Death Rates From CVD Have Declined, Yet the Burden of Disease Remains High

• The 2006 overall death rate from CVD (International Classification of Diseases 10, I00–I99) was 262.5 per 100 000. The rates were 306.6 per 100 000 for white males, 422.8 per 100 000 for black males, 215.5 per 100 000 for white females, and 298.2 per 100 000 for black females. From 1996 to 2006, death rates from CVD declined 29.2%. Mortality data for 2006 show that CVD (I00–I99; Q20–Q28) accounted for 34.3% (831 272) of all 2 426 264 deaths in 2006, or 1 of every 2.9 deaths in the United States.

• On the basis of 2006 mortality rate data, nearly 2300 Americans die of CVD each day, an average of 1 death every 38 seconds. The 2007 overall preliminary death rate from CVD was 250.4. More than 151 000 Americans killed by CVD (I00–I99) in 2006 were <65 years of age. In 2006, nearly 33% of deaths due to CVD occurred before the age of 75 years, which is well before the average life expectancy of 77.7 years.

• Coronary heart disease caused approximately 1 of every 6 deaths in the United States in 2006. Coronary heart disease mortality in 2006 was 425 425. In 2010, an estimated 785 000 Americans will have a new coronary attack, and approximately 470 000 will have a recurrent attack. It is estimated that an additional 195 000 silent first myocardial infarctions occur each year. Approximately every 25 seconds, an American will have a coronary event, and approximately every minute, someone will die of one.

• Each year, approximately 795 000 people experience a new or recurrent stroke. Approximately 610 000 of these are first attacks, and 185 000 are recurrent attacks. Mortality data from 2006 indicate that stroke accounted for approximately 1 of every 18 deaths in the United States. On average, every 40 seconds, someone in the United States has a stroke. From 1996 to 2006, the stroke death rate fell 33.5%, and the actual number of stroke deaths declined 18.4%.

• In 2006, 1 in 8.6 death certificates (282 754 deaths) in the United States mentioned heart failure.

Prevalence and Control of Traditional Risk Factors Remains an Issue for Many Americans

• Data from the National Health and Nutrition Examination Survey (NHANES) 2003–2006 indicate that 33.6% of US adults ?20 years of age have hypertension (Table 6-1). This amounts to an estimated 74 500 000 US adults with hypertension. The prevalence of hypertension is nearly equal between men and women. African-American adults have among the highest rates of hypertension in the world, at >43%. Among hypertensive adults, approximately 78% are aware of their condition, 68% are using antihypertensive medication, and only 44% of those treated had their hypertension controlled.

• Despite 4 decades of progress, in 2008, among Americans ?18 years of age, 23.1% of men and 18.3% of women continued to be cigarette smokers. In grades 9 through 12, 21.3% of male students and 18.7% of female students reported current tobacco use. The percentage of the nonsmoking population with detectable serum cotinine (indicating exposure to secondhand smoke) was 46.4% in 1999–2004 and was highest for those 4 to 11 years of age (60.5%) and those 12 to 19 years of age (55.4%).

• An estimated 35 700 000 adults ?20 years of age have total serum cholesterol levels ?240 mg/dL, with a prevalence of 16.2% (Table 11-1).

• In 2006, an estimated 17 200 000 Americans had diagnosed diabetes, representing 7.7% of the adult population. A further 6 100 000 had undiagnosed diabetes, and 29% had prediabetes, with abnormal fasting glucose levels. African-Americans, Mexican-Americans, Hispanic/Latino individuals, and other ethnic minorities bear a strikingly disproportionate burden of diabetes in the United States (Table 14-1).

The 2010 Update Expands Data Coverage of the Obesity Epidemic and Its Antecedents and Consequences

• The estimated prevalence of overweight and obesity in US adults (?20 years of age) is 144 100 000, which represents 66.3% of this group in 2006. Fully 32.9% of US adults are obese (body mass index ?30 kg/m²). Men and women of all race/ethnic groups in the population are affected by the epidemic of overweight and obesity (Table 13-1).

• Among children 2 to 19 years of age, 31.9% are overweight and obese (which represents 23 500 000 children), and 16.3% are obese (12 000 000 children). Mexican-American boys and girls and African-American girls are disproportionately affected. Over the last 3 decades, the prevalence of obesity in children 6 to 11 years of age has increased from approximately 4% to more than 17%.

• Although there is some debate regarding the amount of excess mortality associated with overweight, it is clear that obesity (body mass index ?30 kg/m²) is associated with marked excess mortality in the US population. Even more notable is the excess morbidity associated with overweight and obesity in terms of risk factor development and incidence of diabetes, CVD end points (including coronary heart disease, stroke, and heart failure), and numerous other health conditions, including asthma, cancer, degenerative joint disease, and many others.

• The prevalence of diabetes is increasing dramatically over time, in parallel with the increases in prevalence of overweight and obesity.

• On the basis of NHANES 2003–2006 data, the age-adjusted prevalence of metabolic syndrome, a cluster of major cardiovascular risk factors related to overweight/obesity and insulin resistance, is 34% (35.1% among men and 32.6% among women).

• The proportion of youth (?18 years of age) who report engaging in no regular physical activity is high, and the proportion increases with age. In 2007, among adolescents in grades 9 through 12, 31.8% of females and 18% of males reported that they had not engaged in 60 minutes of moderate-to-vigorous physical activity, defined as any activity that increased heart rate or breathing rate, even once in the previous 7 days, despite recommendations that children engage in such activity ?5 days per week.

• Fifty-nine percent of adults who responded to the 2008 National Health Interview Survey reported engaging in no vigorous activity (activity that causes heavy sweating and a large increase in breathing or heart rate).

• Data from NHANES indicate that between 1971 and 2004, average total energy consumption among US adults increased by 22% in women (from 1542 to 1886 kcal/d) and by 10% in men (from 2450 to 2693 kcal/d; see Chart 17-1).

• The increases in calories consumed during this time period are attributable primarily to greater average carbohydrate intake, particularly of starches, refined grains, and sugars. Other specific changes related to increased caloric intake in the United States include larger portion sizes, greater food quantity and calories per meal, and increased consumption of sugar-sweetened beverages, snacks, commercially prepared (especially fast food) meals, and higher energy-density foods.

The 2010 Update Provides Critical Data Regarding Cardiovascular Quality of Care, Procedure Utilization, and Costs

In light of the current national focus on healthcare utilization, costs, and quality, it is critical to monitor and understand the magnitude of healthcare delivery and costs, as well as the quality of healthcare delivery, related to CVDs. The Update provides these critical data in several sections.

Disease Prevalence

Prevalence is an estimate of how many people have a disease at a given point or period in time. The NCHS conducts health examination and health interview surveys that provide estimates of the prevalence of diseases and risk factors. In this Update, the health interview part of the NHANES is used for the prevalence of cardiovascular diseases (CVDs). 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 for total CVD, including 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 realistic estimate of burden. Most estimates based on NHANES prevalence rates are based on data collected from 2003 to 2006 (in most cases, these are the latest published figures). These are applied to census population estimates for 2006. Differences in population estimates based on extrapolations of rates beyond the data collection period by use of more recent census population estimates cannot be used to evaluate possible trends in prevalence. Trends can only be evaluated by comparing prevalence rates estimated from surveys conducted in different years.

Risk Factor Prevalence

The NHANES 2003 to 2006 data are used in this Update to present estimates of the percentage of persons with high lipid values, diabetes, overweight, and obesity. The NHIS is used for the prevalence of cigarette smoking and physical inactivity. Data for students in grades 9 through 12 are obtained from the YRBS.

Incidence and Recurrent Attacks

An incidence rate refers to the number of new cases of a disease that develop in a population per unit of time. The unit of time for incidence is not necessarily 1 year, although we often discuss incidence in terms of 1 year. For some statistics, new and recurrent attacks or cases are combined. Our national incidence estimates for the various types of CVD are extrapolations to the US population from the Framingham Heart Study (FHS), the Atherosclerosis Risk in Communities (ARIC) study, and the Cardiovascular Health Study (CHS), all conducted by the NHLBI, as well as the GCNKSS, which is funded by the NINDS. The rates change only when new data are available; they are not computed annually. Do not compare the incidence or the rates with those in past editions of the Heart Disease and Stroke Statistics Update (also known as the Heart and Stroke “Statistical” Update for editions before 2005). Doing so can lead to serious misinterpretation of time trends.

