Published online before print December 28, 2006, doi: 10.1161/CIRCULATIONAHA.106.179918
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(Circulation. 2007;115:e69-e171.)
© 2007 American Heart Association, Inc.
AHA Statistical Update |
Heart Disease and Stroke Statistics—2007 Update
A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee
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Table of Contents |
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Top
Table of Contents
Disease Prevalence- About These Statistics...e70
- Cardiovascular Diseases...e72
- Coronary Heart Disease, Acute Coronary Syndrome, and Angina Pectoris...e89
- Stroke...e99
- High Blood Pressure...e111
- Congenital Cardiovascular Defects...e116
- Heart Failure...e119
- Other Cardiovascular Diseases...e122
- — Arrhythmias (Disorders of Heart Rhythm)...e122
- — Arteries, Diseases of (Including Peripheral Arterial Disease)...e123
- — Bacterial Endocarditis...e124
- — Cardiomyopathy...e124
- — Rheumatic Fever/Rheumatic Heart Disease...e124
- — Valvular Heart Disease...e124
- — Venous Thromboembolism...e125
- — Arteries, Diseases of (Including Peripheral Arterial Disease)...e123
- — Arrhythmias (Disorders of Heart Rhythm)...e122
- Risk Factor: Smoking/Tobacco Use...e128
- Risk Factor: High Blood Cholesterol and Other Lipids...e132
- Risk Factor: Physical Inactivity...e136
- Risk Factor: Overweight and Obesity...e139
- Risk Factor: Diabetes Mellitus...e143
- End-Stage Renal Disease and Chronic Kidney Disease...e149
- Metabolic Syndrome...e151
- Nutrition...e153
- Quality of Care...e155
- Medical Procedures...e159
- Economic Cost of Cardiovascular Diseases...e162
- At-a-Glance Summary Tables...e164
- — Men and Cardiovascular Diseases...e164
- — Women and Cardiovascular Diseases...e165
- — Ethnic Groups and Cardiovascular Diseases...e166
- — Children, Youth, and Cardiovascular Diseases...e167
- — Women and Cardiovascular Diseases...e165
- — Men and Cardiovascular Diseases...e164
- Glossary and Abbreviation Guide...e168
Writing Group Disclosures...e171
Appendix I: List of Statistical Fact Sheets:
http://www.americanheart.org/presenter.jhtml?identifier=2007
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Acknowledgments |
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We thank Drs Robert Adams, Philip Gorelick, Matt Wilson, and Philip Wolf (members of the Statistics Committee or Stroke Statistics Subcommittee); Brian Eigel; Gregg Fonarow; Kathy Jenkins; Gail Pearson; and Michael Wolz for their valuable comments and contributions. We would like to acknowledge Tim Anderson and Tom Schneider for their editorial contributions and Karen Modesitt for her administrative assistance.
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Disease Prevalence |
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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 to provide a more realistic estimate of burden. Most estimates based on NHANES prevalence rates are based on data collected from 1999 to 2004 (in most cases, these are the latest published figures). These are applied to census population estimates for 2004. 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 data across surveys conducted in different years.
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Risk Factor Prevalence |
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The NHANES 1999–2004 data are used in the 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.
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Incidence and Recurrent Attacks |
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An incidence rate refers to the number of new cases of a disease that develop in a population per unit of time. Incidence is not just per 1 year, although that is often how we refer to it. 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 issues of the Heart and Stroke Statistical Update (renamed Heart Disease and Stroke Statistics Update). Doing so can lead to serious misinterpretation of time trends.
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Mortality |
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Mortality data are grouped according to the underlying cause of death. "Total-mention" mortality, however, includes deaths for which the given cause was listed anywhere on the death certificate or was selected as the underlying cause. 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, whether it is the underlying cause or a contributing (secondary) cause—ie, its "total mentions."
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Hospital Discharges and Ambulatory Care Visits |
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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 visits to physicians’ offices.
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International Classification of Diseases |
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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.1 Effective with mortality data for 1999, we are using the 10th revision (ICD-10). It will be few more years before the 10th revision is used for hospital discharge data.
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Age Adjustment |
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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.2 International mortality data are age adjusted to the European standard.3
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Data Years for National Estimates |
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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 2004 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 and are preliminary. The methods used annually by NCHS to collect preliminary mortality counts for a given year make the preliminary counts nearly identical to the final tabulations. Mortality data for the less common causes of death and for some demographic groups have not yet been reported by NCHS for 2004, so we use the 2003 NCHS data and note this substitution where it occurs. Total-mention mortality is for 2002. 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 2004 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 2004, 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 2004, 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 2007.
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Cardiovascular Disease |
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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.
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Race |
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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.
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Contacts |
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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 nancy.haase@heart.org, phone 214-706-1423). Direct all media inquiries to News Media Relations at inquiries@ heart.org 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.
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References |
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1. National Center for Health Statistics. Health, United States, 2005, With Chartbook on Trends in the Health of Americans. Hyattsville, Md: National Center for Health Statistics; 2005. Available at: http://www.cdc.gov/nchs/data/hus/hus05.pdf. Accessed October 25, 2006.
2. Anderson RN, Rosenberg HM. Age standardization of death rates: implementation of the year 2000 standard. Natl Vital Stat Rep. 1998; 47: 1–16, 20.
3. World Health Organization. World Health Statistics Annual. Geneva, Switzerland: World Health Organization; 1998.
2. Cardiovascular Diseases
ICD-9 390–459, 745–747; ICD-10 I00–I99, Q20–Q28; see Glossary (Chapter 21) for details and definitions. See Tables 2-1, 2-2, and 2-3
and Charts 2-1 through 2-19. Also see Charts 2-20 and 2-21 in the online-only Data Supplement.
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Prevalence |
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An estimated 79 400 000 American adults (1 in 3) have 1 or more types of CVD. Of these, 37 500 000 are estimated to be age 65 or older (extrapolated to 2004 from NCHS NHANES 1999–2004). (Total CVD includes diseases in the bullet points below except for congenital CVD.) Except as noted, the estimates were extrapolated to the US population in 2004 from NHANES 1999–2004. Because of overlap, it is not possible to add these conditions to arrive at a total.
- High blood pressure (HBP)—72 000 000. (Defined as systolic pressure 140 mm Hg or greater and/or diastolic pressure 90 mm Hg or greater, taking antihypertensive medication, or being told at least twice by a physician or other health professional that one has HBP.)
- Coronary heart disease (CHD)—15 800 000.
- - MI (heart attack)—7 900 000.
- - AP (chest pain)—8 900 000.
- - AP (chest pain)—8 900 000.
- - MI (heart attack)—7 900 000.
- HF—5 200 000.
- Stroke—5 600 000.
- Congenital cardiovascular defects—650 000 to 1 300 000 (see Chapter 6).
