blood Pressure in adults 20 years of age by age and sex (NHANES: 20052008)

Extent of awareness, treatment and control of high blood pressure by race/ethnicity (NHANES : 2005-2006).


Chart1

78.87982.367.6

69.170.174.752.1

45.446.146.535.2

Total Population

NH Whites

NH Blacks

Mexican Americans

Percent of Population With Hypertension

OVERWT

1960-621971-741976-801988-942001-2004

Men10.712.212.820.630.2

Women15.716.817.126.034.0

Age-Adjusted Prevalence of Obesity* in Adults Ages 20-74 by Sex and Survey

NHES and NHANES: 1960--62, 1971--74, 1976--80, 1988--94 and 2001-2004

Source:Health US, 2007

Obesity is defined as BMI of 30 plus.

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OVERWT

1960-62

1971-74

1976-80

1988-94

2001-2004


cholchild

Trends in Mean Total Blood Cholesterol Among Adolescents Ages 12-17 by Sex and Race and Survey

NHANES:1976-80,1988-94, 1999-02, 2003-04 and 2005-06

1976-801988-941999-022003-042005-06

White Males163163155156151

Black Males171165166161161

White Females170166163164163

Black Females172174168161160

Mex. Am. Males157158

Mex. Am. Females158161

cholchild

11

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#REF!

#REF!


diabetes

NH WhitesNH BlacksMexican Americans

Men5.814.911.3

Women6.113.114.2

Age-Adjusted Prevalence of Physician-Diagnosed Diabetes in Adults Age 20 and Older by Sex and Race/Ethnicity

NHANES: 2005-2006

NH WhitesNH BlacksMexican Americans

Less than high school8.115.313.0

High school6.117.512.2

More than high school5.410.812.0

Prevalence of Physician Diagnosed Type 2 Diabetes in Americans Age 18+

by Education, Race/Ethnicity and Years of Education

NHANES: 2005-2006

`

NCHS and NHLBI.

MaleFemale

Physician diagnosed 1988-945.45.4

Undiagnosed 1988-943.42.5

Physician diagnosed 2005-067.48.0

Undiagnosed 2005-063.82.1

Trends in Diabetes Prevalence in Adults Age 20 and Older, By Sex

NHANES: 1988-94 and 2005-2006


1976-80

1988-94

1999-02

2003-04

2005-06

Mean Total Blood Cholesterol

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diabetes

NH Whites

NH Blacks

Mexican Americans


Hdl&Ldl

Estiamted % of Americans Age 20 and Over with High-Risk LDL-Cholesterol of 130 mg/dL or More by Race and Sex

MenWomen

Total Population32.032.0

NH Whites32.034.0

NH Blacks32.030.0

Mexican Americans39.031.0

Age-Adjusted Prevalence of Americans Age 20 and Older With

LDL-Cholesterol of 130 mg/dL or Higher by Race/Ethnicity and Sex


MenWomen

Total259

NH Whites269

NH Blacks167

Mexican Americans2813

Estimated Age-Adjusted (2000) Prevalence of Adults Age 20 and Over With

HDL-Cholesterol Under 40 mg/dL by Race and Sex

United States: NHANES 2003-2004

Less than high school

High school

More than high school


Male

Female


Hdl&Ldl

Men

Women


smokhschool

`NH WhitesNH BlacksHispanics

Males23.814.918.7

Females22.58.414.6

Prevalence of High School Students in Grades 9-12 Reporting Current Cigarette Use

Within the last 30 days by Race/Ethnicity and Sex

YRBS: 2007

Men

Women


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smokhschool

Males

Females


Metsyndr.

CHD MortalityCVD MortalityTotal Mortality

No MetS or DM2.65.314.4

MetS w/o DM4.37.817.1

MetS w/DM4.88.621.1

DM only6.311.526.1

Prior CVD10.916.730.0

Prior CVD and DM17.028.144.1

Total Mortality Rates in US Adults Age 30-75, with Metabolic Syndrome, With and Without Diabetes and Pre-Existing CVD

NHANES1976-80 Follow-Up Study

Metsyndr.

No MetS or DM

MetS w/o DM

MetS w/DM

DM only

Prior CVD

Prior CVD and DM

Deaths/1,000 Person Years

PhysicAct.

