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(Circulation. 2006;113:e85-e151.)
© 2006 American Heart Association, Inc.

AHA Statistical Update

Heart Disease and Stroke Statistics—2006 Update

A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee

Writing Group: Thomas Thom; Nancy Haase; Wayne Rosamond, PhD; Virginia J. Howard, MSPH, FAHA; John Rumsfeld, MD, PhD, FAHA; Teri Manolio, MD, PhD, FAHA; Zhi-Jie Zheng, MD, PhD^*; Katherine Flegal, PhD^*; Christopher O’Donnell, MD, MPH, FAHA; Steven Kittner, MD; Donald Lloyd-Jones, MD; David C. Goff, Jr, MD, PhD, FAHA; Yuling Hong, MD, MSC, PhD, FAHA; Members of the Statistics Committee and Stroke Statistics Subcommittee^**; Robert Adams, MD; Gary Friday, MD, MPH; Karen Furie, MD, MPH; Philip Gorelick, MD, MPH; Brett Kissela, MD; John Marler, MD; James Meigs, MD; Veronique Roger, MD; Stephen Sidney, MD, MPH; Paul Sorlie, PhD; Julia Steinberger, MD, MSC; Sylvia Wasserthiel-Smoller, PhD; Matthew Wilson, MD; Philip Wolf, MD

	Table of Contents

Top Table of Contents 1. About These Statistics 2. Cardiovascular Diseases 3. Coronary Heart Disease,... 4. Stroke 5. High Blood Pressure 6. Congenital Cardiovascular... 7. Heart Failure 8. Other Cardiovascular Diseases 9. Risk Factors High Blood Cholesterol and... Physical Activity Overweight and Obesity Diabetes Mellitus 10. Metabolic Syndrome 11. Nutrition 12. Quality of Care 13. Medical Procedures 14. Economic Cost of... 15. At-a-Glance Summary Tables 16. Glossary Abbreviation Guide 18. References

 

1. About These Statistics
   
2. Cardiovascular Diseases
   
3. Coronary Heart Disease, Acute Coronary Syndrome and Angina Pectoris
   
4. Stroke and Stroke in Children
   
5. High Blood Pressure (and End-Stage Renal Disease)
   
6. Congenital Cardiovascular Defects
   
7. Heart Failure
   
8. Other Cardiovascular Diseases

      –Arrhythmias (Disorders of Heart Rhythm)
   

      –Arteries, Diseases of (including Peripheral Arterial Disease)
   

      –Bacterial Endocarditis
   

      –Cardiomyopathy
   

      –Rheumatic Fever/Rheumatic Heart Disease
   

      –Valvular Heart Disease
   

      –Venous Thromboembolism
   

   
   
9. Risk Factors

      –Tobacco
   

      –High Blood Cholesterol and Other Lipids
   

      –Physical Inactivity
   

      –Overweight and Obesity
   

      –Diabetes Mellitus
   

   
   
10. Metabolic Syndrome
    
11. Nutrition
    
12. Quality of Care
    
13. Medical Procedures
    
14. Economic Cost of Cardiovascular Diseases
    
15. At-a-Glance Summary Tables

       –Men and Cardiovascular Diseases
    

       –Women and Cardiovascular Diseases
    

       –Ethnic Groups and Cardiovascular Diseases
    

       –Children, Youth and Cardiovascular Diseases
    

    
    
16. Glossary and Abbreviation Guide
    
17. Acknowledgment
    
18. References
    

Appendix I: List of Statistical Fact Sheets. URL: http://www.americanheart.org/presenter.jhtml?identifier=2007

	1. About These Statistics

Top Table of Contents 1. About These Statistics 2. Cardiovascular Diseases 3. Coronary Heart Disease,... 4. Stroke 5. High Blood Pressure 6. Congenital Cardiovascular... 7. Heart Failure 8. Other Cardiovascular Diseases 9. Risk Factors High Blood Cholesterol and... Physical Activity Overweight and Obesity Diabetes Mellitus 10. Metabolic Syndrome 11. Nutrition 12. Quality of Care 13. Medical Procedures 14. Economic Cost of... 15. At-a-Glance Summary Tables 16. Glossary Abbreviation Guide 18. References

 
The American Heart Association works with the Centers for Disease Control and Prevention’s National Center for Health Statistics (CDC/NCHS), the National Heart, Lung, and Blood Institute (NHLBI), the National Institute of Neurological Disorders and Stroke (NINDS), and other government agencies to derive the annual statistics in this update. This section describes the most important sources we use. For more details and an alphabetical list of abbreviations, see the Glossary and Abbreviation Guide.

All statistics are for the most recent year available. Prevalence, mortality and hospitalizations are computed for 2003 unless otherwise noted. Mortality as an underlying or contributing cause of death is for 2002. Economic cost estimates are for 2006. Due to late release of data, some disease mortality are not updated to 2003. Mortality for 2003 are underlying preliminary data, obtained from the NCHS publication National Vital Statistics Report: Deaths: Preliminary Data for 2003 (NVSR, 2005;53:15) and from unpublished tabulations furnished by Robert Anderson of NCHS. US and state death rates and prevalence rates are age-adjusted per 100 000 population (unless otherwise specified) using the 2000 US standard for age standardization.

Morbidity (illness) and mortality (death) data in the United States use a standard classification system—the International Classification of Diseases (ICD). About every 10–20 years, the ICD codes are revised to reflect changes over time in medical technology, diagnosis or terminology. Effective with mortality data for 1999, we’re using the tenth revision (ICD/10). It will be a few more years before the tenth revision is used for hospital discharge data.