Mortality

Mortality data are presented according to the underlying cause of death. “Any-mention” mortality means that the condition was nominally selected as the underlying cause or was otherwise mentioned on the death certificate. For many deaths classified as attributable to CVD, selection of the single most likely underlying cause can be difficult when several major comorbidities are present, as is often the case in the elderly population. It is useful, therefore, to know the extent of mortality due to a given cause regardless of whether it is the underlying cause or a contributing cause—ie, its “any-mention” status. The number of deaths in 2006 with any mention of specific causes of death was tabulated by the NHLBI from the NCHS public-use electronic files on mortality.

The first set of statistics for each disease in this Update includes the number of deaths for which the disease is the underlying cause. Two exceptions are Chapter 7 (Hypertension) and Chapter 9 (Heart Failure). Hypertension increases the mortality risks of CVD and other diseases, and HF is selected as an underlying cause only when the true underlying cause is not known. In this Update, hypertension and HF death rates are presented in 2 ways: (1) As nominally classified as the underlying cause and (2) as any-mention mortality.

National and state mortality data presented according to the underlying cause of death were computed from the Data Warehouse mortality tables of the NCHS World Wide Web site, the Health Data Interactive data system of the NCHS, or the CDC compressed file. Any-mention numbers of deaths were tabulated from the electronic mortality files of the NCHS World Wide Web site and from Health Data Interactive.

Population Estimates

In this publication, we have used national population estimates from the US Census Bureau for 2006 in the computation of morbidity data. NCHS population estimates for 2006 were used in the computation of death rate data. The Census Bureau World Wide Web site¹ contains these data, as well as information on the file layout.

Hospital Discharges and Ambulatory Care Visits

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

International Classification of Diseases

Morbidity (illness) and mortality (death) data in the United States have a standard classification system: the International Classification of Diseases (ICD). Approximately 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 the NCHS are applied as noted.² Effective with mortality data for 1999, we are using the 10th revision (ICD-10). It will be a few more years before the 10th revision is used for hospital discharge data and ambulatory care visit data, which are based on the International Classification of Diseases, Clinical Modification, 9th Revision (ICD-9-CM).³

Age Adjustment

Prevalence and mortality estimates for the United States or individual states comparing demographic groups or estimates over time either are age specific or are age adjusted to the 2000 standard population by the direct method.⁴ International mortality data are age adjusted to the European standard.⁵ Unless otherwise stated, all death rates in this publication are age adjusted and are deaths per 100 000 population.

Data Years for National Estimates

In this Update, we estimate the annual number of new (incidence) and recurrent cases of a disease in the United States by extrapolating to the US population in 2006 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 2006. For disease and risk factor prevalence, most rates in this report are calculated from the 2003 to 2006 NHANES. Rates by age and sex are also applied to the US population in 2006 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 2006, recognizing that this probably underestimates the 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 2006. Numbers of visits to physician offices, hospital EDs, and hospital OPDs are for 2007. Except as noted, economic cost estimates are projected to 2010.

Cardiovascular Disease

For data on hospitalizations, physician office visits, and mortality, CVD is defined according to ICD codes given in Chapter 22 of the present document. This definition includes all diseases of the circulatory system, as well as congenital CVD. Unless so specified, an estimate for total CVD does not include congenital CVD.

Race

Data published by governmental agencies for some racial groups are considered unreliable because of the small sample size in the studies. Because we try to provide data for as many racial groups as possible, we show these data for informational and comparative purposes.

Contacts

If you have questions about statistics or any points made in this Update, please contact the Biostatistics Program Coordinator at the American Heart Association National Center (e-mail 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 World Wide Web site, http://www.americanheart.org/statistics, and in the journal Circulation.

Prevalence

An estimated 81 100 000 American adults (more than 1 in 3) have 1 or more types of CVD. Of these, 38 100 000 are estimated to be ?60 years of age. Total CVD includes diseases listed in the bullet points below, except for congenital CVD. Because of overlap, it is not possible to add these conditions to arrive at a total.

• High BP (HBP)—74 500 000 (defined as systolic pressure ?140 mm Hg and/or diastolic pressure ?90 mm Hg, use of antihypertensive medication, or being told at least twice by a physician or other health professional that one has HBP).

• Coronary heart disease (CHD)—17 600 000.

  •    —MI (heart attack)—8 500 000.

  •    —AP (chest pain)—10 200 000.

• Heart failure (HF)—5 800 000.

• Stroke—6 400 000.

• Congenital cardiovascular defects—650 000 to 1 300 000 (see Chapter 7).

The following age-adjusted prevalence estimates from the NHIS, NCHS are for diagnosed conditions for people ?18 years of age in 2008¹:

• Among whites only, 12.1% have heart disease (HD), 6.5% have CHD, 23.3% have hypertension, and 2.7% have had a stroke.

• Among blacks or African Americans, 10.2% have HD, 5.6% have CHD, 31.8% have hypertension, and 3.6% have had a stroke.

• Among Hispanics or Latinos, 8.1% have HD, 5.7% have CHD, 21.0% have hypertension, and 2.6% have had a stroke.

• Among Asians, 5.2% have HD, 2.9% have CHD, 21.0% have hypertension, and 1.8% have had a stroke.

• Among American Indians or Alaska Natives, 12.1% have HD, 6.6%* have CHD, 25.3% have hypertension, and 3.9% have had a stroke.*

• Among Native Hawaiians or other Pacific Islanders, HD, CHD, and stroke numbers are not reported because of large relative standard errors; 19.7%* have hypertension.

• Asian Indian adults (9%) are approximately 2-fold more likely than Korean adults (4%) to have ever been told they have HD.²

Incidence

• On the basis of the NHLBI’s FHS original and offspring cohort data from 1980 to 2003³:

  •    —The average annual rates of first cardiovascular (CVD) events rise from 3 per 1000 men at 35 to 44 years of age to 74 per 1000 men at 85 to 94 years of age. For women, comparable rates occur 10 years later in life. The gap narrows with advancing age.

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

• Among American Indian men 45 to 74 years of age, the incidence of CVD ranges from 15 to 28 per 1000 population. Among women, it ranges from 9 to 15 per 1000.⁴

• Data from the FHS indicate that the lifetime risk for all CVD in recipients free of disease is 2 in 3 for men and more than 1 in 2 for women at 40 years of age (personal communication, Donald Lloyd-Jones, MD, Northwestern University, Chicago, Ill) (see Table 2-4).

• Analysis of FHS data among participants free of CVD at 50 years of age 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.⁵

Mortality

ICD-10 I00–I99, Q20–Q28 for CVD (CVD mortality includes congenital cardiovascular defects); C00–C97 for cancer; C33–C34 for lung cancer; C50 for breast cancer; J40–J47 for chronic lower respiratory disease (CLRD); G30 for Alzheimer’s disease; E10–E14 for diabetes; and V01–X59, Y85–Y86 for accidents.

• Mortality data show that CVD (I00–I99, Q20–Q28) as the underlying cause of death (including congenital cardiovascular defects) accounted for 34.3% (831 272) of all 2 426 264 deaths in 2006, or 1 of every 2.9 deaths in the United States. CVD any-mentions (1 347 000 deaths in 2006) constituted approximately 56% of all deaths that year (NHLBI; NCHS public-use data files).⁶ Preliminary 2007 mortality (I00–I99) was 807 485. The preliminary death rate was 250.4 (NCHS).⁷ In every year since 1900 except 1918, CVD accounted for more deaths than any other major cause of death in the United States.^6–11

• Nearly 2300 Americans die of CVD each day, an average of 1 death every 38 seconds. CVD claims more lives each year than cancer, CLRD, and accidents combined.⁶

• The 2006 overall death rate due to CVD (I00–I99) was 262.5. The rates were 306.6 for white males, 422.8 for black males, 215.5 for white females, and 298.2 for black females. From 1996 to 2006, death rates due to CVD (ICD-10 I00–I99) declined 29.2%. In the same 10-year period, the actual number of CVD deaths per year declined 12.9%.⁶ (Appropriate comparability ratios were applied.)