NH WhiteNH BlackHispanic

Male46.141.338.6

Female27.921.021.9

Prevalence of Students in Grades 9-12 Who Met Currently Recommended Levels of

Physical Activity During the Past 7 Days by Race/Ethnicity and Sex

YRBS: 2007Centers for disease control and Prevention. Youth risk Behavior Surveillance - United States, 2007. MMWR 2008;57(ss#4)

Men '01Women '01Men '05Women '05

NH White50.646.052.349.6

NH Black40.331.445.336.1

Hispanic42.036.341.940.5

Other race43.141.245.746.6

Prevalence of Leisure-Time Physical Activity Among Adults Age 18+ by Race/Ethnicity, and Sex

BRFSS: 2001, 2005

MMWR, vol.56, no.46, 11/23/07.

NH WhiteNH BlackHispanic

Male16.721.818.8

Female28.242.135.2

Prevalence of Students in Grades 9-12 Who Did Not Meet Currently Recommended Levels of

Moderate-to-Vigorous Physical Activity During the Past 7 Days by Race/Ethnicity and Sex

YRBS: 2007"Currently recommended levels" are defined as activity that increases heart rates and made them breathe hard some of the time for a total of >60 or more minutes/day on >5 or more out of 7 days predeeding the survey.

6-1112-1516-19

Male48.911.910.020-2930-3940-4950-5960-6970+

Female34.73.45.4Male10.39.99.37.16.53.5

Female7.46.56.65.75.82.2

Prevalence of Children Ages 6-19 Who Attained sufficient MVPA to Meet Public Health Recommendations of >60 or More

Minutes/Day on >5 or more of 7 Days by Sex and AgeMean Minutes/Day of MVPA in Bouts of 10+ Minutes by Sex and Age

NHANES 2003-2004

Troiano RP, Berrigan D, Dodd KW, Masse LC, Tilert T, McDowell M. Physical Activity in the United States Measured by Accerometer. MSSE 2008; 40: 181-188.

Troiano RP, Berrigan D, Dodd KW, Masse LC, Tilert T, McDowell M. Physical Activity in the United States Measured by Accerometer. MSSE 2008; 40: 181-188.

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PhysicAct.

NH White

NH Black

Hispanic


smokmf

1212

Under 89-111213-1516 and UpWhites76.644.218.2Whites60.649.120.1

Men27.739.731.526.611.5Blacks26.724.116.4Blacks34.314.112.8

Women16.734.324.122.811.2Mexican Americans34.317.317.5Mexican Americans12.219.510.3

Prevalence of Current Smoking for Men Ages 18-24 by Education and Race/EthnicityPrevalence of Current Smoking for Women Ages 18-24 by Education and Race/Ethnicity

Current Cigarette Smoking for Adults Age 18 and Over by Education and SexUnited States: 1988-94United States: 1988-94

United States: 1998

Non-Hispanic White MenNon-Hispanic White WomenNon-Hispanic Black MenNon-Hispanic Black WomenHispanic MenHispanic WomenMenWomen

CK Friedberg on HypertensionDiseases of the Heart 1966

Hypertension imposes a load on the heart which for many years may be compensated by left ventricular hypertrophy

_______________________________________________________________

_______________________________________________________________

*

CVD Risk Imposed by ECG-LVH Framingham Study 36-yr. Follow-up

Age-adjusted Risk Excess Risk

Rate per 1000 Ratio per 1000

Age Men Women Men Women Men Women

35-64 164 135 4.7*** 7.4*** 129 117

65-94 234 235 2.8*** 4.1*** 51 178

Biennial Rate per 1000. CVD=CHD, stroke, peripheral vascular disease, heart failure***P

Smoking Statement Issued in 1956 by American Heart Association

It is the belief of the committee that much greater knowledge is needed before any conclusions can be drawn concerning relationships between smoking and death rates from coronary heart disease. The acquisition of such knowledge may well require the use of techniques and research methods that have not hitherto been applied to this problem.

Circulation 1960; vol. 23

___________________________________________________________

____________________________________________________________

___________________________________________________________

*

CHD Risk by Cigarette Smoking. Filter Vs. Non-filter. Framingham Study. Men

Source: MMWR Surveill Summ. 2010;59:1142.NH indicates non-Hispanic.



Prevalence of students in grades 9 to 12 reporting current cigarette use by sex and race/ethnicity (YRBSS, 2009)

All percentages are age-adjusted. NH indicates non-Hispanic. *Includes both Hispanics and non-Hispanics. Data derived from Centers for Disease Control and Prevention/National Center for Health Statistics, Health Data Interactive.



Prevalence of current smoking for adults > 18 years of age by race/ethnicity and sex (NHIS: 2007-2009)

Source: CDC/NCHS, Health Data Interactive. All percentages are age-adjusted. NH indicates non-Hispanic.

* Includes both Hispanics and non-Hispanics.