- The following prevalence estimates are for people age 18 and older from NCHS NHIS, 20041:
- - Among whites only, 11.9% have heart disease, 6.6% have CHD, 21.2% have hypertension, and 2.5% have had a stroke.
- - Among blacks or African Americans only, 9.6% have heart disease, 5.2% have CHD, 29.2% have hypertension, and 3.2% have had a stroke.
- - Among Hispanics or Latinos, 9.2% have heart disease, 6.0% have CHD, 19.6% have hypertension, and 2.8% have had a stroke.
- - Among Asians, 6.7% have heart disease, 4.2% have CHD, 16.9% have hypertension, and 2.4% have had a stroke.
- - Among Native Hawaiians or other Pacific Islanders, 13.8% have heart disease, 13.8% have CHD, 20.7% have hypertension, and 8.1% have had a stroke.
- - Among American Indians or Alaska Natives, 11.6% have heart disease, 7.6% have CHD, 25.4% have hypertension, and 5.1% have had a stroke.
- - Among blacks or African Americans only, 9.6% have heart disease, 5.2% have CHD, 29.2% have hypertension, and 3.2% have had a stroke.
- - Among whites only, 11.9% have heart disease, 6.6% have CHD, 21.2% have hypertension, and 2.5% have had a stroke.
- Data from the Agency for Healthcare Research and Quality (AHRQ) show that 11.6% (12.9 million) of women and 11.4% (11.7 million) of men age 18 and older reported being told by a doctor that they have CVD. CVD includes CHD, congestive HF (CHF), MI, and stroke. (Note: These data do not include hypertension as a separate condition.)2
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Incidence |
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- On the basis of the NHLBI’s FHS in its 44-year follow-up of participants and the 20-year follow-up of their offspring3:
- - The average annual rates of first major cardiovascular events rise from 7 per 1000 men at ages 35 to 44 years to 68 per 1000 at ages 85 to 94 years. For women, comparable rates occur 10 years later in life. The gap narrows with advancing age.
- - Before age 75, a higher proportion of CVD events due to CHD occur in men than in women, and a higher proportion of events due to CHF occur in women than in men.
- - Before age 75, a higher proportion of CVD events due to CHD occur in men than in women, and a higher proportion of events due to CHF occur in women than in men.
- - The average annual rates of first major cardiovascular events rise from 7 per 1000 men at ages 35 to 44 years to 68 per 1000 at ages 85 to 94 years. For women, comparable rates occur 10 years later in life. The gap narrows with advancing age.
- Among American Indian men ages 45 to 74 years, the incidence of CVD ranges from 15 to 28 per 1000 population. Among women, it ranges from 9 to 15 per 1000.4
- 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 age 40 (personal communication, Donald Lloyd-Jones, MD, Northwestern University, Chicago, Ill).
- A study of data from the first NHANES Epidemiologic Follow-up Study, which includes participants ages 35 to 74 years, from 1971–1982 and 1982–1992 cohorts, found that the decrease in CVD mortality was due to declines in both the incidence and case fatality rates in this national sample. These findings suggest that both primary and secondary prevention and treatment contributed to the decline in CVD mortality in the United States.5
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Mortality |
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ICD-10 I00–I99 for CVD; C00–C99 for cancer; C33–C34 for lung cancer; C50 for breast cancer; J40–J47 for chronic obstructive pulmonary disease; G30 for Alzheimer’s disease; E10–E14 for diabetes; and V01–X59, Y85–Y86 for accidents.
- Mortality data show that CVD (I00–I99) as the underlying cause of death accounted for 36.3% (871 517) of all 2 398 000 deaths in 2004, or 1 of every 2.8 deaths in the United States. CVD total mentions (1 408 000 deaths in 2002) constituted about 58% of all deaths that year.6
- In every year since 1900 except 1918, CVD accounted for more deaths than any other single cause or group of causes of death in the United States.
- Nearly 2400 Americans die of CVD each day, an average of 1 death every 36 seconds. CVD claims more lives each year than cancer, chronic lower respiratory diseases, accidents, and diabetes mellitus combined.6
- The 2004 overall death rate from CVD (I00–I99) was 288.6. The rates were 335.7 for white males, 448.9 for black males, 239.3 for white females, and 331.6 for black females. From 1994 to 2004, death rates from CVD (ICD-10 I00–I99) declined 25%. In the same 10-year period, actual CVD deaths declined 8%.6
- Among other causes of death in 2004, cancer caused 550 270 deaths; accidents, 108 694; Alzheimer’s disease, 65 829; and HIV (AIDS), 12 995.6
- The 2004 CVD death rates were 341.8 for males and 246.3 for females. Cancer (malignant neoplasms) death rates were 226.4 for males and 156.2 for females. Breast cancer claimed the lives of 40 539 females in 2004; lung cancer claimed 67 838. Death rates for females were 24.2 for breast cancer and 40.5 for lung cancer. One in 30 female deaths was from breast cancer, whereas 1 in 6 was from CHD. By comparison, 1 in 4.6 women died of cancer, whereas 1 in 2.6 died of CVD. On the basis of 2004 mortality, CVD caused about 1 death a minute among females—more than 460 000 female lives in 2004. That represents more female lives than were claimed by cancer, chronic lower respiratory disease, Alzheimer’s disease, diabetes, and accidents combined (NCHS, unpublished mortality tables, 2004; personal communication with NHLBI).
- More than 147 000 Americans killed by CVD in 2004 were under age 65. In 2004, 32% of deaths from CVD occurred prematurely (ie, before age 75, which is close to the average life expectancy of 77.9 years).6
- In 2003, the age-adjusted death rates for diseases of the heart in American Indians or Alaska Natives were 203.2 for males and 127.5 for females; for Asians or Pacific Islanders, they were 158.3 for males and 104.2 for females; for Hispanics or Latinos, they were 206.8 for males and 145.8 for females.8
- 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 from major CVD (I00–I78) is 47%, and the chance of dying from cancer is 22%. Additional probabilities are 3% for accidents, 2% for diabetes, and 0.7% for HIV.9
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Out-of-Hospital Cardiac Arrest |
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There is a wide variation in the reported incidence and outcome for out-of-hospital cardiac arrest. These differences are due in part to differences in definition and ascertainment of cardiac arrest, as well as differences in treatment after its onset.
Cardiac arrest is the cessation of cardiac mechanical activity, as 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 (sudden cardiac arrest). Therefore, surrogate data are often used for epidemiological purposes to estimate the incidence of cardiac arrest, especially in the out-of-hospital setting. Those surrogate data include deaths due to "coronary heart disease" (ICD codes I20–I25) and "cardiac arrest," defined as coronary death that occurred within 1 hour of symptom onset in the out-of-hospital setting and without other probable cause of death.12 Datasets based on either definition are not optimal. Out-of-hospital data that are based on the latter definition of cardiac arrest can be especially unreliable because of the difficulty in determining the duration of symptoms before the onset of the episode. The following information summarizes representative data from several sources in an attempt to characterize the incidence and outcome of out-of-hospital cardiac arrest and demonstrate the need for a comprehensive system of capturing more meaningful data.