• Among other causes of death in 2006, cancer caused 559 888 deaths; accidents, 121 599; Alzheimer’s disease, 72 432; and HIV (human immunodeficiency virus)/AIDS (acquired immune deficiency syndrome), 12 113.⁶

• The 2006 CVD (I00–I99) death rates were 313.3 for males and 221.6 for females. Death rates for cancer (malignant neoplasms) were 220.1 for males and 153.6 for females. Breast cancer claimed the lives of 40 821 females in 2006; lung cancer claimed 69 385. Death rates for females were 23.5 for breast cancer and 40.0 for lung cancer. One in 30 female deaths was due to breast cancer, whereas 1 in 6 was due to CHD. For comparison, 1 in 4.5 females died of cancer, whereas 1 in 2.8 died of CVD (I00–I99, Q20–Q28). On the basis of 2006 mortality data, CVD caused approximately 1 death per minute among females, or 432 709 female deaths in 2006. That represents more female lives than were claimed by cancer, CLRD, Alzheimer’s disease, and accidents combined.⁶

• More than 151 000 Americans died of CVD (I00–I99) in 2006 who were <65 years of age, and nearly 33% of deaths due to CVD occurred before the age of 75 years, which is well before the average life expectancy of 77.7 years.⁶

• In 2006, death rates for diseases of the heart in American Indians or Alaska Natives were 170.2 for males and 113.2 for females; for Asians or Pacific Islanders, they were 136.3 for males and 87.3 for females; and for Hispanics or Latinos, they were 175.2 for males and 118.9 for females.¹¹

• 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 estimated gain would be 3 years. According to the same study, the probability at birth of eventually dying of major CVD (I00–I78) is 47%, and the chance of dying of cancer is 22%. Additional probabilities are 3% for accidents, 2% for diabetes mellitus (DM), and 0.7% for HIV.¹²

• In 2006, the leading causes of death in women ?65 years of age were diseases of the heart (No. 1), cancer (No. 2), stroke (No. 3), and CLRD (No. 4). In older men, they were diseases of the heart (No. 1), cancer (No. 2), CLRD (No. 3), and stroke (No. 4).^6,13

• A recent study of the decrease in US deaths due to CHD from 1980 to 2000 suggests that approximately 47% of the decrease was attributable to evidence-based medical therapies and 44% to changes in risk factors in the population due to lifestyle and environmental changes.¹⁴

• Analysis of data from NCHS was used to determine the number of disease-specific deaths attributable to all nonoptimal levels of each risk factor exposure, by age and sex. In 2005, tobacco smoking and high BP were responsible for an estimated 467 000 deaths, accounting for approximately 1 in 5 or 6 deaths among US adults. Overweight/obesity and physical inactivity were each responsible for nearly 1 in 10 deaths. High dietary salt, low dietary omega-3 fatty acids, and high dietary trans fatty acids were the dietary risks with the largest mortality effects.¹⁵

Aftermath

• Among an estimated 45 million people with functional disabilities in the United States, HD, stroke, and hypertension are among the 15 leading conditions that caused those disabilities. Disabilities were defined as difficulty with activities of daily living or instrumental activities of daily living, specific functional limitations (except vision, hearing, or speech), and limitation in ability to do housework or work at a job or business.¹⁶

Out-of-Hospital Cardiac Arrest

There is a wide variation in the reported incidence of and outcome for out-of-hospital cardiac arrest. These differences are due in part to differences in definition and ascertainment of cardiac arrest data, as well as differences in treatment after the onset of cardiac arrest. Cardiac arrest is defined as cessation of cardiac mechanical activity and is confirmed by the absence of signs of circulation.¹⁷

• Extrapolation of the mortality rate observed in the Resuscitation Outcomes Consortium to the total population of the United States suggests that each year, there are 295 000 (quasi confidence intervals 236 000 to 325 000) emergency medical services (EMS)–assessed out-of-hospital cardiac arrests in the United States.¹⁸

• Approximately 60% of out-of-hospital cardiac deaths are treated by EMS personnel.¹⁹

• Only 33% of those with EMS-treated out-of-hospital cardiac arrest have symptoms within 1 hour of death.²⁰

• Among EMS-treated out-of-hospital cardiac arrests, 23% have an initial rhythm of ventricular fibrillation (VF), ventricular tachycardia, or shockable by automated external defibrillator (AED); 31% receive bystander cardiopulmonary resuscitation (CPR).¹⁸

• The incidence of cardiac arrest with an initial rhythm of VF is decreasing over time; however, the incidence of cardiac arrest with any initial rhythm is not decreasing.²¹

• The incidence of lay-responder defibrillation is low (2.05% in 2002) but is increasing over time.²²

• If bystander CPR is not provided, a sudden cardiac arrest victim’s chances of survival fall 7% to 10% for every minute of delay until defibrillation.^23–27

• The median survival rate to hospital discharge after EMS-treated out-of-hospital cardiac arrest with any first recorded rhythm is 7.9%.¹⁸

• The median survival rate after VF is 21%.¹⁸

• Extrapolation of data from ARIC, CHS, and Framingham suggests that there are 138 000 CHD deaths within 1 hour of symptom onset (Thomas Thom, NHLBI, written communication, May 20, 2008).

• A study conducted in New York City found the age-adjusted incidence of out-of-hospital cardiac arrest per 10 000 adults was 10.1 among blacks, 6.5 among Hispanics, and 5.8 among whites. The age-adjusted survival to 30 days after discharge was more than twice as poor for blacks as for whites, and survival among Hispanics was also lower than among whites.³⁰

Out-of-Hospital Cardiac Arrest: Children

• The reported incidence of out-of-hospital pediatric cardiac arrest varies widely (approximately 8 per 100 000).³¹

• There are more than 72 million individuals <18 years of age in the United States³²; this implies that there are about 5760 pediatric out-of-hospital cardiac arrests annually of all causes (including trauma, sudden infant death syndrome, respiratory causes, cardiovascular causes, and submersion).

• Seven percent of EMS-treated pediatric cardiac arrest patients had an initial rhythm of VF, ventricular tachycardia, or shockable by AED; 35% received bystander CPR.³¹

• 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.^33,34 Although incomplete, these numbers provide a basis for estimating the number of deaths in this age range.

• One report describes the incidence of nontraumatic pediatric cardiac arrest (among students 3 to 18 years of age) that occurs in schools and estimates rates (per 100 000 person-school-years) for elementary, middle, and high schools to be 0.18, 0.19, and 0.15, respectively, for the geographic area (King County, Washington) and time frame (January 1, 1990, to December 31, 2005) studied.³⁵

• The reported average rate of survival to hospital discharge after pediatric out-of-hospital cardiac arrest is 6%.

• Most sudden deaths in athletes were due to CVD (56%). Of the cardiovascular deaths that occurred, 29% occurred in blacks, 54% in high school students, and 82% with physical exertion during competition/training, and only 11% occurred in females, although this increased over time.³⁶

In-Hospital Cardiac Arrest

• A total of 292 facilities reported 20 913 events to the National Registry for Cardiopulmonary Resuscitation from August 1, 2007, to July 31, 2008.

  •    —The rates of survival to discharge after in-hospital cardiac arrest were 35% among children and 19% among adults. Of these, 95% were monitored or witnessed.

  •    —Eighteen percent had VF or pulseless ventricular tachycardia as the first recorded rhythm. Of these, 78% received a defibrillation attempt within 3 minutes.

• Patients who experience cardiac arrest during the weekday have an absolute 5.6% greater survival than those who experience cardiac arrest during the night or on weekends.

Awareness of CPR

• Seventy-nine percent of the lay public are confident that they know what actions to take in a medical emergency; 98% recognize an AED as something that administers an electrical shock to restore a normal heart beat among victims of sudden cardiac arrest; and 60% are familiar with CPR (Harris Interactive survey conducted on behalf of the AHA among 1132 US residents 18 years of age and older, January 8, 2008, through January 21, 2008).