Prevalence
Prevalence is an estimate of how many people have a disease at a given point in time. Government agencies periodically conduct health examination surveys. Rates for specific diseases are calculated from those surveys. These rates are applied as the population changes for several years, until a new health examination survey is done and new rates are established. It’s important to realize that the prevalence rates do not change from year to year until there is a new survey.

The annual changes in prevalence as reported in this update only reflect changes in the population. It’s impossible to develop a prevalence "trend" by comparing numbers from yearly versions of this update or its precursors. Many of our prevalence estimates come from the NHANES studies of the CDC/NCHS, and the ARIC, CHS and FHS studies of the NHLBI. Coronary heart disease (CHD), myocardial infarction (MI), angina pectoris (AP) and stroke prevalence are based on self-reports in national health interviews.

Incidence
Incidence is an estimate of the number of new cases of a disease that develop in a population in a 1-year period. For some statistics, new and recurrent attacks or cases are combined.

The incidence of a specific cardiovascular disease (CVD) in the United States is estimated by multiplying the incidence rates reported in community- or hospital-based studies by the US population. The rates change only when new data are available; they are not computed annually. The estimates were revised to reflect the 2000 US Census. 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.

Our incidence estimates for the various cardiovascular diseases are extrapolations from the Framingham Heart Study (FHS), Atherosclerosis Risk in Communities (ARIC) study and Cardiovascular Health Study (CHS) conducted by the NHLBI and Greater Cincinnati/Northern Kentucky Stroke Study and others conducted by the NIH.

Note: data published by governmental agencies for some racial groups, are considered unreliable due to the small sample size in the studies. Since we try to provide data for as many racial groups as possible, we show these data for informational and comparative purposes, etc.

If you have questions about statistics or any points made in this booklet, please contact the Biostatistics Program Coordinator at the American Heart Association National Center, nancy.haase@heart.org, 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’ll provide corrections at our Web site, http://www.americanheart.org/statistics.

	2. Cardiovascular Diseases

Top Table of Contents 1. About These Statistics 2. Cardiovascular Diseases 3. Coronary Heart Disease,... 4. Stroke 5. High Blood Pressure 6. Congenital Cardiovascular... 7. Heart Failure 8. Other Cardiovascular Diseases 9. Risk Factors High Blood Cholesterol and... Physical Activity Overweight and Obesity Diabetes Mellitus 10. Metabolic Syndrome 11. Nutrition 12. Quality of Care 13. Medical Procedures 14. Economic Cost of... 15. At-a-Glance Summary Tables 16. Glossary Abbreviation Guide 18. References

 
(ICD/9 390–459, 745–747) (ICD/10 I00–I99, Q20–Q28; see Glossary for details and definitions). See Table 2A.

View this table: [in this window] [in a new window]   TABLE 2A. CVD

Prevalence
Of the 71 300 000 American adults with 1 or more types of cardiovascular disease (CVD), 27 400 000 are estimated to be age 65 or older (National Health and Nutrition Examination Survey [NHANES 1999–2002], CDC/NCHS). Bullet points below are from NHANES 1999–2002 unless otherwise noted.

The following are the latest estimates of prevalence for these conditions. Due to overlap, it is not possible to add these conditions to arrive at a total.

• High blood pressure (HBP)—65 000 000. (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 you have high blood pressure.)
  
• Coronary heart disease (CHD)—13 200 000.

     –Myocardial infarction (MI, or heart attack)—7 200 000.
  

     –Angina pectoris (AP, or chest pain)—6 500 000.
  

  
  
• Heart failure (HF)—5 000 000.
  
• Stroke—5 500 000.
  
• Congenital cardiovascular defects—1 000 000 (Unpublished NHIS survey data, 1993–95, CDC/NCHS).
  
• 1 in 3 adult men and women has some form of CVD (NHANES 1999–02, CDC/NCHS).
  
• The following prevalence estimates are for people age 18 and older¹:

     –Among whites only, 11.4% have heart disease, 5.9% have CHD, 20.5% have hypertension and 2.3% have had a stroke.
  

     –Among blacks or African Americans only, 9.9% have heart disease, 5.3% have CHD, 31.6% have hypertension and 3.5% have had a stroke.
  

     –Among Hispanics or Latinos, 7.7% have heart disease, 4.5% have CHD, 19.0% have hypertension and 2.2% have had a stroke.
  

     –Among Asians, 5.6% have heart disease, 3.8% have CHD, 16.1% have hypertension and 1.8% have had a stroke.
  

     –Among Native Hawaiians or other Pacific Islanders, 16.6% have heart disease, 4.9% have CHD, and 18.2% have hypertension.
  

     –Among American Indians or Alaska Natives, 13.8% have heart disease, 8.2% have CHD, 23.9% have hypertension and 3.1% have had a stroke.
  

  
  

Incidence

• Based on the NHLBI’s Framingham Heart Study (FHS) in its 44-year follow-up of participants and the 20-year follow-up of their offspring²...

     –The average annual rates of first major cardiovascular events rise from 7 per 1000 men at ages 35–44 to 68 per 1000 at ages 85–94. For women, comparable rates occur 10 years later in life. The gap narrows with advancing age.
  

     –Under 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 congestive heart failure (CHF) occur in women than in men.
  

  
  
• Among American Indian men ages 45–74, the incidence of CVD ranges from 15 to 28 per 1000. Among women it ranges from 9 to 15 per 1000.³
  
• Data from the FHS indicate that the lifetime risk for CVD is 2 in 3 for men and more than 1 in 2 for women at age 40 (personal communication, Donald Lloyd-Jones, MD).
  