- According to NCHS Data Warehouse mortality data, 325 000 CHD deaths occur out of hospital or in hospital emergency departments annually (2003) (ICD-10 codes I20–I25).13
- The annual incidence of out-of-hospital cardiac arrest in North America is about 0.55 per 1000 population.15,16 With an estimated US population of 299 210 182,17 this implies that about 164 600 out-of-hospital cardiac arrests occur annually in the United States.
- About two thirds of unexpected cardiac deaths occur without prior recognition of cardiac disease.18
- About 60% of unexpected cardiac deaths are treated by emergency medical services (EMS).19
- In a population aged at least 20 years, incidence of EMS-treated out-of-hospital cardiac arrest is 36/100 000 to 81/100 000.19,20 This implies EMS treats 77 000 to 174 000 cardiac arrests in the United States annually.
- Of these, 20% to 38% have ventricular fibrillation or ventricular tachycardia as the first recorded rhythm. This implies 15 500 to 66 100 ventricular fibrillation arrests annually.15,20
- The incidence of cardiac arrest with an initial rhythm of ventricular fibrillation is decreasing over time.20 However, the incidence of cardiac arrest with any initial rhythm is decreasing.13
- The median reported survival to discharge after any first recorded rhythm is 6.4%.21 Survival during a recent 1-year experience in Seattle, Wash, of all treated cardiac arrests considered to be of cardiac origin was reported to be 20% (personal communication, L. Cobb, Seattle Medic One, December 7, 2005).
- The average proportion of cases of out-of-hospital cardiac arrest that receive bystander cardiopulmonary resuscitation is 27.4%.21
- The incidence of lay responder defibrillation is low (2.05% in 2002) but increasing over time.22
- Unexpected death in the pediatric patient is usually due to trauma, sudden infant death syndrome, respiratory causes, or submersion.23 Ventricular fibrillation is an uncommon cause of cardiac arrest in children, but it is observed in approximately 5% to 15% of children with out-of-hospital cardiac arrest.24
- The reported incidences of out-of-hospital pediatric cardiac arrest vary widely (from 2.6 to 19.7 annual cases per 100 000).25
- Because there are 72 293 812 individuals under age 18 in the United States,17 this implies that there are 1900 to 14 200 pediatric out-of-hospital cardiac arrests annually from all causes (including trauma, sudden infant death syndrome, respiratory causes, cardiovascular causes, and submersion).
- 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.26,27 Although incomplete, these numbers provide a basis for estimating the number of deaths in this age range.
- The reported average survival to discharge after pediatric out-of-hospital cardiac arrest is 6.7%.25
- The incidence of in-hospital cardiac arrest is unknown.
- The rates of survival to discharge after in-hospital cardiac arrest are 27% among children and 18% among adults. However, children and adults with an initial rhythm of ventricular fibrillation or ventricular tachycardia have a similarly favorable prognosis (30% versus 32% survival to discharge).28
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Risk Factors |
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- Data from the 2003 CDC BRFSS survey of adults age 18 and older showed the prevalence of respondents reporting 2 or more risk factors for heart disease and stroke increased among successive age groups. The prevalence of having 2 or more 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 or more had the lowest prevalence (28.8%), and those reporting $10 000 or less had the highest prevalence (52.5%). Adults who reported being unable to work had the highest prevalence (69.3%) of 2 or more risk factors, followed by retired persons (45.1%), unemployed adults (43.4%), homemakers (34.3%), and employed persons (34.0%). Prevalence of 2 or more 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% or more: Alabama, Arkansas, Georgia, Indiana, Kentucky, Louisiana, Mississippi, North Carolina, Ohio, Oklahoma, Tennessee, West Virginia, Guam, and Puerto Rico.29
- Data from the BRFSS (CDC) showed that young women and men ages 18 to 24 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, ages 65 to 74, 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).30
- Data from the Chicago Heart Association Detection Project (1967–1973, with an average follow-up of 31 years) showed that in younger women (ages 18 to 39) with favorable levels for all 5 major risk factors (blood pressure [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, as compared with those who have unfavorable or elevated risk factor levels at young ages. Similar findings applied to men in this study.31,32
- Data from the BRFSS (CDC) showed that in adults age 18 and older, 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 in both groups of educational status. CHD and stroke were inversely related to education, income, and poverty status. Hospitalization was greater in men for total heart disease and acute MI but greater in women for CHF and stroke. 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 higher in whites than blacks, by about 5 years. CVD mortality at all ages tended to be highest in blacks.33
- In respondents ages 18 to 74 years, 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 physical activity, 22.2%. The overall prevalence of the healthy lifestyle indicator (ie, having all 4 healthy lifestyle characteristics) was only 3%, with little variation among subgroups.34
- 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.35
- The aging of the population will undoubtedly result in an increased number of cases of chronic diseases, including coronary artery disease, HF, and stroke.36
- - The US Census estimates that there will be 40 million Americans age 65 and older in 2010.
- - There has been an explosive increase in the prevalence of obesity and type 2 diabetes. Their related complications—hypertension, hyperlipidemia, and atherosclerotic vascular disease—also have increased.
- - An alarming increase in unattended risk factors in the younger generations will continue to fuel the cardiovascular epidemic for years to come.
- - There has been an explosive increase in the prevalence of obesity and type 2 diabetes. Their related complications—hypertension, hyperlipidemia, and atherosclerotic vascular disease—also have increased.
- - The US Census estimates that there will be 40 million Americans age 65 and older in 2010.
- Analysis of FHS data among participants free of CVD at age 50 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.47
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 in order to improve healthy longevity.
- The lifetime risk for CVD and median survival were highly associated with risk factor burden at age 50 among more than 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 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 age 50, compared with 68.9% in men and 50.2% in women with 2 or more major risk factors at age 50. In addition, men and women with optimal risk factors had a median life expectancy at least 10 years longer than those with 2 or more major risk factors at age 50.47
- 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 age 85 and beyond. Low levels of the major risk factors in middle age predicted overall survival and morbidity-free survival to age 85 years.48
- - Overall, 35.7% survived to age 85, and 22% survived to age 85 free of major morbidities.
- - Factors associated with survival to age 85 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 age 85 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.
- - Factors associated with survival to age 85 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 age 85 free of MI, unstable angina, HF, stroke, dementia, and cancer were nearly identical.
- - Overall, 35.7% survived to age 85, and 22% survived to age 85 free of major morbidities.