Awareness of Warning Signs and Risk Factors for CVD

• Surveys conducted by the AHA in 1997, 2000, 2003, and 2006 to evaluate trends in women’s awareness, knowledge, and perceptions related to CVD found that in 2006, awareness of HD as the leading cause of death among women was 57%, significantly higher than in prior surveys. Awareness was lower among black and Hispanic women than among white women, and the racial/ethnic difference has not changed appreciably over time. In 2006, more than twice as many women felt uninformed about stroke compared with HD. Hispanic women were more likely than white women to report that there is nothing they can do to keep themselves from getting CVD. The majority of respondents reported confusion related to basic CVD prevention strategies.³⁸

• A nationally representative sample of women responded to a questionnaire about history of CVD risk factors, self-reported actions taken to reduce risk, and barriers to heart health. According to the study, published in 2006, the rate of awareness of CVD as the leading cause of death had nearly doubled since 1997, was significantly greater for whites than for blacks and Hispanics, and was independently correlated with increased physical activity (PA) and weight loss in the previous year. Fewer than half of the respondents were aware of healthy levels of risk factors. Awareness that their personal level was not healthy was positively associated with preventive action. Most women took steps to lower risk in family members and themselves.³⁹

• A total of 875 students in 4 Michigan high schools were given a survey to obtain data on the perception of risk factors and other knowledge-based assessment questions about CVD. Accidents were rated as the greatest perceived lifetime health risk (39%). Nearly 17% selected CVD as the greatest lifetime risk, which made it the third most popular choice after accidents and cancer. When asked to identify the greatest cause of death for each sex, 42% correctly recognized CVD for men, and 14% correctly recognized CVD for women; 40% incorrectly chose abuse/use behavior with a substance other than cigarettes as the most important CVD risk behavior.⁴⁰

Risk Factors

• Data from the 2003 CDC BRFSS survey of adults ?18 years of age showed the prevalence of respondents who reported having ?2 risk factors for HD and stroke was successively higher at higher age groups. The prevalence of having ?2 risk factors was highest among blacks (48.7%) and American Indians/Alaska Natives (46.7%) and lowest among Asians (25.9%); prevalence was similar in women (36.4%) and men (37.8%). The prevalence of multiple risk factors ranged from 25.9% among college graduates to 52.5% among those with less than a high school diploma (or its equivalent). Persons reporting household income of ?$50 000 had the lowest prevalence (28.8%), and those reporting household income of ?$10 000 had the highest prevalence (52.5%). Adults who reported being unable to work had the highest prevalence (69.3%) of ?2 risk factors, followed by retired persons (45.1%), unemployed adults (43.4%), homemakers (34.3%), and employed persons (34.0%). Prevalence of ?2 risk factors varied by state/territory and ranged from 27.0% (Hawaii) to 46.2% (Kentucky). Twelve states and 2 territories had a multiple-risk-factor prevalence of ?40%: Alabama, Arkansas, Georgia, Indiana, Kentucky, Louisiana, Mississippi, North Carolina, Ohio, Oklahoma, Tennessee, West Virginia, Guam, and Puerto Rico.⁴¹

• Data from the Chicago Heart Association Detection Project (1967 to 1973, with an average follow-up of 31 years) showed that in younger women (18 to 39 years of age) with favorable levels for all 5 major risk factors (BP, serum cholesterol, body mass index [BMI], DM, and smoking), future incidence of CHD and CVD is rare, and long-term and all-cause mortality are much lower than for those who have unfavorable or elevated risk factor levels at young ages. Similar findings applied to men in this study.^42,43

• Analysis of several data sets by the CDC showed that in adults ?18 years of age, disparities were common in all risk factors examined. In men, the highest prevalence of obesity (29.7%) was found in Mexican Americans who had completed a high school education. Black women with or without a high school education had a high prevalence of obesity (48.4%). Hypertension prevalence was high among blacks (41.2%) regardless of sex or educational status. Hypercholesterolemia was high among white and Mexican American men and white women regardless of educational status. CHD and stroke were inversely related to education, income, and poverty status. Hospitalization for total HD and acute MI was greater among men, but hospitalization for congestive heart failure (CHF) and stroke was greater among women. Among Medicare enrollees, CHF hospitalization was higher in blacks, Hispanics, and American Indians/Alaska Natives than among whites, and stroke hospitalization was highest in blacks. Hospitalizations for CHF and stroke were highest in the southeastern United States. Life expectancy remains higher in women than in men and in whites than in blacks by approximately 5 years. CVD mortality at all ages tended to be highest in blacks.⁴⁴

• In respondents 18 to 74 years of age, data from the 2000 BRFSS (CDC) showed the prevalence of healthy lifestyle characteristics was as follows: No smoking, 76.0%; healthy weight, 40.1%; consumption of 5 fruits and vegetables per day, 23.3%; and regular PA, 22.2%. The overall prevalence of the healthy lifestyle indicators (ie, having all 4 healthy lifestyle characteristics) was only 3%, with little variation among subgroups.⁴⁵

• Analysis of 5 cross-sectional, nationally representative surveys from the National Health Examination Survey (NHES) 1960 to 1962 to the NHANES 1999 to 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.⁴⁶

• Analysis of >14 000 middle-aged subjects in the ARIC study sponsored by the NHLBI showed that >90% of CVD events in black subjects, compared with approximately 70% in white subjects, were explained by elevated or borderline risk factors. Furthermore, the prevalence of participants with elevated risk factors was higher in black subjects; after accounting for education and risk factors, the incidence of CVD was identical in black and white subjects. Thus, the observed higher CVD incidence rate in black subjects appears to be largely attributable to a greater prevalence of elevated risk factors. The primary prevention of elevated risk factors might largely eliminate the incidence of CVD, and these beneficial effects would be applicable not only for white but also for black subjects.⁴⁷

• Data from the MEPS 2004 Full-Year Data File showed that nearly 26 million US adults ?18 years of age were told by a doctor that they had HD, stroke, or any other heart-related disease⁴⁸:

  •    —56.6% of those surveyed said they engaged in moderate-to-vigorous PA 3 times per week; 57.9% of those surveyed who had not been told they had HD engaged in regular PA, more than those who had been told they had HD (46.3%).

  •    —38.6% maintained a healthy weight. Among those told that they had HD, 33.9% had a healthy weight compared with 39.3% who had never been told they had HD.

  •    —78.8% did not currently smoke. Among those ever told that they had indicators of HD, 18.3% continued to smoke.

  •    —More than 93% engaged in at least 1 recommended behavior for prevention of HD: 75.5% engaged in 1 or 2; 18% engaged in all 3; and 6.5% did not engage in any of the recommended behaviors.

  •    —Age-based variations:

    •       ?Moderate to vigorous PA ?3 times per week varied according to age. Younger people (18 to 44 years of age) were more likely (59.9%) than those who were older (45 to 64 and ?65 years of age, 55.3% and 48.5%, respectively) to engage in regular PA.

    •       ?A greater percentage of those 18 to 44 years of age had a healthy weight (43.7%) than did those 45 to 64 years of age and ?65 years of age (31.4% and 37.3%, respectively).

    •       ?Persons ?65 years of age were more likely to be current nonsmokers (89.7%) than were people 18 to 44 years of age and 45 to 64 years of age (76.1% and 77.7%, respectively).

  •    —Race/ethnicity-based variations:

    •       ?Non-Hispanic whites were more likely than Hispanics or non-Hispanic blacks to engage in moderate-to-vigorous PA (58.5% versus 51.4% and 52.5%, respectively).

    •       ?Non-Hispanic whites were more likely to have maintained a healthy weight than were Hispanics or non-Hispanic blacks (39.8% versus 32.1% and 29.7%, respectively).

    •       ?Hispanics were more likely to be nonsmokers (84.2%) than were non-Hispanic whites and non-Hispanic blacks (77.8% and 76.3%, respectively).

  •    —Sex-based variations:

    •       ?Men were more likely to have engaged in moderate-to-vigorous PA ?3 times per week than women (60.3% versus 53.1%, respectively).

    •       ?Women were more likely than men to have maintained a healthy weight (45.1% versus 31.7%, respectively).

    •       ?81.7% of women did not currently smoke, compared with 75.7% of men.

  •    —Variations based on education level:

    •       ?A greater percentage of adults with at least some college education engaged in moderate-to-vigorous PA ?3 times per week (60.8%) than did those with a high school education or less than a high school education (55.3% and 48.3%, respectively).

    •       ?A greater percentage of adults with at least some college education had a healthy weight (41.2%) than did those with a high school or less than high school education (36.2% and 36.1%, respectively).

    •       ?There was a greater percentage of nonsmokers among those with a college education (85.5%) than among those with a high school or less than high school education (73.8% and 69.9%, respectively).