Mortality

• Preliminary mortality data show that CVD as the underlying cause of death accounted for 37.3% of all 2 440 000 deaths in 2003 or 1 of every 2.7 deaths in the United States. CVD as an underlying or contributing cause of death (1 408 000 deaths in 2002) was about 58% of all deaths that year.
  
• Since 1900, CVD has been the No. 1 killer in the United States every year but 1918. Nearly 2500 Americans die of CVD each day, an average of 1 death every 35 seconds. CVD claims more lives each year than the next 4 leading causes of death combined, which are cancer, chronic lower respiratory diseases, accidents, and diabetes mellitus.
  
• The 2003 overall preliminary death rate from CVD was 308.8. The rates were 359.1 for white males and 479.6 for black males; 256.2 for white females and 354.8 for black females. From 1993–2003, death rates from CVD (ICD/10 I00–I99) declined 22.1%. In the same 10-year period actual CVD deaths declined 4.6%.
  
• Other causes of death in 2003—cancer 554 643; accidents 105 695; Alzheimer’s disease 63 343; HIV (AIDS) 13 544. (preliminary data)
  
• The 2003 preliminary CVD death rates were 364.2 for males and 262.5 for females. Cancer death rates were 232.3 for males and 160.2 for females. Breast cancer claimed the lives of 41 566 females in 2003; lung cancer claimed 67 894. Death rates for females were 25.2 for breast cancer and 41.1 for lung cancer. One in 30 female deaths are from breast cancer, while 1 in 2.6 are from CVD. Based on preliminary 2003 mortality, CVD caused about a death a minute among females—over 480 000 female lives every year. That’s more female lives than were claimed by the next five leading causes of death combined (cancer, COPD, Alzheimer’s, diabetes and accidents).
  
• Over 152 000 Americans killed by CVD each year are under age 65. In 2002, 32% of deaths from CVD occurred prematurely (ie, before age 75, which is close to the average life expectancy).
  
• In 2002, the age-adjusted death rate for diseases of the heart in American Indians or Alaska Natives was 201.2 for males and 123.6 for females; for Asians or Pacific Islanders it was 169.8 for males and 108.1 for females; for Hispanics or Latinos it was 219.8 for males and 149.7 for females (Health, United States, 2004; CDC/NCHS).
  
• According to the CDC/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.⁴
  
• Based on revised 2000 population data, the average life expectancy of people born in the United States in 2003 is 77.6 years (preliminary data for 2003. NSVR, Vol. 53, No. 15, Hyattsville, Md: National Center for Health Statistics, 2005).
  
• In 2001, the proportion of premature deaths (<65 years) from diseases of the heart (I00–I09, I11, I13, I20–I51) was greatest among American Indians or Alaska Natives (36%) and blacks (31.5%) and lowest among whites (14.7%). Premature death was higher for Hispanics (23.5%) than non-Hispanics (16.5%), and for males (24%) than females (10%). Hispanic whites (23.3%) had lower proportions than Hispanic blacks (27.5%), and non-Hispanic (NH) whites (14.4%) had lower proportions than NH blacks (31.5%).⁵
  
• Age-adjusted death rates for diseases of the heart from 1990–98 declined 17% for Hispanics, 15% for NH whites, 14% for Asians/Pacific Islanders, 11% for NH blacks, and 8% for American Indians or Alaska Natives. In 1998 the rate for NH blacks was 2.8 times the rate for Asian or Pacific Islanders.⁶
  

Out-of-Hospital Cardiac Arrest
There is a wide variation in the reported incidence and outcome for out-of-hospital cardiac arrest. These differences are due to 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.^6a Available epidemiological databases do not record deaths due to 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.^6b 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 prior to the onset of the episode. The following information summarizes representative data from several sources in an attempt to characterize the incidence and outcome of sudden cardiac arrest and demonstrate the need for a comprehensive system of capturing more meaningful data.

• 330 000 coronary heart disease deaths occur out-of-hospital or in hospital emergency departments annually (2002) (ICD-10 codes I20-I25) (personal communication, Thomas Thom, NHLBI/NIH).
  
• In 1998, 456 076 deaths from cardiac disease (ICD-9 code 390 to 398, 402, or 404 to 429) were reported in the United States (among people aged 35 years and above) in an emergency room, before reaching a hospital, or as "dead on arrival."⁷
  
• The annual incidence of sudden cardiac arrest in North America is about 0.55 per 1000 population.^8,9 With an estimated US population of 296 766 821,¹⁰ this implies that about 163 221 out-of-hospital sudden cardiac arrests occur annually in the United States.
  
• About two thirds of unexpected cardiac deaths occur without prior recognition of cardiac disease.¹¹
  
• About 60% of unexpected cardiac deaths are treated by EMS.¹²
  
• Incidence of EMS-treated out-of-hospital cardiac arrest is 36/100 000–81/100 000.^12,13 This implies EMS treats 107 000 to 240 000 cardiac arrests in the United States annually.
  