- A study of 366 000 men and women from the Multiple Risk Factor Intervention Trial (MRFIT) screenee 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, and 6 to 10 years greater life expectancy.32
- A study of 84 129 women enrolled in the Nurses’ Health Study identified 5 healthy lifestyle factors, including absence of current smoking, drinking
glass or more of wine per day (or equivalent alcohol consumption), hour or more per day of moderate or vigorous physical activity, 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 14 years 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%.49
- Among individuals ages 70 to 90 years, adherence to a Mediterranean-style diet and greater physical activity are associated with 65% to 73% lower rates of all-cause mortality, as well as mortality due to CHD, CVD, and cancer.50
- Seventeen-year mortality data from the NHANES II Mortality Follow-Up Study indicate 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) compared with 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.51
- 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 (about 25 years later) and lower average annual Medicare costs at older ages.
- - 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.52
- - Similarly, 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).53
- - Similarly, 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).53
- - 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.52
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Hospital Discharges, Ambulatory Care Visits, and Nursing Home Visits |
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- From 1979 to 2004, the number of inpatient discharges from short-stay hospitals with CVD as the first-listed diagnosis increased 30% to 6 363 000 discharges (NCHS, NHDS). In 2004, CVD ranked highest among all disease categories in hospital discharges.54
- In 2004, there were 72 648 000 physician office visits with a primary diagnosis of CVD (NCHS, NAMCS).55
- In 2004, there were 4 164 000 visits to emergency departments with a primary diagnosis of CVD (NCHS, NHAMCS).56
- In 1999, 23% of nursing home residents age 65 or older had a primary diagnosis of CVD at admission. This was the highest disease category for these residents (NCHS, NNHS).57
- In 2004, there were 6 369 000 outpatient department visits with a primary diagnosis of CVD (NHAMCS).58
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Cost |
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- The estimated direct and indirect cost of CVD for 2007 is $431.8 billion.
- In 2001, $29.3 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 $8354 per discharge.59
- A study of the 1987 National Medicaid Expenditure Survey and the 2000 Medical Expenditure Panel Survey, 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%.60
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Operations and Procedures |
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- In 2004, an estimated 6 363 000 inpatient cardiovascular operations and procedures were performed in the United States; 3.2 million were performed on males, and 3.1 million were performed on females (NHDS).54
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References |
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1. Lethridge-Cejku M, Rose D, Vickerie J. Summary health statistics for United States adults: National Health Interview Survey, 2004. Vital Health Stat 10. 2006; 228.
2. AHRQ’s Medical Expenditure Panel Survey. Available at: (http://www.meps.ahrq.gov/. Accessed December 19, 2006.
3. Thom TJ, Kannel WB, Silbershatz H, D’Agostino RB. Cardiovascular disease in the United States and preventive approaches. In: Fuster V, Alexander RW, O’Rourke RA, eds. Hurst’s The Heart, Arteries and Veins. 10th ed. New York, NY: McGraw-Hill; 2001.
4. Ali T, Jarvis B, O’Leary M. Strong Heart Study Data Book: A Report to American Indian Communities. Rockville, Md: National Institutes of Health, National Heart, Lung, and Blood Institute; 2001.
5. Ergin A, Muntner P, Sherwin R, He J. Secular trends in cardiovascular disease mortality, incidence, and case fatality rates in adults in the United States. Am J Med. 2004; 117: 219–227.[CrossRef][Medline] [Order article via Infotrieve]
6. Minino AM, Heron MP, Smith BL. Deaths: preliminary data for 2004. Natl Vital Stat Rep. 2006; 54: 1–49.[Medline] [Order article via Infotrieve]
8. National Center for Health Statistics. Health, United States, 2005. With Chartbook on Trends in the Health of Americans. Hyattsville, Md: National Center for Health Statistics; 2005. Available at: http://www.cdc.gov/nchs/data/hus/hus05.pdf. Accessed October 25, 2006.
9. National Center for Health Statistics. U.S. Decennial Life Tables for 1989–91, Volume 1, No. 4. Eliminating Certain Causes of Death, 1989–91. Hyattsville, Md: National Center for Health Statistics, 1999.
11. Jacobs I, Nadkarni V, Bahr J, Berg RA, Billi JE, Bossaert L, Cassan P, Coovadia A, D’Este K, Finn J, Halperin H, Handley A, Herlitz J, Hickey R, Idris A, Kloeck W, Larkin GL, Mancini ME, Mason P, Mears G, Monsieurs K, Montgomery W, Morley P, Nichol G, Nolan J, Okada K, Perlman J, Shuster M, Steen PA, Sterz F, Tibballs J, Timerman S, Truitt T, Zideman D; International Liaison Committee on Resuscitation; American Heart Association; European Resuscitation Council; Australian Resuscitation Council; New Zealand Resuscitation Council; Heart and Stroke Foundation of Canada; InterAmerican Heart Foundation; Resuscitation Councils of Southern Africa; ILCOR Task Force on Cardiac Arrest and Cardiopulmonary Resuscitation Outcomes. Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries: a statement for healthcare professionals from a task force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Councils of Southern Africa). Circulation. 2004; 110: 3385–3397.
12. Fox CS, Evans JC, Larson MG, Lloyd-Jones DM, O’Donnell CJ, Sorlie PD, Manolio TA, Kannel WB, Levy D. A comparison of death certificate out-of-hospital coronary heart disease death with physician-adjudicated sudden cardiac death. Am J Cardiol. 2005; 95: 856–859.[CrossRef][Medline] [Order article via Infotrieve]
13. Vital Statistics of the U.S., Data Warehouse, National Center for Health Statistics. Available at: http://www.cdc.gov/nchs/datawh.htm. Accessed October 25, 2006.
15. Vaillancourt C, Stiell IG, Canadian Cardiac Outcomes Research Team. Cardiac arrest care and emergency medical services in Canada. Can J Cardiol. 2004; 20: 1081–1090.[Medline] [Order article via Infotrieve]
16. Rea TD, Eisenberg MS, Sinibaldi G, White RD. Incidence of EMS-treated out-of-hospital cardiac arrest in the United States. Resuscitation. 2004; 63: 17–24.[CrossRef][Medline] [Order article via Infotrieve]
17. Monthly Postcensal Resident Population (8/1/2005): U.S. Census data. Available at: http://www.census.gov. Accessed October 19, 2005.
18. Myerburg RJ, Kessler KM, Castellanos A. Sudden cardiac death: epidemiology, transient risk, and intervention assessment. Ann Intern Med. 1993; 119: 1187–1197.
19. Chugh SS, Jui J, Gunson K, Stecker EC, John BT, Thompson B, Ilias N, Vickers C, Dogra V, Daya M, Kron J, Zheng ZJ, Mensah G, McAnulty J. Current burden of sudden cardiac death: multiple source surveillance versus retrospective death certificate–based review in a large U.S. community. J Am Coll Cardiol. 2004; 44: 1268–1275.