• Participants (18 to 64 years of age at baseline) in the Chicago Heart Association Detection Project in Industry without a history of MI were investigated to determine whether traditional CVD risk factors were similarly associated with CVD mortality in black and white men and women. In general, the magnitude and direction of associations were similar by race. Most traditional risk factors demonstrated similar associations with mortality in black and white adults of the same sex. Small differences were primarily in the strength, not the direction, of association.⁴⁹

• A study of nearly 1500 participants in the Multi-Ethnic Study of Atherosclerosis (MESA) found that Hispanics with hypertension, hypercholesterolemia, and/or diabetes who speak Spanish at home and/or have spent less than half a year in the United States have higher systolic BP, low-density lipoprotein (LDL) cholesterol, and fasting blood glucose, respectively, than Hispanics who speak English and who have lived a longer period of time in the United States.⁵⁰

Family History of Premature-Onset CVD

• There is consistent evidence from multiple large-scale prospective epidemiology studies for a strong and significant association of a reported family history of premature parental CHD with incident MI or CHD in offspring. In the FHS, the occurrence of a validated premature atherosclerotic CVD event in either a parent⁵¹ or a sibling⁵² was associated with an approximately 2-fold elevated risk for CVD, independent of other traditional risk factors.

• Addition of family history of premature CVD to a model that contained traditional risk factors provided modestly improved prognostic value in the FHS.⁵¹ Family history of premature MI is also an independent risk factor in other multivariable risk models that contain traditional risk factors in large cohorts of women⁵³ and men.⁵⁴

• Parental history of premature CHD is associated with increased burden of atherosclerosis in the coronary arteries and the abdominal aorta.^55,56

• In the FHS, a parental history of validated HF is associated with a 1.7-fold higher risk of HF in offspring, after multivariable adjustment.⁵⁷

• A family history of early-onset sudden cardiac death in a first-degree relative is associated with a >2-fold higher risk for sudden cardiac death in offspring on the basis of available case-control studies.⁵⁸

• A recent survey of persons in the United States indicated that most respondents believe that knowing their family history is important for their own health, but few are aware of the specific health information from relatives necessary to develop a family history.⁵⁹

• An accurate and complete family history may identify rare mendelian conditions such as hypertrophic cardiomyopathy, long-QT syndrome, or familial hypercholesterolemia. However, in most persons with a family history of a CVD event, a known rare mendelian condition is not identified.

• Studies are under way to determine genetic variants that may help identify persons at increased risk of CVD.

Impact of Healthy Lifestyle and Low Risk Factor Levels

Much of the literature on CVD has focused on factors associated with increasing risk for CVD and on factors associated with poorer outcomes in the presence of CVD; however, in recent years, a number of studies have defined the beneficial effects of healthy lifestyle factors and lower CVD risk factor burden on CVD outcomes and longevity. These studies suggest that prevention of risk factor development at younger ages may be the key to “successful aging,” and they highlight the need for intensive prevention efforts at younger and middle ages once risk factors develop to improve healthy longevity.

• The lifetime risk for CVD and median survival were highly associated with risk factor burden at 50 years of age among >7900 men and women from the FHS followed up for 111 000 person-years. In this study, optimal risk factor burden at 50 years of age was defined as BP <120/80 mm Hg, total cholesterol <180 mg/dL, absence of diabetes, and absence of smoking. Elevated risk factors were defined as stage 1 hypertension or borderline high cholesterol (200 to 239 mg/dL). Major risk factors were defined as stage 2 hypertension, elevated cholesterol (? 240 mg/dL), current smoking, and diabetes. Remaining lifetime risks for atherosclerotic CVD events were only 5.2% in men and 8.2% in women with optimal risk factors at 50 years of age compared with 68.9% in men and 50.2% in women with ?2 major risk factors at age 50. In addition, men and women with optimal risk factors had a median life expectancy ?10 years longer than those with ?2 major risk factors at age 50 years.⁵

• A recent study examined the association between low lifetime predicted risk for CVD (ie, having all optimal or near-optimal risk factor levels) and burden of subclinical atherosclerosis in younger adults in the Coronary Artery Risk Development in Young Adults (CARDIA) and MESA studies of the NHLBI. Among participants <50 years of age, nearly half had low and half had high predicted lifetime risks for CVD. Those with low predicted lifetime risk had lower prevalence and less severe amounts of coronary calcification and less carotid intima-media thickening, even at these younger ages, than those with high predicted lifetime risk. During follow-up, those with low predicted lifetime risk also had less progression of coronary calcium.⁶⁰

• In another study, FHS investigators followed up 2531 men and women who were examined between the ages of 40 and 50 years and observed their overall rates of survival and survival free of CVD to 85 years of age and beyond. Low levels of the major risk factors in middle age predicted overall survival and morbidity-free survival to 85 years of age or more.⁶¹

  •    —Overall, 35.7% survived to the age of 85 years, and 22% survived to that age free of major morbidities.

  •    —Factors associated with survival to the age of 85 years included female sex, lower systolic BP, lower total cholesterol, better glucose tolerance, absence of current smoking, and higher level of education attained. Factors associated with survival to the age of 85 years free of MI, unstable angina, HF, stroke, dementia, and cancer were nearly identical.

  •    —When adverse levels of 4 of these factors were present in middle age, fewer than 5% of men and approximately 15% of women survived to 85 years of age.

• A study of 366 000 men and women from the Multiple Risk Factor Intervention Trial (MRFIT) and Chicago Heart Association Detection Project in Industry 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 relative risk (RR) for CVD mortality, 40% to 60% lower total mortality rates, and 6 to 10 years’ longer life expectancy.⁴³

• A study of 84 129 women enrolled in the Nurses’ Health Study identified 5 healthy lifestyle factors, including absence of current smoking, drinking half a glass or more of wine per day (or equivalent alcohol consumption), half an hour or more per day of moderate or vigorous PA, BMI <25 kg/m², and dietary score in the top 40% (which included 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, the RR for CHD over a 14-year period was reduced by 57%; when 4 were present, RR was reduced by 66%; and when all 5 factors were present, RR was reduced by 83%.⁶²

• In the Chicago Heart Association Detection Project in Industry, remaining lifetime risks for CVD death were noted to increase substantially and in a graded fashion according to the number of risk factors present in middle age (40 to 59 years of age). However, remaining lifetime risks for non-CVD death also increased dramatically with increasing CVD risk factor burden. These data help to explain the markedly greater longevity experienced by those who reach middle age free of major CVD risk factors.⁶³

• Among individuals 70 to 90 years of age, adherence to a Mediterranean-style diet and greater PA are associated with 65% to 73% lower rates of all-cause mortality, as well as lower mortality rates due to CHD, CVD, and cancer.⁶⁴

• Seventeen-year mortality data from the NHANES II Mortality Follow-Up Study indicated that the RR for fatal CHD was 51% lower for men and 71% lower for women with none of 3 major risk factors (hypertension, current smoking, and elevated total cholesterol [? 240 mg/dL]) than for those with 1 or more risk factors. Had all 3 major risk factors not occurred, it is estimated that 64% of all CHD deaths among women and 45% of CHD deaths in men could have been avoided.⁶⁵

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

  •    —The presence of a greater number of risk factors in middle age is associated with lower scores at older ages on assessment of social functioning, mental health, walking, and health perception in women, with similar findings in men.⁶⁶

  •    —Similarly, the existence of a greater number of risk factors in middle age is associated with higher average annual CVD-related and total Medicare costs (once Medicare eligibility is attained).⁶⁷

  •    —Data from NHANES 1999 to 2002 showed that about one third of adults complied with 6 or more of the recommended heart-healthy behaviors. Dietary recommendations in general and daily fruit intake recommendations in particular were least likely to be followed.⁶⁸

Hospital Discharges, Ambulatory Care Visits, and Nursing Home Residents

• From 1996 to 2006, the number of inpatient discharges from short-stay hospitals with CVD as the first-listed diagnosis increased from 6 107 000 to 6 161 000 (NCHS, NHDS). In 2006, CVD ranked highest among all disease categories in hospital discharges.⁶⁹

• In 2007, there were 79 697 000 physician office visits with a primary diagnosis of CVD (NCHS, NAMCS).⁷⁰

• In 2007, there were 4 048 000 ED visits with a primary diagnosis of CVD (NCHS, NHAMCS).⁷¹