• Of these, 20%–38% have ventricular fibrillation or ventricular tachycardia as the first recorded rhythm. This implies 21 000–91 000 ventricular fibrillation arrests annually.^8,13
  
• The incidence of ventricular fibrillation among cardiac arrest victims with any first initial rhythm is decreasing over time.¹³
  
• The median reported survival to discharge after any first recorded rhythm is 6.4%.¹⁴ Survival during a recent one year experience in Seattle 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 CPR is 27.4%.¹⁴
  
• The incidence of lay responder defibrillation is low, 2.05% in 2002, but increasing over time.¹⁵
  
• Unexpected death in the pediatric patient is usually due to trauma, sudden infant death syndrome, respiratory causes or submersion.¹⁶ 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.¹⁷
  
• The reported incidences of out-of-hospital pediatric cardiac arrest vary widely in number (from 2.6–19.7 annual cases per 100 000) and inclusion criteria (age, cause of arrest, etc).¹⁸
  
• Since there are 73 559 232 individuals aged <18 years in the United States,¹⁰ this implies that there are 1 900–14 000 pediatric out-of-hospital cardiac arrests, annually, from all causes (including trauma, sudden infant death syndrome, respiratory causes, cardiovascular causes and submersion).
  
• The incidence of sudden cardiac arrest in children in the out-of-hospital setting is unknown. Studies that document voluntary reports of deaths among high school athletes suggest that the incidence of sudden cardiac arrest ranges from 0.28–1.0 deaths per 100 000 high school athletes annually nationwide.^19,20 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%.¹⁸
  

Risk Factors

• Black and Mexican-American women have higher prevalence of CVD risk factors than white women of comparable socioeconomic status (SES).²¹
  
• Data from the 2003 BRFSS study 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 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.²²
  
• Data from the BRFSS study of the CDC showed that young women and men, ages 18–24, had poor health profiles and experienced adverse changes from 1990–2000. After adjustment for education and income, these young people had the highest prevalence of smoking (34–36% current smokers among whites); the largest increases in smoking (10–12% among whites and 9% among Hispanic women); large increases in obesity (4–9% increase in all groups). All groups had high levels of sedentary behavior (approximately 20–30%) and low vegetable or fruit intake (approximately 35–50%). In contrast, older Hispanics and older black men, ages 65–74, showed some of the most positive changes. They had the largest decreases in smoking (Hispanic women), largest decreases in sedentary behavior (Hispanic women and black men), and largest increases in vegetable or fruit intake (Hispanic women and black men).²³
  
• Data from the Chicago Heart Association Detection Project (1967–73, with an average follow-up of 31 years) showed that in younger women (ages 18–39) with favorable levels for all 5 major risk factors (blood pressure, serum cholesterol, BMI, diabetes and smoking), future incidence of CHD and CVD is rare, and long-term and all-cause mortality are much lower compared with those who have unfavorable or elevated risk factor levels at young ages. Similar findings applied to men in this study.^24,25
  
• Data from the BRFSS study of the CDC showed that in adults age 18 and over, disparities in CVD health 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.²⁶
  
• In respondents ages 18–74, data from the 2000 BRFSS study showed the prevalence of Healthy Lifestyle Characteristics (HLC) was as follows: nonsmoking, 76.0%; healthy weight, 40.1%; 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 HLCs) was only 3%, with little variation among subgroups.²⁷
  
• Analysis of 5 cross-sectional, nationally representative surveys, from NHES 1960–62 to NHANES 1999–2000, showed that the prevalence of key risk factors, ie, high cholesterol, high blood pressure, 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.²⁸
  
• The aging of the population will undoubtedly result in an increased incidence of chronic diseases, including coronary artery disease, heart failure and stroke.²⁹

     –The US Census estimates that there will be 40 million Americans age 65 and older in 2010.
  

     –There’s 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.
  

  
  

Hospital/Physician/Nursing Home Visits

• From 1979–2003, the number of discharges from short-stay hospitals with CVD as the first listed diagnosis increased 31%. In 2003, CVD ranked highest among all disease categories in hospital discharges.³⁰
  
• In 2003, there were 70 681 000 physician office visits with a primary diagnosis of CVD.³¹
  
• In 2003, there were 4 497 000 visits to emergency departments with a primary diagnosis of CVD.³²
  
• 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.³³
  
• In 2002, there were 6 024 000 outpatient department visits with a primary diagnosis of CVD.³⁴
  

Cost

• The estimated direct and indirect cost of CVD for 2006 is $403.1 billion.
  
• In 2001, $29.3 billion in program payments were made to Medicare beneficiaries discharged from short-stay hospitals with a principal diagnosis of cardiovascular disease. That was an average of $8 354 per discharge.³⁵
  
• 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 percent increase in total healthcare spending for each condition from 1987–2000. The following are some of the top 15 conditions, by order of rank, and their percentage impact on health care 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%.³⁶
  

Operations and Procedures

• In 2003, an estimated 6 821 000 inpatient cardiovascular operations and procedures were performed in the United States; 3.9 million were performed on males and 2.9 million were performed on females.
  

View this table: [in this window] [in a new window]   CHART 2S. 2002 Age-Adjusted Death Rates for Total Cardiovascular Disease, Coronary Heart Disease and Stroke by State (includes District of Columbia and Puerto Rico)

	3. Coronary Heart Disease, Acute Coronary Syndrome and Angina Pectoris

Top Table of Contents 1. About These Statistics 2. Cardiovascular Diseases 3. Coronary Heart Disease,... 4. Stroke 5. High Blood Pressure 6. Congenital Cardiovascular... 7. Heart Failure 8. Other Cardiovascular Diseases 9. Risk Factors High Blood Cholesterol and... Physical Activity Overweight and Obesity Diabetes Mellitus 10. Metabolic Syndrome 11. Nutrition 12. Quality of Care 13. Medical Procedures 14. Economic Cost of... 15. At-a-Glance Summary Tables 16. Glossary Abbreviation Guide 18. References

 
Coronary Heart Disease
(ICD/9 410–414, 429.2) (ICD/10 I20–I25; see Glossary for details and definitions). See Table 3A.