Prevalence of current smoking for adults > 18 years of age by race/ethnicity and sex (NHIS: 2006-2008)

Diseases of The HeartCharles K Friedberg MD, WB Saunders Co. Philadelphia, 1949

The proper control of diabetes is obviously desirable even though there is uncertainty as to whether coronary atherosclerosis is more frequent or severe in the uncontrolled diabetic

________________________________________________________________

______________________________________________________________

*

Risk of Cardiovascular Events in Diabetics Framingham Study

Age-adjusted

Biennial Rate Age-adjusted

Per 1000 Risk Ratio

Cardiovascular Event Men Women Men Women

Coronary Disease 39 21 1.5** 2.2***

Stroke15 6 2.9*** 2.6***

Peripheral Artery Dis. 18 18 3.4*** 6.4***

Cardiac Failure 23 21 4.4*** 7.8***

All CVD Events 76 65 2.2*** 3.7***

Subjects 35-64 36-year Follow-up **P

Source: NCHS and NHLBI. NH indicates non-Hispanic.



Age-adjusted prevalence of physician-diagnosed diabetes in adults 20 years of age by race/ethnicity and sex (NHANES: 20052008).

Source: NCHS, NHLBI.



Trends in diabetes prevalence in adults 20 years of age, by sex (NHANES: 19881994 and 20052008).

Skepticism About Importance of Obesity

Keys A, Aravanis C, Blackburn H, et al. Ann Intern Med 1972; 77:15-27.

Concluded that all the excess risk of coronary heart disease in the obese derives from its atherogenic accompaniments, illogically leaving the impression that obesity is therefore unimportant.

Mann GV. N Engl J Med 1974; 291:226-232.

The contribution of obesity to CHD is either small or non-existent. It cannot be expected that treating obesity is either logical or a promising approach to the management of CHD.

Barrett-Connor EL. Ann Intern Med 1985; 103:1010-1019

NIH consensus panel is equivocal about the role of obesity as a cause of CHD.

*

Relation of Weight Change to Changes in

Atherogenic Traits: The Framingham Study

Frantz Ashley, Jr. and William B Kannel

J Chronic Dis 1974

Weight gain is accompanied by atherogenic alterations in blood lipids, blood pressure, uric acid and carbohydrate tolerance.

It seems reasonable to expect that correction of overweight will improve the coronary risk problem.

Avoidance of overweight would seem a desirable goal in the general population if the appalling annual toll from disease is to be substantially reduced.

*



Trends in the prevalence of obesity among US children and adolescents by age and survey year (National Health and Nutrition Examination Survey: 1971-1974, 1976-1980, 1988-1994, 1999-2002 and 20052008)

Data derived from Health, United States, 2010: With Special Feature on Death and Dying. NCHS, 2011.



Data derived from Health, United States, 2010: With Special Feature on Death and Dying. NCHS, 2011.

Age-adjusted prevalence of obesity in adults 2074 years of age, by sex and survey year (NHES: 196062; NHANES: 197174, 197680, 198894, 1999-2002 and 2005-08)

3

2.4

1.8

1.2

0.6

0

Q1Q2Q3Q4Q5Overall

Thin

Obese

Risk Factor Sum and Obesity

(1971-74) and (1989-93)

Risk Factor Sum

Risk variables include bottom quintile for HDL-C and top quintiles for cholesterol, SBP, triglycerides and glucose

Wilson PWF, & Kannel WB Nutr Clin Care 1999; 1:44-50

Framingham Study

Risk factors accumulate with weight gain

*

Currently recommended levels is defined as activity that increased their heart rate and made them breathe hard some of the time for a total of at least 60 minutes per day on 5 of the 7 days preceding the survey. Source: MMWR Surveillance Summaries.1 NH indicates non-Hispanic.



Prevalence of students in grades 912 who met currently recommended levels of PA during the past 7 days by race/ethnicity and sex (YRBS: 2009).

Source: Pleis et al, 2010. NH indicates non-Hispanic. Percents are age-adjusted. Regular leisure-time physical activity is defined as 3 or more sessions

per week of vigorous activity lasting at least 20 minutes or five or more sessions per week of light/moderate activity lasting at least 30 minutes.



Prevalence of regular leisure-time physical activity among adults > 18 years of age by race/ethnicity and sex (NHIS: 2009).

Prevalence of students in grades 9 to 12 reporting current cigarette use

by sex and race/ethnicity (YRBSS, 2009).

Source: MMWR Surveill Summ. 2010;59:1142.NH indicates non-Hispanic.