• In 2007, there were 7 929 000 hospital OPD visits with a primary diagnosis of CVD (NHAMCS).⁷² In 2005, approximately 1 of every 6 hospital stays, or almost 6 million, resulted from CVD (AHRQ, NIS). The total inpatient hospital cost for CVD was $71.2 billion, approximately one fourth of the total cost of inpatient hospital care in the United States. The average cost per hospitalization was approximately 41% higher than the average cost for all stays. Hospital admissions that originated in the ED accounted for 60.7% of all hospital stays for CVD. This was 41% higher than the overall rate of 43.1%; 3.3% of patients admitted to the hospital for CVD died in the hospital, which was significantly higher than the average in-hospital death rate of 2.1%.⁷³

• In 2004, coronary atherosclerosis was estimated to be responsible for 1.2 million hospital stays and was the most expensive condition treated. This condition resulted in more than $44 billion in expenses. More than half of the hospital stays for coronary atherosclerosis were among patients who also received percutaneous coronary intervention or cardiac revascularization (coronary artery bypass graft [CABG]) during their stay. Acute MI resulted in $31 billion of inpatient hospital charges for 695 000 hospital stays. The 1.1 million hospitalizations for CHF amounted to nearly $29 billion in hospital charges.⁷⁵

• In 2003, approximately 48.3% of inpatient hospital stays for CVD were for women, who accounted for 42.8% of the national cost ($187 billion) associated with these conditions. Although only 40% of hospital stays for acute MI and coronary atherosclerosis were for women, more than half of all stays for nonspecific chest pain, CHF, and stroke were for women. There was no difference between men and women in hospitalizations for cardiac dysrhythmias.⁷⁵

• Circulatory disorders were the most frequent reason for admission to the hospital through the ED, accounting for 26.3% of all admissions through the ED. After pneumonia, the most common heart-related conditions (in descending order) were CHF, chest pain, hardening of the arteries, and heart attack, which together accounted for >15% of all admissions through the ED. Stroke and irregular heart beat ranked seventh and eighth, respectively.⁷⁶

• In 2004, nursing home residents had a primary diagnosis of CVD at admission (23.7%) and at the time of interview (25%). This was the leading primary diagnosis for these residents (NCHS, NNHS).⁷⁷

Operations and Procedures

• In 2006, an estimated 7 235 000 inpatient cardiovascular operations and procedures were performed in the United States; 4.1 million were performed on males, and 3.1 million were performed on females (NHDS, NCHS, and NHLBI).

Cost

• The estimated direct and indirect cost of CVD for 2010 is $503.2 billion.

• In 2006, $32.7 billion in program payments were made to Medicare beneficiaries discharged from short-stay hospitals with a principal diagnosis of CVD. That was an average of $10 201 per discharge.⁷⁸

Coronary Artery Calcification

Carotid IMT

CAC and Carotid IMT

• In the NHLBI’s MESA study of white, black, Chinese, and Hispanic adults 45 to 84 years of age, carotid IMT and CAC were found to be commonly associated, but patterns of association differed somewhat by sex and race.¹²

  •    —Common and internal carotid IMT were greater in women and men who had CAC than in those who did not, regardless of ethnicity.

  •    —Overall, CAC prevalence and scores were associated with carotid IMT, but associations were somewhat weaker in blacks than in other ethnic groups.

  •    —In general, blacks had the thickest carotid IMT of all 4 ethnic groups, regardless of the presence of CAC.

  •    —Common carotid IMT differed little by race/ethnicity in women with any CAC, but among women with no CAC, IMT was higher among blacks (0.86 mm) than in the other 3 groups (0.76 to 0.80 mm).

• In a more recent analysis from the NHLBI’s MESA study, the investigators reported on follow-up of 6698 men and women in 4 ethnic groups over 5.3 years and compared the predictive utility of carotid IMT and CAC.¹³

  •    —CAC was associated more strongly than carotid IMT with the risk of incident CVD.

  •    —After adjustment for each other (CAC score and IMT) and for traditional CVD risk factors, the HR for CVD increased 2.1-fold for each 1–standard deviation (SD) increment of log-transformed CAC score versus 1.3-fold for each 1-SD increment of the maximum carotid IMT.

  •    —For CHD events, the HRs per 1-SD increment increased 2.5-fold for CAC score and 1.2-fold for IMT.

  •    —A receiver operating characteristic curve analysis also suggested that CAC score was a better predictor of incident CVD than was IMT, with areas under the curve of 0.81 versus 0.78, respectively.

  •    —Investigators from the NHLBI’s CARDIA and MESA studies examined the burden and progression of subclinical atherosclerosis among adults <50 years of age. Ten-year and lifetime risks for CVD were estimated for each participant, and the young adults were stratified into 3 groups: (1) Those with low 10-year (<10%) and low lifetime (<39%) predicted risk for CVD; (2) those with low 10-year (<10%) but high lifetime (?39%) predicted risk; and (3) those with high 10-year risk (>10%). The latter group had the highest burden and greatest progression of subclinical atherosclerosis. Given the young age of those studied, ?90% of participants were at low 10-year risk, but of these, half had high predicted lifetime risk. Compared with those with low short-term/low lifetime predicted risks, those with low short-term/high lifetime predicted risk had significantly greater burden and progression of CAC and significantly greater burden of carotid IMT, even at these younger ages. These data confirm the importance of early exposure to risk factors for the onset and progression of subclinical atherosclerosis.¹⁴

Coronary Heart Disease

ICD-9 410 to 414, 429.2; ICD-10 I20–I25; see Glossary (Chapter 22) for details and definitions. See Tables 4-1 and 4-2⇓. See Charts 4-1 through 4-8⇓⇓⇓⇓⇓⇓⇓.

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Chart 4-1. Prevalence of CHD by age and sex (NHANES: 2003–2006). Source: NCHS and NHLBI.

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Chart 4-2. Annual number of adults having diagnosed heart attack by age and sex (ARIC Surveillance: 1987–2004 and CHS: 1989–2004). These data include MI and fatal CHD but not silent MI. Source: NHLBI.

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Chart 4-3. Annual rate of first heart attacks by age, sex, and race (ARIC Surveillance: 1987–2004). Source: NHLBI.

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Chart 4-4. Incidence of MI* by age, race, and sex (ARIC Surveillance, 1987–2004). *MI diagnosis by expert committee based on review of hospital records. Source: Unpublished data from ARIC, NHLBI.

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Chart 4-5. Incidence of AP* by age, race, and sex (FHS 1980–2002/2003). *AP uncomplicated based on physician interview of patient. (Rate for women 45–54 years of age considered unreliable.) Source: NHLBI.⁷

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Chart 4-6. Estimated 10-year CHD risk in adults 55 years of age according to levels of various risk factors (Framingham Heart Study). Source: Wilson et al.⁵¹

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Chart 4-7. Hospital discharges for CHD by sex (United States: 1970–2006). Hospital discharges include people discharged alive, dead, and status unknown. Source: NHDS/NCHS and NHLBI.

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Chart 4-8. Prevalence of low CHD risk, overall and by sex, ages 25 to 74 years (NHANES: 1971–2006). Source: Personal communication with NHLBI, June 28, 2007. Low risk is defined as SBP <120 mm Hg and DBP <80 mm Hg; cholesterol <200 mg/dL; BMI <25 kg/m²; currently not smoking cigarettes; and no prior MI or DM.

Prevalence

• On the basis of data from NHANES 2003 to 2006 (NCHS; Table 4-1; Chart 4-1), an estimated 17 600 000 Americans ?20 years of age have CHD:

  •    —Total CHD prevalence is 7.9% in US adults ?20 years of age. CHD prevalence is 9.1% for men and 7.0% for women.

  •    —Among non-Hispanic whites, CHD prevalence is 9.4% for men and 6.9% for women.

  •    —Among non-Hispanic blacks, CHD prevalence is 7.8% for men and 8.8% for women.

  •    —Among Mexican Americans, CHD prevalence is 5.3% for men and 6.6% for women.

  •    —Among Hispanic or Latino individuals ?18 years of age, CHD prevalence is 5.7% (NHIS, NCHS).¹

  •    —Among American Indians/Alaska Natives ?18 years of age, it is estimated that 6.6% have CHD (estimate considered unreliable), and among Asians ?18 years of age, it is 2.9% (NHIS, NCHS).¹

• According to data from NHANES 2003 to 2006 (NCHS) the overall prevalence for MI is 3.6% in US adults ?20 years of age. MI prevalence is 4.7% for men and 2.6% for women.¹

  •    —Among non-Hispanic whites, MI prevalence is 5.1% for men and 2.6% for women.