View this table: [in this window] [in a new window]   TABLE 3A. CHD

Prevalence

• Among Americans ages 40–74, NHANES data found the age-adjusted prevalence of self-reported MI and ECG-MI (verified by electrocardiogram) to be higher among men than women, but angina prevalence to be higher in women than 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.³⁸
  

Incidence

• This year an estimated 700 000 Americans will have a new coronary attack and about 500 000 will have a recurrent attack.³⁹ It is estimated that an additional 175 000 silent first heart attacks occur each year.
  
• The estimated incidence of MI (ICD/9 410) (ICD/10 I21, I22) is 565 000 new attacks and 300 000 recurrent attacks annually.³⁹
  
• The average age of a person having a first heart attack is 65.8 for men and 70.4 for women (ARIC and CHS, NHLBI).
  
• Based on the NHLBI’s FHS in its 44-year follow-up of participants and the 20-year follow-up of their offspring²:

     –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 is 49% for men and 32% for women.⁴⁰
  

     –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.
  

  
  
• In the NHLBI’s ARIC study, average age-adjusted CHD incidence rates per 1000 person-years were: white men, 12.5; black men, 10.6; white women, 4.0; and black women, 5.1. Incidence rates excluding revascularization procedures were: 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.⁴¹
  
• The annual rates per 1000 population of first heart attack (MI or CHD death) in non-black men are 19.2 for ages 65–74, 28.3 for ages 75–84, and 50.6 for age 85 and older. For non-black women in the same age groups the rates are 6.8, 14.2 and 33.2, respectively. For black men the rates are 21.6, 27.9 and 57.1, and for black women the rates are 8.6, 17.6 and 24.8, respectively (CHS [1989–2000], NHLBI).
  
• Combining the rates for possible and definite CHD shows that 17 to 25 of every 100 American Indian men ages 45–74 had some evidence of heart disease.³
  
• Among American Indians ages 65–74, the annual rates per 1000 population of new and recurrent heart attacks are 7.6 for men and 4.9 for women (SHS [1989-2002], NHLBI).
  
• CHD rates in women after menopause are 2–3 times those of women the same age before menopause.⁴²
  

Mortality
CHD caused 1 of every 5 deaths in the United States in 2003. CHD mortality as an underlying or contributing cause of death—653 000. MI mortality as an underlying or contributing cause of death—221 000.

• 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 40% of the people who experience a coronary attack in a given year will die from it.
  
• A study of 1275 HMO enrollees ages 50–79 who had cardiac arrest (CA), showed the incidence of out-of-hospital CA was 6.0/1000 subject-years in subjects with any clinically recognized heart disease compared to 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 heart failure.⁴³
  
• An analysis of data from the FHS from 1950–99 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.⁴⁴
  
• From 1993–2003, the death rate from CHD declined 30.2%, but the actual number of deaths declined only 14.7%. In 2003, the overall CHD death rate was 162.6 per 100 000 population. The death rates were 209.2 for white males and 241.1 for black males; for white females the rate was 125.1 and for black females it was 160.3. The 2002 death rates for CHD were 138.3 for Hispanics or Latinos, 114.0 for American Indians or Alaska Natives, and 98.6 for Asians or Pacific Islanders (Health, United States, 2004).
  
• Over 83% of people who die of CHD are age 65 or older (CDC/NCHS).
  
• The estimated average number of years of life lost due to a heart attack is 14.2 (NHLBI).
  
• Based on data from the FHS study of the NHLBI²:

     –25% of men and 38% of women will die within 1 year after having an initial recognized MI. In part because women have heart attacks at older ages than men do, they’re more likely to die from them within a few weeks. Almost half of men and women under age 65 who have a heart attack (MI) die within 8 years.
  

     –50% 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 3–4 times higher in men than in women. However, this disparity decreases with advancing age.
  

     –People who’ve had a heart attack have a sudden death rate that’s 4–6 times that of the general population.
  

     –Sudden cardiac death accounts for 19% of sudden deaths in children between 1 and 13 years of age and 30% between 14 and 21 years of age. The overall incidence is low, 600 cases per year.
  

  
  
• According to data from the National Registry of Myocardial Infarction⁴⁵:

     –From 1990–1999, in-hospital AMI mortality declined from 11.2% to 9.4%.⁴⁶
  

     –Mortality increases for every 30 minutes that elapse before a patient with ST-segment elevation is recognized and treated.⁴⁷
  

     –The median door-to-drug time for thrombolytic therapy was reduced by nearly half, from 61.8 minutes to 37.8 minutes, during the NRMI data collection used in this study. However, many hospitals are still working to meet the goal of 30 minutes set in 1991 (www.nrmi.org).
  

     –Women under 50 are twice as likely to die after an AMI than men in the same age group.⁴⁸
  

  
  

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 blood pressure-lowering drugs, current cigarette use, and clinical report of diabetes.⁴⁹
  
• According to a case-control study of 52 countries (INTERHEART), 9 easily measured and potentially modifiable risk factors account for over 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, making the study applicable worldwide. These 9 risk factors include cigarette smoking, abnormal blood lipid levels, hypertension, diabetes, abdominal obesity, a lack of physical activity, low daily fruit and vegetable consumption, alcohol overconsumption, and psychosocial index.⁵⁰
  
• A study of over 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%.⁵¹
  
• Low CHD risk is defined as blood pressure <120/80 mm Hg, cholesterol <200 mg/dL and not currently smoking. Age-adjusted prevalence was estimated in nondiabetic persons without a history of MI participating in 4 NHANES surveys conducted in 1971–75, 1976–80, 1988–94, and 1999–2000.⁵²

     –The prevalence of low risk rose from 6% in 1971–75 to 17% in 1988–94 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 1971–75); 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 65–74 (3%) and was progressively greater at younger ages (29% at ages 25–34), with similar increases in prevalence over time across age groups.
  