Risk Assessment

Count major risk factors
For patients with multiple (2+) risk factorsPerform 10-year risk assessmentFor patients with 01 risk factor10 year risk assessment not requiredMost patients have 10-year risk

ATP III Assessment of CHD Risk

For persons without known CHD, other forms of atherosclerotic disease, or diabetes:
Count the number of risk factors:Cigarette smokingHypertension (BP 140/90 mmHg or on antihypertensive medication)Low HDL cholesterol (

Note: Risk estimates were derived from the experience of the Framingham Heart Study, a predominantly Caucasian population in Massachusetts, USA.

Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.

Assessing CHD Risk in Men

Step 2: Total Cholesterol

TC Points atPoints atPoints atPoints atPoints at(mg/dL) Age 20-39Age 40-49Age 50-59Age 60-69Age 70-79

Point Total10-Year RiskPoint Total10-Year Risk

Step 1: Age

Expert Panel on Detection, Evaluation, and Treatment of High BloodCholesterol in Adults. JAMA. 2001;285:2486-2497.

ATP III Framingham Risk Scoring

2001, Professional Postgraduate Services

www.lipidhealth.org

*

Step 2: Total Cholesterol

Note: TC and HDL-C values should be the average of at least two fasting lipoprotein measurements.


Men

TC Points atPoints atPoints atPoints atPoints at(mg/dL) Age 20-39Age 40-49Age 50-59Age 60-69Age 70-79

Step 3: HDL-Cholesterol

Note: HDL-C and TC values should be the average of at least two fasting lipoprotein measurements.


Men

Women



www.lipidhealth.org

*

Step 4: Systolic Blood Pressure

Note: The average of several BP measurements is needed for an accuratemeasurement of baseline BP. If an individual is on antihypertensive treatment,extra points are added.




www.lipidhealth.org

*

Step 5: Smoking Status

Note: Any cigarette smoking in the past month.




www.lipidhealth.org

*

Step 6: Adding Up the Points(Sum From Steps 15)




www.lipidhealth.org

*

Step 7: CHD Risk for Men

Note: Determine the 10-year absolute risk for hard CHD (MI and coronary death) from point total.




www.lipidhealth.org

*

Presentation

Examination:Height: 6 ft 2 inWeight: 220 lb (BMI 28 kg/m2)Waist circumference: 41 inBP: 150/88 mm HgP: 64 bpm RR: 12 breaths/minCardiopulmonary exam: normalLaboratory results: TC: 220 mg/dLHDL-C: 36 mg/dLLDL-C: 140 mg/dLTG: 220 mg/dLFBS: 120 mg/dL

*

What is WJCs 10-year absolute riskof fatal/nonfatal MI?

A 12% absolute risk is derived from points assigned in Framingham Risk Scoring to:Age: 6TC: 3HDL-C: 2SBP: 2Total: 13 points

In 1992 he exercised 14 minutes in a Bruce protocol exercise stress test to 91% of his maximum predicted heart rate without any abnormal ECG changes. He started on a statin in 2001. But in Sept 2004, he needed urgent coronary bypass surgery.

*

Step 7: CHD Risk for Women

Note: Determine the 10-year absolute risk for hard CHD (MI and coronary death) from point total.




www.lipidhealth.org

*

CHD Risk Equivalents

Risk for major coronary events equal to that in established CHD10-year risk for hard CHD >20%

Hard CHD = myocardial infarction + coronary death

*

Diabetes as a CHD Risk Equivalent

10-year risk for CHD 20%High mortality with established CHDHigh mortality with acute MIHigh mortality post acute MI

*

CHD Risk Equivalents

Other clinical forms of atherosclerotic disease (peripheral arterial disease, abdominal aortic aneurysm, and symptomatic carotid artery disease)DiabetesMultiple risk factors that confer a 10-year risk for CHD >20%

*

Framingham 10-year Total CVD Risk Algorithm (DAgostino et al 2008)

International Comparisons in CVD Morbidity and Mortality

CVD accounts for 25-45% of deaths among different countriesCVD death rates (per 100,000) range from 1310 in Russia to 201 in Japan (6.5 fold difference) in men and from 581 in Russia to 84 in France (7-fold difference)USA ranks 16th for both men (413) and women (201)

*

Secular Trends in CHD and Stroke Mortality

From 1985-1992, greatest annual decline (6-7%) in CHD seen in Israel among men and France among women, USA intermediate (4%), increases in Poland and Romania.Stroke death rates declined most in Australia, Italy, and France (8-9%), USA about 3%.