20. Cobb LA, Fahrenbruch CE, Olsufka M, Copass MK. Changing incidence of out-of-hospital ventricular fibrillation, 1980–2000. JAMA. 2002; 288: 3008–3013.
21. Nichol G, Stiell IG, Laupacis A, Pham B, De Maio V, Wells GA. A cumulative meta-analysis of the effectiveness of defibrillator-capable emergency medical services for victims of out-of-hospital cardiac arrest. Ann Emerg Med. 1999; 34: 517–525.[CrossRef][Medline] [Order article via Infotrieve]
22. Culley LL, Rea TD, Murray JA, Welles B, Fahrenbruch CE, Olsufka M, Eisenberg MS, Copass MK. Public access defibrillation in out-of-hospital cardiac arrest: a community-based study. Circulation. 2004; 109: 1859–1863.
23. Young KD, Gausche-Hill M, McClung CD, Lewis RJ. A prospective, population-based study of the epidemiology and outcome of out-of-hospital pediatric cardiopulmonary arrest. Pediatrics. 2004; 114: 157–164.
24. Mogayzel C, Quan L, Graves JR, Tiedeman D, Fahrenbruch C, Herndon P. Out-of-hospital ventricular fibrillation in children and adolescents: causes and outcomes. Ann Emerg Med. 1995; 25: 484–491.[CrossRef][Medline] [Order article via Infotrieve]
25. Donoghue A, Nadkarni V, Berg RA, Osmond MH, Wells GA, Nesbitt L, Stiell IG, CanAm Pediatric Cardiac Arrest Investigators. Out-of-hospital pediatric cardiac arrest: an epidemiologic review and assessment of current knowledge. Ann Emerg Med. 2005; 46: 512–522.[CrossRef][Medline] [Order article via Infotrieve]
26. Luckstead EF, Patel DR. Catastrophic pediatric sports injuries. Pediatr Clin North Am. 2002; 49: 581–591.[CrossRef][Medline] [Order article via Infotrieve]
27. Maron BJ, Gohman TE, Aeppli D. Prevalence of sudden cardiac death during competitive sports activities in Minnesota high school athletes. J Am Coll Cardiol. 1998; 32: 1881–1884.
28. Nadkarni VM, Larkin GL, Peberdy MA, Carey SM, Kaye W, Mancini ME, Nichol G, Lane-Truitt T, Potts J, Ornato JP, Berg RA, National Registry of Cardiopulmonary Resuscitation Investigators. First documented rhythm and clinical outcomes from in-hospital cardiac arrest among children and adults. JAMA. 2006; 295: 50–57.
29. Centers for Disease Control and Prevention (CDC). Racial/ethnic and socioeconomic disparities in multiple risk factors for heart disease and stroke: United States, 2003. MMWR Morb Mortal Wkly Rep. 2005; 54: 113–117.[Medline] [Order article via Infotrieve]
30. Winkleby MA, Cubbin C. Changing patterns in health behaviors and risk factors related to chronic diseases, 1990–2000. Am J Health Promot. 2004; 19: 19–27.[Medline] [Order article via Infotrieve]
31. Daviglus ML, Stamler J, Pirzada A, Yan LL, Garside DB, Liu K, Wang R, Dyer AR, Lloyd-Jones DM, Greenland P. Favorable cardiovascular risk profile in young women and long-term risk of cardiovascular and all-cause mortality. JAMA. 2004; 292: 1588–1592.
32. Stamler J, Stamler R, Neaton JD, Wentworth D, Daviglus ML, Garside D, Dyer AR, Liu K, Greenland P. Low risk-factor profile and long-term cardiovascular and noncardiovascular mortality and life expectancy: findings for 5 large cohorts of young adult and middle-aged men and women. JAMA. 1999; 282: 2012–2018.
33. Mensah GA, Mokdad AH, Ford ES, Greenlund KJ, Croft JB. State of disparities in cardiovascular health in the United States. Circulation. 2005; 111: 1233–1241.
34. Reeves MJ, Rafferty AP. Healthy lifestyle characteristics among adults in the United States, 2000. Arch Intern Med. 2005; 165: 854–857.
35. Gregg EW, Cheng YJ, Cadwell BL, Imperatore G, Williams DE, Flegal KM, Narayan KM, Williamson DF. Secular trends in cardiovascular disease risk factors according to body mass index in US adults. JAMA. 2005; 293: 1868–1874.Erratum in: JAMA. 2005;294:182.
36. Bonow RO, Smaha LA, Smith SC Jr., Mensah GA, Lenfant C. World Heart Day 2002: the international burden of cardiovascular disease: responding to the emerging global epidemic. Circulation. 2002; 106: 1602–1605.
37. Lloyd-Jones DM, Larson MG, Beiser A, Levy D. Lifetime risk of developing coronary heart disease. Lancet. 1999; 353: 89–92.[CrossRef][Medline] [Order article via Infotrieve]
38. Lloyd-Jones DM, Wang TJ, Leip EP, Larson MG, Levy D, Vasan RS, D’Agostino RB, Massaro JM, Beiser A, Wolf PA, Benjamin EJ. Lifetime risk for development of atrial fibrillation: the Framingham Heart Study. Circulation. 2004; 110: 1042–1046.
39. Lloyd-Jones DM, Larson MG, Leip EP, Beiser A, D’Agostino RB, Kannel WB, Murabito JM, Vasan RS, Benjamin EJ, Levy D. Lifetime risk for developing congestive heart failure: the Framingham Heart Study. Circulation. 2002; 106: 3068–3072.
40. Seshadri S, Beiser A, Kelly-Hayes M, Kase CS, Au R, Kannel WB, Wolf PA. The lifetime risk of stroke: estimates from the Framingham Study. Stroke. 2006; 37: 345–350.
41. Cummings SR, Black DM, Rubin SM. Lifetime risks of hip, colles’, or vertebral fracture and coronary heart disease among white postmenopausal women. Arch Intern Med. 1989; 149: 2445–2448.
42. Seer cancer statistics review, 1975–2000. Available at: http://seercancergov/csr/1975_2000/results_merged/topic_lifetime_risk.pdf. Accessed July 18, 2006.
43. Feuer EJ, Wun LM, Boring CC, Flanders WD, Timmel MJ, Tong T. The lifetime risk of developing breast cancer. J Natl Cancer Inst. 1993; 85: 892–897.
44. Narayan KM, Boyle JP, Thompson TJ, Sorensen SW, Williamson DF. Lifetime risk for diabetes mellitus in the United States. JAMA. 2003; 290: 1884–1890.
45. Vasan RS, Beiser A, Seshadri S, Larson MG, Kannel WB, D’Agostino RB, Levy D. Residual lifetime risk for developing hypertension in middle-aged women and men: the Framingham Heart Study. JAMA. 2002; 287: 1003–1010.