     –The greatest changes in the components of low risk from 1971–2000 were in prevalence of favorable diastolic blood pressure (from 38% to 71%), compared to favorable systolic blood pressure (from 32% to 47%), nonsmoking (from 60% to 79%), and favorable cholesterol (from 33% to 46%).
  

  
  
• Taking into account CHD risk factors in combination provides a very potent predictor of 10-year risk of CHD compared with individual risk factors. Among participants ages 20–79 in the NHANES III study of the CDC/NCHS, without self-reported CHD, stroke, peripheral vascular disease and diabetes, 81.7% had a 10-year risk for CHD of <10%, 15.5% had a risk of 10–20%, and 2.9% had a risk of >20%. Among participants age 60 and over, 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 of >20% increased with advancing age and was higher among men than women but varied little with race or ethnicity.⁵³
  
• A study of NH white persons, ages 35–74, in the Framingham Heart Study 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 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.⁵⁴
  

Aftermath

• Depending on their gender and clinical outcome, people who survive the acute stage of a heart attack have a chance of illness and death that’s 1.5–15 times higher than that of the general population. The risk of another heart attack, sudden death, AP, HF and stroke—for both men and women—is substantial (FHS, NHLBI).²
  
• A study conducted by the Mayo Clinic found that cardiac rehabilitation after a heart attack 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– 69-year-olds and 81% of those under age 60.⁵⁵
  
• Within 6 years after a recognized heart attack (MI) (FHS, NHLBI)²...

     –18% of men and 35% of women will have another heart attack.
  

     –7% of men and 6% of women will experience sudden death.
  

     –About 22% of men and 46% of women will be disabled with heart failure.
  

     –8% of men and 11% of women will have a stroke.
  

  
  

Hospital Discharges

• From 1979–2003, the number of discharges from short-stay hospitals with CHD as the first listed diagnosis increased 16% (National Hospital Discharge Survey, CDC/NCHS).
  
• From 1990–99, the median duration of hospital stay related to acute myocardial infarction dropped from 8.3 days to 4.3 days, according to an analysis of the NRMI. Findings were similar for both patients receiving primary PTCA and those receiving thrombolytic therapy.⁴⁶
  
• Data from Ambulatory Care Visits to Physician Offices, Hospital Outpatient Departments, and Emergency Departments: US, 1999–2000, showed the number of visits for CHD were 12.2 million.⁵⁶
  

Awareness of Warning Signs and Risk Factors for Heart Disease

• Surveys conducted by the AHA between 1997 and 2003 showed the 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.⁵⁷
  
• 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 2000.⁵⁷
  
• In 1997, a telephone survey of 1000 US households found that only 8% of women respondents identified heart disease as their greatest health concern; less than 33% identified heart disease as the leading cause of death.⁵⁸
  
• Data from the Women Veteran Cohort, age 35 and over, showed 42% of women were concerned about heart disease. Only 8–20% were aware that coronary artery disease (CAD) is the major cause of death for women.⁵⁹
  
• Data from the 2001 BRFSS study of the CDC showed that 95% of respondents recognized chest pain as a heart attack symptom. However, only 11% correctly classified all symptoms and knew to call 911 when someone was having a heart attack. This random digit-dialed telephone survey was conducted in 17 states and the US Virgin Islands.⁶⁰
  
• 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, and blood cholesterol/high-fat diet as CVD risk factors, while there was a decrease in the identification of overweight and blood pressure.⁶¹
  
• Three population-based cross-sectional surveys in 2 northern California cities were conducted between 1980 and 1990. Significant differentials in baseline knowledge widened over the 10-year period. Individuals with less than 12 years of education had only slight improvement in their knowledge of CVD risk factors; those with more than 16 years of education had twice as much improvement. There were similar time-effect disparities in knowledge of risk-reduction strategies. In contrast, interest in risk modification was high for all educational groups and remained uniform across time.⁶²
  
• A national study of physician awareness and adherence to CVD prevention guidelines, conducted in late 2004, showed that fewer than 1 in 5 physicians knew that more women than men die each year from CVD.⁶³
  
• A recent community surveillance study in 4 US communities reported that in 2000, the overall proportion of persons with delays from onset of symptoms of acute MI to hospital arrival of 4 or more hours was 49.5%. The study also reported that there was no statistically significant change in the proportion of patients delaying 4 or more hours from 1987–2000, indicating 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 emergency medical services increased over this period from 37% in 1987 to 55% in 2000, the total time between onset and hospital arrival did not change appreciably.⁶⁴
  

Cost

• In 2006, the estimated direct and indirect cost of CHD is $142.5 billion.
  
• In 2001, $11.6 billion was paid to Medicare beneficiaries for CHD ($11 201 per discharge for acute MI; $11 308 per discharge for coronary atherosclerosis; and $3513 per discharge for other ischemic heart disease).³⁵
  

Operations and Procedures

• In 2003, an estimated 1 244 000 inpatient angioplasty procedures, 467 000 inpatient bypass procedures, 1 414 000 inpatient diagnostic cardiac catheterizations, 64 000 inpatient implantable defibrillators and 197 000 inpatient pacemaker procedures were performed in the United States.
  