  •    —Among non-Hispanic blacks, MI prevalence is 3.6% for men and 2.9% for women.

  •    —Among Mexican Americans, MI prevalence is 2.6% for men and 2.0% for women.

• Data from 2008 from the BRFSS survey of the CDC found that 4.2% of respondents had been told that they had had an MI. The highest prevalence was in Alabama (5.8%) and West Virginia (7.6%). The lowest prevalence was in the District of Columbia (2.2%). In the same survey, 4.1% of respondents were told that they had angina or CHD. The highest prevalence was in West Virginia (8.1%), and the lowest was in the District of Columbia (2.5%).²

Incidence

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

  •    —This year, ?785 000 Americans will have a new coronary attack, and ?470 000 will have a recurrent attack. It is estimated that an additional 195 000 silent MIs occur each year. That assumes that ?21% of the 935 000 first and recurrent MIs are silent.^3,4

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    Abbreviations Used in Chapter 4

  •    —The estimated annual incidence of MI is 610 000 new attacks and 325 000 recurrent attacks.

  •    —Average age at first MI is 64.5 years for men and 70.3 years for women.

• On the basis of the NHLBI-sponsored FHS:

  •    —CHD makes up more than half of all cardiovascular events in men and women <75 years of age.³

  •    —The lifetime risk of developing CHD after 40 years of age is 49% for men and 32% for women.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.³

• In the NHLBI-sponsored ARIC study, in participants 45 to 64 years of age, the average age-adjusted CHD incidence rates per 1000 person-years were as follows: White men, 12.5; black men, 10.6; white women, 4.0; and black women, 5.1. Incidence rates excluding revascularization procedures were as follows: White men, 7.9; black men, 9.2; white women, 2.9; and black women, 4.9. In a multivariable analysis, hypertension was a particularly strong risk factor in black women, with HR 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). DM was somewhat more predictive in white women than in other groups. HR ratios (95% CI) 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

• Incidence rates for MI in the NHLBI-sponsored ARIC study are displayed in Charts 4-3 and 4-4⇑, stratified by age, race, and gender. The annual age-adjusted rates per 1000 population of first MI (1987–2001) in ARIC Surveillance (NHLBI) were 4.2 in black men, 3.9 in white men, 2.8 in black women, and 1.7 in white women.⁷

• Analysis of more than 40 years of physician-validated acute MI (AMI) data in the FHS study of the NHLBI found that AMI rates diagnosed by electrocardiographic (ECG) criteria declined approximately 50% with a concomitant 2-fold increase in rates of AMI diagnosed by blood markers. National MI trend data may be biased by a diagnostic drift that has resulted from the advent of diagnostic biomarker tests for AMI; investigators were able to identify and quantify the possible magnitude of this effect within the study setting. These findings may explain the paradoxical stability of AMI rates in the United States despite concomitant improvements in CHD risk factors.⁸

• Among American Indians 65 to 74 years of age, the annual rates per 1000 population of new and recurrent MIs were 7.6 for men and 4.9 for women.⁹ Analysis of data from NHANES III (1988–1994) and NHANES 1999 to 2002 (NCHS) showed that in adults 20 to 74 years of age, the overall distribution of 10-year risk of developing CHD changed little during this time. Among the 3 racial/ethnic groups, blacks had the highest proportion of participants in the high-risk group.¹⁰

Mortality

• CHD caused ?1 of every 6 deaths in the United States in 2006. CHD mortality was 425 425.¹¹ CHD any-mention mortality was 587 000. MI mortality was 141 462. MI any-mention mortality was 181 000 (NHLBI; NCHS public-use data files). Preliminary 2007 CHD mortality was 403 741. The preliminary 2007 CHD death rate was 125.2.¹² CHD is the largest major killer of American males and females.¹³ Approximately every 25 seconds, an American will suffer a coronary event, and approximately every minute, someone will die of one. Approximately 34% of the people who experience a coronary attack in a given year will die of it, and ?15% who experience a heart attack (MI) will die of it (AHA computation). Approximately every 34 seconds, an American will have an MI. The percentage of CHD deaths that occurred out of the hospital in 2006 was 70%. According to NCHS Data Warehouse mortality data, 309 000 CHD deaths occur out of the hospital or in hospital EDs annually (2005, ICD-10 codes I20 to I25).¹⁴

• A study of 1275 health maintenance organization (HMO) enrollees 50 to 79 years of age who had cardiac arrest showed that the incidence of out-of-hospital cardiac arrest was 6.0/1000 subject-years in subjects with any clinically recognized HD compared with 0.8/1000 subject-years in subjects without HD. In subgroups with HD, incidence was 13.6/1000 subject-years in subjects with prior MI and 21.9/1000 subject-years in subjects with HF.¹⁵

Temporal Trends in CHD Mortality

• An analysis of FHS data (NHLBI) from 1950 to 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.¹⁶

• From 1996 to 2006, the annual death rate due to CHD declined 36.4%, and the actual number of deaths declined 21.9%. (Appropriate comparability ratios were applied.) In 2006, the overall CHD death rate was 134.9 per 100 000 population. The death rates were 176.3 for white males and 206.4 for black males; for white females, the rate was 101.5, and for black females, it was 130.0.^11,13

  •    —2006 Age-adjusted death rates for CHD were 132.8 for Hispanic or Latino males and 85.4 for females, 122.4 for American Indian or Alaska Native males and 76.4 for females, and 101.3 for Asian or Pacific Islander males and 58.9 for females.¹¹

• Approximately 81% of people who die of CHD are ?65 years of age (NCHS; AHA computation).

• The estimated average number of years of life lost because of an MI is 15.¹⁷

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

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

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

• According to data from the National Registry of Myocardial Infarction¹⁸:

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

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

• CHD death rates have fallen from 1968 to the present. Analysis of NHANES (NCHS) data compared CHD death rates between 1980 and 2000 to determine how much of the decline in deaths due to CHD over that period could be explained by the use of medical and surgical treatments versus changes in CVD risk factors (resulting from lifestyle/behavior). After 1980 and 2000 data were compared, it was estimated that ?47% of the decrease in CHD deaths was attributable to treatments, including the following¹⁹:

  •    —Secondary preventive therapies after MI or revascularization (11%);

  •    —initial treatments for AMI or unstable angina (UA; 10%);

  •    —treatments for HF (9%);

  •    —revascularization for chronic angina (5%); and

  •    —other therapies (12%), including antihypertensive and lipid-lowering primary prevention therapies.

• It was also estimated that a similar amount of the reduction in CHD deaths, ?44%, was attributable to changes in risk factors, including the following¹⁹:

  •    —Lower total cholesterol (24%);

  •    —lower SBP (20%);

  •    —lower smoking prevalence (12%); and

  •    —decreased physical inactivity (5%).

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

• Between 1980 and 2002, death rates due to CHD among men and women ?65 years of age fell by 52% in men and 49% in women. Among men, the death rate declined on average by 2.9% per year in the 1980s, 2.6% per year during the 1990s, and 4.4% per year from 2000 to 2002. Among women, death rates fell by 2.6%, 2.4%, and 4.4%, respectively. However, when stratified by age, among men 35 to 54 years of age, the average annual rate of death fell by 6.2%, 2.3%, and 0.5%, respectively. Among women 35 to 54 years of age, the average annual rate of death fell by 5.4% and 1.2% and then increased by 1.5%, respectively. This increase was not statistically significant; however, in even younger women (35 to 44 years of age), the rate of death has been increasing by an average of 1.3% annually between 1997 and 2002, which is statistically significant.²⁰

• An analysis of 28 studies published from 1977 to 2007 found that revascularization by coronary bypass surgery or percutaneous intervention in conjunction with medical therapy in patients with nonacute CAD is associated with significantly improved survival compared with medical therapy alone.²¹

Risk Factors

• Risk factors for CHD act synergistically to increase CHD risk, as shown in the example in Chart 4-6.