46. Vasan RS, Pencina MJ, Cobain M, Freiberg MS, D’Agostino RB. Estimated risks for developing obesity in the Framingham heart study. Ann Intern Med. 2005; 143: 473–480.
47. Lloyd-Jones DM, Leip EP, Larson MG, D’Agostino RB, Beiser A, Wilson PW, Wolf PA, Levy D. Prediction of lifetime risk for cardiovascular disease by risk factor burden at 50 years of age. Circulation. 2006; 113: 791–798.
48. Terry DF, Pencina MJ, Vasan RS, Murabito JM, Wolf PA, Hayes MK, Levy D, D’Agostino RB, Benjamin EJ. Cardiovascular risk factors predictive for survival and morbidity-free survival in the oldest-old Framingham Heart Study participants. J Am Geriatr Soc. 2005; 53: 1944–1950.[CrossRef][Medline] [Order article via Infotrieve]
49. Stampfer MJ, Hu FB, Manson JE, Rimm EB, Willett WC. Primary prevention of coronary heart disease in women through diet and lifestyle. N Engl J Med. 2000; 343: 16–22.
50. Knoops KT, de Groot LC Kromhout D, Perrin AE, Moreiras-Varela O, Menotti A, van Staveren WA. Mediterranean diet, lifestyle factors, and 10-year mortality in elderly European men and women: the HALE project. JAMA. 2004; 292: 1433–1439.
51. Mensah GA, Brown DW, Croft JB, Greenlund KJ. Major coronary risk factors and death from coronary heart disease: baseline and follow-up mortality data from the Second National Health and Nutrition Examination Survey (NHANES II). Am J Prev Med. 2005; 29 (5 Suppl 1): 68–74.[CrossRef][Medline] [Order article via Infotrieve]
52. Daviglus ML, Liu K, Pirzada A, Yan LL, Garside DB, Feinglass J, Guralnik JM, Greenland P, Stamler J. Favorable cardiovascular risk profile in middle age and health-related quality of life in older age. Arch Intern Med. 2003; 163: 2460–2468.
53. Daviglus ML, Liu K, Greenland P, Dyer AR, Garside DB, Manheim L, Lowe LP, Rodin M, Lubitz J, Stamler J. Benefit of a favorable cardiovascular risk-factor profile in middle age with respect to medicare costs. N Engl J Med. 1998; 339: 1122–1129.
54. DeFrances CJ, Podgornik MN. 2004 National Hospital Discharge Survey. Adv Data. 2006; 371: 1–19.[Medline] [Order article via Infotrieve]
55. Hing E, Cherry DK, Woodwell DA. National Ambulatory Medical Care Survey: 2004 summary. Adv Data. 2006; 374: 1–33.[Medline] [Order article via Infotrieve]
56. McCaig LF, Nawar EW. National Hospital Ambulatory Medical Care Survey: 2004 emergency department summary. Adv Data. 2006; 372: 1–29.[Medline] [Order article via Infotrieve]
57. Jones A. The National Nursing Home Survey: 1999 Summary. National Center for Health Statistics. Vital Health Stat 13. 2002; 152: 1–116.
58. Middleton KR Hing E, National Hospital Ambulatory Medical Care Survey: 2004 outpatient department summary. Adv Data. 2006; 373: 1–27.[Medline] [Order article via Infotrieve]
59. Centers for Medicare and Medicaid Services. Health Care Financing Review: Medicare and Medicaid Statistical Supplement. Baltimore, Md: Centers for Medicare and Medicaid Services; 2003. Available at: http://www.cms.hhs.gov/apps/review/Supp/. Accessed October 28, 2006.
60. Thorpe KE, Florence CS, Howard DH, Joski P. The impact of obesity on rising medical spending. Health Aff (Millwood). 2004; suppl web exclusives: W4–480–486.
61. Briefel RR, Johnson CL. Secular trends in dietary intake in the United States. Annu Rev Nutr. 2004; 24: 401–431.[CrossRef][Medline] [Order article via Infotrieve]
62. Incidence and Prevalence: 2006 Chart Book on Cardiovascular and Lung Diseases. Bethesda, Md: National Heart, Lung, and Blood Institute; 2006.
3. Coronary Heart Disease, Acute Coronary Syndrome, and Angina Pectoris
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Coronary Heart Disease |
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ICD-9 410–414, 429.2; ICD-10 I20–I25; see Glossary (Chapter 21) for details and definitions. See Table 3-1 and Charts 3-1 through 3-6
. Also see Chart 3-7 in the online-only Data Supplement.
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Prevalence
- Among Americans ages 40 to 74 years, NHANES data found the age-adjusted prevalence of self-reported MI and electrocardiographically verified MI to be higher among men than women but AP prevalence to be higher in women than in men. Age-adjusted rates of self-reported MI increased among African-American men and women and Mexican-American men but decreased among white men and women.1
Incidence
- This year, an estimated 700 000 Americans will have a new coronary attack and about 500 000 will have a recurrent attack. It is estimated that an additional 175 000 silent first MIs occur each year (NHLBI: based on unpublished data from the ARIC study and the CHS).2
- The estimated annual incidence of MI is 565 000 new attacks and 300 000 recurrent attacks annually (NHLBI: based on unpublished data from the ARIC study and the CHS).2
- Average age at first MI is 65.8 years for men and 70.4 years for women (NHLBI: based on unpublished data from the ARIC study and the CHS).
- On the basis of the NHLBI’s FHS, in its 44-year follow-up of participants and 20-year follow-up of their offspring4:
- - CHD comprises more than half of all cardiovascular events in men and women under age 75.
- - The lifetime risk of developing CHD after age 40 years is 49% for men and 32% for women.5
- - 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.
- - The lifetime risk of developing CHD after age 40 years is 49% for men and 32% for women.5
- - CHD comprises more than half of all cardiovascular events in men and women under age 75.
- In the NHLBI’s ARIC study, 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. Hypertension was a particularly powerful risk factor for CHD in black persons, especially in black women. Diabetes was a weaker predictor of CHD in black than in white persons. In a multivariable analysis, hypertension was a particularly strong risk factor in black women, with hazard rate ratios (95% confidence interval [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).6
- The annual age-adjusted rates per 1000 population of first MI, 1987 to 2001, in ARIC Surveillance were 4.2 in black men, 3.9 in white men, 2.8 in black women, and 1.7 in white women (NHLBI Incidence & Prevalence: 2006 Chart Book on Cardiovascular and Lung Diseases).
- Combining the rates for possible and definite CHD shows that 17 to 25 of every 100 American Indian men ages 45 to 74 had some evidence of heart disease.7
- Among American Indians ages 65 to 74, the annual rates per 1000 population of new and recurrent MIs are 7.6 for men and 4.9 for women (Strong Heart Study [1989–2002], personal communication with NHLBI).