Acute Coronary Syndrome (ACS)
(ICD/9 codes 410, 411)

The term "acute coronary syndrome" (ACS) is increasingly used to describe patients who present with either acute MI or UA. (UA is chest pain or discomfort that’s unexpected and usually occurs while at rest. The discomfort may be more severe and prolonged than typical angina or be the first time a person has angina.)

• A conservative estimate for the number of discharges with ACS from hospitals in 2003 is 879 000. Of these, an estimated 497 000 are male and 382 000 are female. This estimate is derived by adding the first listed hospital discharges for myocardial infarction (767 000) to those for unstable angina (112 000) (CDC/NCHS).
  
• When including secondary discharge diagnoses, the corresponding number of hospital discharges was 1 555 000 unique hospitalizations for ACS, 946 000 for MI, and 650 000 for UA (31 000 hospitalizations received both diagnoses) (CDC/NCHS).
  

Decisions regarding 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 troponins, as follows:

• ST elevation myocardial infarction (STEMI)
  
• non-ST elevation myocardial infarction
  
• unstable angina
  

Studies evaluating the percentage of ACS patients who have STEMI range from 30–45%.⁶⁵ These are only preliminary estimates, in part because of dramatically changing practices in the unstable angina discharge diagnosis in the past decade. Factors affecting the UA diagnosis include changes in reimbursement policies, the advent of more sensitive assays for myocardial injury (leading to increased diagnosis of MI over UA), and greater care of patients in same-day "chest pain units" and same-day catheterization procedures.

• A study of over 1300 elderly patients admitted to all intensive cardiovascular care units (CCUs) and cardiology departments in Israel, showed the mean age of women versus men was comparable. Comorbidities were more frequent in women, whereas previous coronary disease and typical anginal pain on admission were more frequent in men. Medical treatment and revascularization procedures during the index hospitalization were comparable. Crude and covariate-adjusted mortality rates were higher in women at 7 days, but not at 6 months. This difference was attributed to ST elevation (STE)-ACS in women versus men. Seven-day mortality rates were higher in patients with STE-ACS who were denied coronary angiography, especially women.⁶⁶
  

Angina Pectoris
(ICD/9 413) (ICD/10 I20). See Table 3B.

View this table: [in this window] [in a new window]   TABLE 3B. Angina Pectoris

Prevalence

• A study of 4 national cross-sectional health examination studies found that, among Americans ages 40–74, the age-adjusted prevalence of AP was higher among women than men. Increases in the prevalence of AP occurred for Mexican-American men and women, and African-American women, but were not statistically significant for the latter.³⁸
  

Incidence

• Only 20% of coronary attacks are preceded by long-standing angina.²
  
• The annual rates per 1000 population of new and recurrent episodes of angina for non-black men are 44.3 for ages 65–74, 56.4 for ages 75–84, and 42.6 for age 85 and older. For non-black women in the same age groups the rates are 18.8, 30.8 and 19.8, respectively. For black men the rates are 26.1, 52.2 and 43.5, and for black women the rates are 29.4, 37.7 and 15.2, respectively (CHS, NHLBI).
  

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

	4. Stroke

Top Table of Contents 1. About These Statistics 2. Cardiovascular Diseases 3. Coronary Heart Disease,... 4. Stroke 5. High Blood Pressure 6. Congenital Cardiovascular... 7. Heart Failure 8. Other Cardiovascular Diseases 9. Risk Factors High Blood Cholesterol and... Physical Activity Overweight and Obesity Diabetes Mellitus 10. Metabolic Syndrome 11. Nutrition 12. Quality of Care 13. Medical Procedures 14. Economic Cost of... 15. At-a-Glance Summary Tables 16. Glossary Abbreviation Guide 18. References

 
(ICD/9 430–438) (ICD/10 I60–I69). See Table 4A.⁶⁸

View this table: [in this window] [in a new window]   TABLE 4A. Stroke

Prevalence

• From the early 1970s to the early 1990s, the estimated number of noninstitutionalized stroke survivors increased from 1.5 million to 2.4 million.⁶⁹
  
• The prevalence of stroke in American Indian men ages 45–74 ranges from 0.2–1.4% and in women from 0.2–0.7%.³
  
• 1999–2003 data from the NHIS study of the CDC/NCHS showed that 3.6% of American Indians/Alaska Natives, age 18 and over, have had a stroke. Among blacks or African Americans it was 3.3%, among whites it was 2.2%, and among Asians it was 2.0%.⁷⁰
  
• 2003 data from the BRFSS survey of the CDC showed a higher prevalence of stroke in 10 southeastern states than in 13 non-southeastern states and the District of Columbia. Prevalence was higher in blacks than in whites. The highest age-adjusted prevalence of stroke was among southeastern blacks, followed by non-southeastern blacks, southeastern whites and non-southeastern whites.⁷¹
  
• The prevalence of silent cerebral infarction between ages 55–64 is about 11%. This prevalence increases to 22% between ages 65 and 69, 28% between ages 70 and 74, 32% between ages 75 and 79, 40% between ages 80 and 85, and 43% above age 85. Applying these rates to 1998 US population estimates results in an estimated 13 million people with prevalent silent stroke.^71a,71b
  

Transient Ischemic Attack (TIA)

• The prevalence of transient ischemic attacks (TIA) in men is 2.7% for ages 65–69 and 3.6% for ages 75–79. (A TIA, or transient ischemic attack, is a mini-stroke that lasts less than 24 hours.) For women, TIA prevalence is 1.6% for ages 65–69 and 4.1% for ages 75–79.⁷²
  