*

Age-Adjusted Death Rates for Coronary Heart Disease by Country and Sex, Ages 35-74, 1999

Age-Adjusted to European StandardData for 1999 unless noted

Source: NHLBI 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases

*

Age-Adjusted Death Rates for Stroke by Country and Sex, Ages 35-74, 1999

Age-Adjusted to European StandardData for 1999 unless noted


*

Change in Age-Adjusted Death Rates for Coronary Heart Disease by Country and Sex, Ages 35-74, 1990-1999

Age-Adjusted to European StandardLatest data year note in parentheses


Men

Women

*

Change in Age-Adjusted Death Rates for Stroke by Country and Sex, Ages 35-74, 1990-1999

Age-Adjusted to European StandardLatest data year note in parentheses


Men

Women

*

Migrant Studies

Ni-Hon-San Study showed Japanese living in Japan to have the lowest cholesterol levels and lowest rates of CHD, those living in Hawaii to have intermediate rates for both, and those living in San Francisco to have the highest cholesterol levels and CHD incidence

*

Pyramid of Risk (Werner et al. Canadian Journal of Cardiology 1998; 14(Suppl) B:3B-10B)

*

Approaches to Primary and Secondary Prevention of CVD

Primary prevention involves prevention of onset of disease in persons without symptoms.Primordial prevention involves the prevention of risk factors causative o the disease, thereby reducing the likelihood of development of the disease.Secondary prevention refers to the prevention of death or recurrence of disease in those who are already symptomatic

*

Risk Factor Concepts in Primary Prevention

Nonmodifiable risk factors include age, sexc, race, and family history of CVD, which can identify high-risk populationsBehavioral risk factors include sedentary lifestyle, unhealthful diet, heavy alcohol or cigarette consumption.Physiological risk factors include hypertension, obesity, lipid problems, and diabetes, which may be a consequence of behavioral risk factors.

*

Population vs. High-Risk Approach

Risk factors, such as cholesterol or blood pressure, have a wide bell-shaped distribution, often with a tail of high values.The high-risk approach involves identification and intensive treatment of those at the high end of the tail, often at greatest risk of CVD, reducing levels to normal.But most cases of CVD do not occur among the highest levels of a given risk factor, and in fact, occur among those in the average risk group.Significant reduction in the population burden of CVD can occur only from a population approach shifting the entire population distribution to lower levels.

*

Expected Shifts in Cholesterol Distribution from High-Risk, Population, and Combined Approaches

*

Population and Community-Wide CVD Risk Reduction Approaches

Populations with high rates of CVD are those with Western lifestyles of high-fat diets, physical inactivity, and tobacco use.Targets of a population-wide approach must be these behaviors causative of the physiologic risk factors or directly causative of CVD.Requires public health services such as surveillance (e.g.,BFRSS), education (AHA, NCEP), organizational partnerships (Singapore Declaration), and legislation/policy (Anti-Tobacco policies)Activities in a variety of community settings: schools, worksites, churches, healthcare facilities, entire communities

*

A conceptual framework for public health practice in CVD prevention. (From Pearson et al., J Public Health. 2001; 29:69 78)

*

Communitywide CVD Prevention Programs

Stanford 3-Community Study (1972-75) showed mass media vs. no intervention in high-risk residents to result in 23% reduction in CHD risk scoreNorth Karelia (1972-) showed public education campaign to reduce smoking, fat consumption, blood pressure, and cholesterolStanford 5-City Project (1980-86) showed reductions in smoking, cholesterol, BP, and CHD riskMinnesota Heart Health Program (1980-88) showed some increases in physical activity and in women reductions in smoking

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Materials Developed for US Community Intervention Trials

Mass media, brochures and direct mailEvents and contestsScreeningsGroup and direct educationSchool programs and worksite interventionsPhysician and medical setting programsGrocery store and restaurant projectsChurch interventionsPolicies

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Individual and High-Risk Approaches

Primary Prevention Guidelines (1995) and Secondary Prevention Guidelines (Revised 2001) released by the American Heart Association provide advice regarding risk factor assessment, lifestyle modification, and pharmacologic interventions for specific risk factorsBarriers exist in the community and healthcare setting that prevent efficient risk reductionSurveys of CVD prevention-related services show disappointing results regarding cholesterol-lowering therapy, smoking cessation, and other measures of risk reduction

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Hospital Specialty_FINAL ATS

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2.03

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Rupture of atherosclerotic plaque and subsequent thrombosis of the vessel is responsible for the development of acute ischemic coronary syndromes. A lipid-rich core (particularly in the shoulder regions of lesions), abundance of inflammatory cells, a thin fibrous cap and dysfunctional overlying endothelium characterize plaques that are prone to rupture.

Reference

Weissberg PL. Eur Heart J Supplements 1999:1:T1318.

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2.07

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2.05

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