- CHD rates in women after menopause are 2 to 3 times those of women the same age before menopause.8
Mortality
CHD caused 1 of every 5 deaths in the United States in 2004. CHD total-mention mortality in 2002 was 653 000. MI total-mention mortality in 2002 was 221 000 (Vital Statistics of the United States, NCHS). CHD is the single largest killer of American males and females. 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 ages 50 to 79 years who had cardiac arrest showed the incidence of out-of-hospital cardiac arrest was 6.0/1000 subject-years in subjects with any clinically recognized heart disease, as 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 data from the FHS 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 150.5 per 100 000 population. The death rates were 194.4 for white males and 222.2 for black males; for white females, the rate was 115.4, and for black females it was 148.6 (NCHS and NHLBI). The 2003 age-adjusted death rates for CHD were 130.0 for Hispanics or Latinos, 114.1 for American Indians or Alaska Natives, and 92.8 for Asians or Pacific Islanders.11
- About 83% of people who die of CHD are age 65 or older (NCHS) (AHA computation).
- The estimated average number of years of life lost due to an MI is 15.12
- On the basis of data from the FHS of the NHLBI4:
- - Fifty percent of men and 64% of women who died suddenly of CHD had 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.
- - Sudden cardiac death accounts for 19% of sudden deaths in children ages 1 to 13 and 30% between 14 and 21 years of age. The overall incidence is low, 600 cases per year.
- - People who have had an MI have a sudden death rate 4 to 6 times that of the general population.
- - Fifty percent of men and 64% of women who died suddenly of CHD had 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.
- 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%.14
- - Mortality increases for every 30 minutes that elapse before a patient with ST-segment elevation is recognized and treated.15
- - The median door-to-drug time for thrombolytic therapy was reduced by nearly half, from 61.8 to 37.8 minutes. However, many hospitals are still working to meet the goal of 30 minutes set in 1991 (www.nrmi.org).
- - Women under 50 years of age are twice as likely to die after an acute MI as are men in the same age group.16
- - Mortality increases for every 30 minutes that elapse before a patient with ST-segment elevation is recognized and treated.15
- - From 1990 to 1999, in-hospital acute MI mortality declined from 11.2% to 9.4%.14
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.17
- According to a case–control study of 52 countries (INTERHEART), 9 easily measured and potentially modifiable risk factors account for more than 90% of 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 (PA), low daily fruit and vegetable consumption, alcohol overconsumption, and psychosocial index.18
- A study of more than 3000 members of the FHS 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 (metabolic equivalent) increment in exercise capacity reduced risk by 13%.19
- 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 surveys conducted in 1971–1975, 1976–1980, 1988–1994, and 1999–2000.20
- - 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 ages 65 to 74 (3%) and was progressively greater at younger ages (29% at ages 25 to 34), 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%), as compared with favorable systolic BP (from 32% to 47%), nonsmoking (from 60% to 79%), and favorable cholesterol (from 33% to 46%).
- - Prevalence of low risk was about twice as high in women as in men throughout the period.
- - The prevalence of low risk rose from 6% in 1971–1975 to 17% in 1988–1994 and 1999–2000.
- Taking into account CHD risk factors in combination provides a very potent predictor of 10-year risk of CHD, as compared with individual risk factors. Among participants ages 20 to 79 in the NHANES III study of the NCHS without self-reported CHD, stroke, peripheral vascular disease, and diabetes, 81.7% had a 10-year risk for CHD <10%, 15.5% had a risk of 10% to 20%, and 2.9% had a risk >20%. Among participants age 60 and older, 40.3% of men and 8.2% of women were at "intermediate risk" (10% to 20%). The proportion of participants with a 10-year risk of CHD >20% increased with advancing age and was higher among men than women but varied little with race or ethnicity.21
- A study of non-Hispanic white persons ages 35 to 74 in the FHS and the NHANES III studies showed that 26% of men and 41% of women had at least 1 borderline risk factor in NHANES III. It is estimated that more than 90% of CHD events will occur in individuals with at least 1 elevated risk factor and approximately 8% will occur in people with only borderline levels of multiple risk factors. Absolute 10-year CHD risk exceeded 10% in men older than age 45 who had 1 elevated risk factor and 4 or more borderline risk factors and in those who had at least 2 elevated risk factors. In women, absolute CHD risk exceeded 10% only in those over age 55 who had at least 3 elevated risk factors.22
- Analysis of data from the Cardiovascular Health Study (NHLBI) among participants age 65 and older 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.23
Awareness of Warning Signs and Risk Factors for Heart Disease
- Surveys conducted by the AHA between 1997 and 2003 showed that awareness of heart disease as the leading cause of death in women rose from 30% in 1997 to 46% in 2003. Awareness in white women (55%) was nearly twice as high as among African-American (30%) and Hispanic (27%) women.24
- In 2003, 46% of respondents to a nationally representative telephone survey of women age 25 and older identified heart disease as the leading killer of women, up from 30% in 1997 and 34% in 2000.24
- In 1997, a telephone survey of 1000 US households found that only 8% of women respondents identified heart disease as their greatest health concern; fewer than 33% of respondents identified heart disease as the leading cause of death.25
- Data from the Women Veteran Cohort, age 35 and older, showed 42% of women were concerned about heart disease. Only 8% to 20% were aware that coronary artery disease is the major cause of death for women.26
- 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.27
- A study of public knowledge of CVD risk factors and risk-reduction techniques in 2 New England communities showed that prevention knowledge improved significantly over time in both locations and in every demographic subgroup. Scores were higher for native-born citizens, women, more educated individuals, and English-speaking people. There was an increase in the identification of physical inactivity, high blood cholesterol, and high-fat diet as CVD risk factors, while there was a decrease in the identification of overweight and HBP.28
- 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.29
- A recent community surveillance study in 4 US communities reported that in 2000, the overall proportion of persons with delays of 4 or more hours from onset of symptoms of acute MI 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 or more 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.30
- Although age-adjusted prevalence of hypertension is lower among Hispanics than among blacks or non-Hispanic whites, recent data indicate that certain Hispanic subpopulations (Mexican Americans, Puerto Rican Americans, Cuban Americans, and other Hispanic Americans) are characterized by low levels of hypertension awareness, treatment, and control. CDC analysis of death certificate data from 1995 and 2002 indicated that Puerto Rican Americans had consistently higher hypertension-related mortality rates than all other Hispanic subpopulations and non-Hispanic whites.31
- Among ever-smokers who had 1 circulatory disorder, 52.1% were current smokers, and among those who reported that they had 3 or more circulatory disorders, 28% were current smokers at the time of the interview. The adjusted odds of being a current smoker were lower for individuals who had ever smoked in life and had 2 or more central circulatory disorders, such as MI, HF, or stroke, than for ever-smokers without a central circulatory disorder.32
- A nationally representative study of more than 1000 women showed awareness of CVD as the leading cause of death nearly doubled from 1997 to 2003 (55% versus 30%), was greater for whites than blacks or Hispanics (62% versus 38% and 34% respectively), and was independently correlated with increased PA and weight loss. Fewer than half of respondents were aware of healthy levels of risk factors.33
- Using the Healthstyles 2002 survey, about 20% of respondents reported that they had HBP, and 53% of these were taking medications to lower BP. Black men had the highest adjusted prevalence of HBP (32%). Medication use among persons with HBP was lower among Hispanics (45%) than among blacks (54%) and whites (54%). Persons with HBP were 5 times more likely to report having been told to go on a diet or change eating habits and reduce salt or sodium in their diet but 5 times less likely to have received advice to exercise than those reporting not having HBP.34
- A study of more than 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.35
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. The risk of another MI, sudden death, AP, HF, and stroke—for both men and women—is substantial (FHS, NHLBI).4
- 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 age 70 or older participated in cardiac rehabilitation, in comparison to 66% of 60- to 69-year-olds and 81% of those under age 60.36
- On the basis of pooled data from the FHS, ARIC, and CHS studies of the NHLBI, within 1 year after a first MI:
- - At age 40 and older, 18% of men and 23% of women will die.