• Approximately 15% of all strokes are heralded by a TIA.⁷³
  
• A third of spells characterized as TIAs using the classic definition (focal neurological deficits resolving within 24 hours) would be considered infarctions based on diffusion- weighted MRI findings.⁷⁴
  
• In population-based studies, the age and gender adjusted incidence rates for TIA range from 68.2–83/100 000. Males and blacks have higher rates of TIA.^75,76 Approximately half of patients who experience a TIA fail to report it to their healthcare providers.^77,78
  
• After TIA, the 90-day risk of stroke is 3–17.3%, highest within the first 30 days.^{75–77,79,80}
  
• Within a year of TIA, up to a quarter of patients will die.^76,81
  
• Individuals who have a TIA have a 10-year stroke risk of 18.8%, and a combined 10-year stroke, MI or vascular death risk of 42.8% (4% a year).⁸²
  
• In the North American Symptomatic Carotid Endarterectomy Trial (NASCET) study, patients with a first-ever hemispheric TIA had a 90-day stroke risk of 20.1%. The risk of stroke after TIA exceeded the risk after hemispheric stroke.⁸³
  

Incidence

• Each year about 700 000 people experience a new or recurrent stroke. About 500 000 of these are first attacks, and 200 000 are recurrent attacks (GCNKSS, FHS, ARIC).
  
• On average, every 45 seconds someone in the United States has a stroke.
  
• Each year, about 46 000 more women than men have a stroke (GCNKSS).
  
• Men’s stroke incidence rates are 1.25 times greater than women’s. The difference in incidence rates between the sexes is somewhat higher at younger ages but nonexistent at older ages. The male/female incidence was 1.59 for ages 65–69; 1.46 for ages 70–74; 1.35 for ages 75–79 and 0.74 for age 80 and older (CHS, NHLBI).
  
• Of all strokes, 88% are ischemic, 9% are intracerebral hemorrhage, and 3% are subarachnoid hemorrhage (GCNKSS, FHS, ARIC).
  
• Blacks have almost twice the risk of first-ever stroke compared with whites. The age-adjusted stroke incidence rates (per 100 000) for first-ever strokes are 167 for white males, 138 for white females, 323 for black males and 260 for black females (GCNKSS, FHS, ARIC).
  
• The Brain Attack Surveillance in Corpus Christi project (BASIC) clearly demonstrated an increased incidence of stroke among Mexican Americans compared with NH whites in this community. The crude cumulative incidence was 168/10 000 in Mexican Americans and 136/10 000 in NH whites. Specifically, Mexican Americans have an increased incidence of intracerebral hemorrhage and subarachnoid hemorrhage compared with NH whites adjusted for age, as well as an increased incidence of ischemic stroke and TIA at younger ages when compared with NH whites.⁸⁶
  
• The age-adjusted annual incidence rate (per 1000) for total stroke in Japanese-American men has declined markedly from 5.1 to 2.4; for thromboembolic stroke, from 3.5 to 1.9; and for hemorrhagic stroke, from 1.1 to 0.6. The estimated average annual declines are 5% for total stroke, 3.5% for thromboembolic stroke, and 4.3% for hemorrhagic stroke. The decline in stroke mortality in the Honolulu Heart Program (HHP) target population was similar to that reported for US white males ages 60–69 during the same period (during the 1969–88 follow-up period of the HHP, NHLBI).
  
• Among American Indians ages 65–74, the annual rates per 1000 population of new and recurrent strokes are 6.1 for men and 6.6 for women (SHS [1989–2002], NHLBI).
  
• Data from the Northern Manhattan Study showed the age-adjusted incidence of first ischemic stroke per 100 000 was 88 in whites, 149 in Hispanics and 191 in blacks. Among blacks compared with whites, the relative rate of intracranial atherosclerotic stroke was 5.85; extracranial atherosclerotic stroke, 3.18; lacunar stroke, 3.09; and cardioembolic stroke, 1.58. Among Hispanics compared with whites, the relative rate of intracranial atherosclerotic stroke was 5.00; extracranial atherosclerotic stroke, 1.71; lacunar stroke, 2.32; and cardioembolic stroke, 1.42.⁸⁷
  

Mortality
Stroke accounted for about 1 of every 15 deaths in the United States in 2003. About 50% of these deaths occurred out of hospital. Stroke as an underlying or contributing cause of death—about 273 000.

• When considered separately from other cardiovascular diseases, stroke ranks No. 3 among all causes of death, behind diseases of the heart and cancer (CDC/NCHS).
  
• On average, about every 3 minutes someone dies of a stroke.
  
• Eight to 12% of ischemic strokes and 37–38% of hemorrhagic strokes result in death within 30 days.⁸⁸
  
• From 1993–2003, the stroke death rate fell 18.5%, and the actual number of stroke deaths declined 0.7% (CDC/NCHS).
  
• The 2003 overall death rate for stroke was 54.3. Death rates were 51.9 for white males and 78.8 for black males; for white females it was 50.5 and for black females it was 69.1.
  
• 2002 age-adjusted death rates for stroke were 44.3 for Hispanic or Latino males and 38.6 for females; 50.8 for Asian or Pacific Islander males and 45.4 for females; and 37.1 for American Indians or Alaska Native males and 38.0 for females (Health, United States, 2004, CDC/NCHS).
  
• Because women live longer than men, more women than men die of stroke each year. Women accounted for 6