- - At ages 40 to 69, 8% of white men, 12% of white women, 14% of black men, and 11% of black women will die.
- - At age 70 and older, 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.
- - At ages 40 to 69, 8% of white men, 12% of white women, 14% of black men, and 11% of black women will die.
- - At age 40 and older, 18% of men and 23% of women will die.
- Within 5 years after a first MI:
- - At age 40 and older, 33% of men and 43% of women will die.
- - At ages 40 to 69, 15% of white men, 22% of white women, 27% of black men, and 32% of black women will die.
- - At age 70 and older, 50% of white men, 56% of white women, 56% of black men, and 62% of black women will die.
- - At ages 40 to 69, 15% of white men, 22% of white women, 27% of black men, and 32% of black women will die.
- - At age 40 and older, 33% of men and 43% of women will die.
- Of those who have a first MI, the percentage with a recurrent MI or fatal CHD within 5 years is:
- - at ages 40 to 69, 16% of men and 22% of women.
- - at age 70 and older, 24% of men and 25% of women.
- - at ages 40 to 69, 14% of white men, 18% of white women, 27% of black men, and 29% of black women.
- - at age 70 and older, 24% of white men and women, 30% of black men, and 32% of black women.
- - at age 70 and older, 24% of men and 25% of women.
- - at ages 40 to 69, 16% of men and 22% of women.
- The percentage of persons with a first MI who will have HF in 5 years is:
- - at ages 40 to 69, 7% of men and 12% of women.
- - at age 70 and older, 22% of men and 25% of women.
- - at ages 40 to 69, 7% of white men, 11% of white women, 11% of black men, and 14% of black women.
- - at age 70 and older, 21% of white men, 25% of white women, 29% of black men, and 24% of black women.
- - at age 70 and older, 22% of men and 25% of women.
- - at ages 40 to 69, 7% of men and 12% of women.
- The percentage of persons with a first MI who will have a stroke within 5 years is:
- - at ages 40 to 69, 4% of men and 6% of women.
- - at age 70 and older, 6% of men and 11% of women.
- - at ages 40 to 69, 3% of white men, 5% of white women, 8% of black men, and 9% of black women.
- - at age 70 and older, 6% of white men, 10% of white women, 7% of black men, and 17% of black women.
- - at age 70 and older, 6% of men and 11% of women.
- - at ages 40 to 69, 4% of men and 6% of women.
- The percentage of persons with a first MI who will experience sudden death in 5 years is:
- - at ages 40 to 69, 1.1% of white men, 1.9% of white women, 2.5% of black men, and 1.4% of black women.
- - at age 70 and older, 6.0% of white men, 3.5% of white women, 14.9% of black men, and 4.8% of black women.
- - at age 70 and older, 6.0% of white men, 3.5% of white women, 14.9% of black men, and 4.8% of black women.
- - at ages 40 to 69, 1.1% of white men, 1.9% of white women, 2.5% of black men, and 1.4% of black women.
- The median survival time (in years) after a first MI is:
- - at ages 60 to 69, data not available for men and 7.4 for women.
- - at ages 70 to 79, 7.4 for men and 10.4 for women.
- - at age 80 and older, 2.0 for men and 6.4 for women.
- - at ages 70 to 79, 7.4 for men and 10.4 for women.
- - at ages 60 to 69, data not available for men and 7.4 for women.
Hospital Discharges and Ambulatory Care Visits
- From 1979 to 2004, the number of inpatient discharges from short-stay hospitals with CHD as the first-listed diagnosis increased 14% to 1 981 000 (annual issues of the National Hospital Discharge Survey, NCHS; AHA computation).
- From 1990 to 1999, the median duration of hospital stays related to acute MI dropped from 8.3 to 4.3 days, according to an analysis of the National Registry of Myocardial Infarction. Findings were similar both for patients receiving primary percutaneous transluminal coronary angioplasty and for those receiving thrombolytic therapy.14
- Data from Ambulatory Care Visits to Physician Offices, Hospital Outpatient Departments, and Emergency Departments: US, 1999–2000, showed the number of visits for CHD as 12.2 million (NAMCS, NHAMCS).37
Cost
- The estimated direct and indirect cost of CHD for 2007 is $151.6 billion.
- In 2001, $11.6 billion was paid to Medicare beneficiaries for in-hospital costs where CHD was the principal diagnosis ($11 201 per discharge for acute MI, $11 308 per discharge for coronary atherosclerosis, and $3513 per discharge for other ischemic heart disease).38
Operations and Procedures
- In 2004, an estimated 1 285 000 inpatient angioplasty procedures, 427 000 inpatient bypass procedures, 1 471 000 inpatient diagnostic cardiac catheterizations, 68 000 inpatient implantable defibrillators, and 170 000 pacemaker procedures were performed for inpatients in the United States (unpublished data from the NHDS 2004, NCHS; personal communication, May 17, 2006).
|
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 unexpected and usually occurs while at rest. The discomfort may be more severe and prolonged than typical AP or may be the first time a person has AP.)
- A conservative estimate for the number of discharges with ACS from hospitals in 2004 is 840 000. Of these, an estimated 476 000 are male and 364 000 are female. This estimate is derived by adding the first-listed inpatient hospital discharges for MI (732 000) to those for UA (108 000) (NHDS, NCHS).
- When including secondary discharge diagnoses in 2004, the corresponding numbers of inpatient hospital discharges were 1 565 000 unique hospitalizations for ACS, 896 000 for MI, and 669 000 for UA (21 000 hospitalizations received both diagnoses) (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 electrocardiogram and abnormal ("positive") elevations of myocardial biomarkers, such as tropo