• 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. Approximately 90% of 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.²²

• According to a case-control study of 52 countries (INTERHEART), optimization of 9 easily measured and potentially modifiable risk factors could result in a 90% reduction in the risk of an initial AMI. 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 PA, low daily fruit and vegetable consumption, alcohol overconsumption, and psychosocial index.²³

• A study of >3000 members of the FHS (NHLBI) Offspring Cohort without CHD showed that among men with 10-year predicted risk for CHD of 20%, both failure to reach target heart rate and ST-segment depression more than doubled the risk of an event, and each metabolic equivalent (MET) increment in exercise capacity reduced risk by 13%.²⁴

• A study of non-Hispanic white persons 35 to 74 years of age in the FHS (NHLBI) and the NHANES III (NCHS) studies showed that 26% of men and 41% of women had at least 1 borderline risk factor in NHANES III. It is estimated that >90% of CHD events will occur in individuals with at least 1 elevated risk factor and that ?8% will occur in people with only borderline levels of multiple risk factors. Absolute 10-year CHD risk exceeded 10% both in men >45 years of age who had 1 elevated risk factor and ?4 borderline risk factors and in those who had ?2 elevated risk factors. In women, absolute CHD risk was >10% only in those >55 years of age who had ?3 elevated risk factors.²⁵

• A recent analysis examined the number and combination of risk factors necessary to exceed Adult Treatment Panel III (ATP III) treatment thresholds. In this analysis, relatively high risk factor levels were required to exceed ATP III treatment thresholds in men <45 years of age and women <65 years of age, which suggests that alternative means of risk prediction that focus on a longer time horizon than the 10 years captured by the traditional Framingham CHD risk score may be necessary to estimate risk in these individuals.²⁶

• Analysis of data from the CHS study (NHLBI) among participants ?65 years of age at entry into the study showed that subclinical CVD is very prevalent among older individuals, is independently associated with risk of CHD (even over a 10-year follow-up period), and substantially increases the risk of CHD among participants with hypertension or DM.²⁷

• On the basis of data from the CDC/BRFSS, it was found that patients with CHD are less likely to comply with PA recommendations than are subjects without CHD. Only 32% of CHD patients met moderate PA recommendations, 22% met vigorous PA recommendations, and 40% met total PA recommendations. In contrast, the percentage of subjects without CHD who met PA recommendations was significantly higher, and this percentage almost achieved the Healthy People 2010 objectives for PA.²⁸

• Analysis of data from the PREMIER trial (Prospective Registry Evaluating Myocardial Infarction: Events and Recovery), sponsored by the NHLBI, found that in people with prehypertension or stage 1 hypertension, 2 multicomponent behavioral interventions significantly reduced estimated 10-year CHD risk by 12% and 14% respectively, compared with advice only.²⁹

Awareness of Warning Signs and Risk Factors for HD

• Data from the Women Veterans Cohort showed that 42% of women ?35 years of age were concerned about HD. Only 8% to 20% were aware that CAD is the major cause of death for women.³⁰

• Among people in 14 states and Washington, DC, participating in the 2005 BRFSS, only 27% were aware of 5 heart attack warning signs and symptoms (1, pain in jaw, neck, or back; 2, weak, lightheaded, or faint; 3, chest pain or discomfort; 4, pain or discomfort in arms or shoulder; and 5, shortness of breath) and indicated that they would first call 911 if they thought someone was having a heart attack or stroke. Awareness of all 5 heart attack warning signs and symptoms and the need to call 911 was higher among non-Hispanic whites (30.2%), women (30.8%), and those with a college education or more (33.4%) than among non-Hispanic blacks and Hispanics (16.2% and 14.3%, respectively), men (22.5%), and those with less than a high school education (15.7%), respectively. By state, awareness was highest in West Virginia (35.5%) and lowest in Washington, DC (16.0%).³¹

• 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 of CVD.³²

• A recent community surveillance study in 4 US communities reported that in 2000, the overall proportion of persons with delays of ?4 hours from onset of AMI symptoms to hospital arrival was 49.5%. The study also reported that from 1987 to 2000, there was no statistically significant change in the proportion of patients whose delays were ?4 hours, which indicates that there has been little improvement in the speed at which patients with MI symptoms arrive at the hospital after symptom 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.³³

• According to 2003 data from the BRFSS (CDC), 36.5% of all women surveyed had multiple risk factors for HD and stroke. The age-standardized prevalence of multiple risk factors was lowest in whites and Asians. After adjustment for age, income, education, and health coverage, the odds for multiple risk factors were greater in black and Native American women and lower for Hispanic women than for white women. Prevalence estimates and odds of multiple risk factors increased with age; decreased with education, income, and employment; and were lower in those with no health coverage. Smoking was more common in younger women, whereas older women were more likely to have medical conditions and to be physically inactive.³⁴

• Individuals with documented CHD have 5 to 7 times the risk of having a heart attack or dying as the general population. Survival rates improve after a heart attack if treatment begins within 1 hour; however, most patients are admitted to the hospital 2.5 to 3 hours after symptoms begin. More than 3500 patients surveyed with a history of CHD were asked to identify possible symptoms of heart attack. Despite their history of CHD, 44% had low knowledge levels. In this group, who were all at high risk of future AMI, 43% assessed their risk as less than or the same as others their age. More men than women perceived themselves as being at low risk, at 47% versus 36%, respectively.³⁵

• Data from Worcester, Mass, indicate that the average time from symptom onset to hospital arrival has not improved and that delays in hospital arrival are associated with less receipt of guidelines-based care. Mean and median prehospital delay times from symptom onset to arrival at the hospital were 4.1 and 2.0 hours in 1986 and 4.6 and 2.0 hours in 2005. Compared with those arriving within 2 hours of symptom onset, those with prolonged prehospital delay were less likely to receive thrombolytic therapy and percutaneous coronary intervention (PCI) within 90 minutes of hospital arrival.³⁶

• In an analysis from ARIC, low neighborhood household income (OR 1.46, 95% CI 1.09 to 1.96) and being a Medicaid recipient (OR 1.87, 95% CI 1.10 to 3.19) were associated with increased odds of having prolonged prehospital delays from symptom onset to hospital arrival for AMI compared with individuals with higher neighborhood household income and other insurance providers, respectively.³⁷

Aftermath

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

• A Mayo Clinic study found that cardiac rehabilitation after an MI is underused, particularly in women and the elderly. Women were 55% less likely than men to participate in cardiac rehabilitation, and older study patients were less likely to participate than younger participants. Only 32% of men and women ?70 years of age participated in cardiac rehabilitation compared with 66% of those 60 to 69 years of age and 81% of those <60 years of age.³⁸

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

  •    —At ?40 years of age, 18% of men and 23% of women will die.

  •    —At 40 to 69 years of age, 8% of white men, 12% of white women, 14% of black men, and 11% of black women will die.

  •    —At ?70 years of age, 27% of white men, 32% of white women, 26% of black men, and 28% of black women will die.

  •    —In part because women have MIs at older ages than men, they are more likely to die of MIs within a few weeks.

• Within 5 years after a first MI:

  •    —At ?40 years of age, 33% of men and 43% of women will die.

  •    —At 40 to 69 years of age, 15% of white men, 22% of white women, 27% of black men, and 32% of black women will die.

  •    —At ?70 years of age, 50% of white men, 56% of white women, 56% of black men, and 62% of black women will die.

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

  •    —At 40 to 69 years of age, 16% of men and 22% of women.

  •    —At 40 to 69 years of age, 14% of white men, 18% of white women, 27% of black men, and 29% of black women.

  •    —At ?70 years of age, 24% of white men and women, 30% of black men, and 32% of black women.

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

  •    —At 40 to 69 years of age, 7% of men and 12% of women.

  •    —At ?70 years of age, 22% of men and 25% of women.

  •    —At 40 to 69 years of age, 7% of white men, 11% of white women, 11% of black men, and 14% of black women.

  •    —At ?70 years of age, 21% of white men, 25% of white women, 29% of black men, and 24% of black women.

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

  •    —At 40 to 69 years of age, 4% of men and 6% of women.

  •    —At ?70 years of age, 6% of men and 11% of women.

  •    —At 40 to 69 years of age, 3% of white men, 5% of white women, 8% of black men, and 9% of black women.

  •    —At ?70 years of age, 6% of white men, 10% of white women, 7% of black men, and 17% of black women.

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

  •    —At 40 to 69 years of age, 1.1% of white men, 1.9% of white women, 2.5% of black men, and 1.4% of black women.

  •    —At ?70 years of age, 6.0% of white men, 3.5% of white women, 14.9% of black men, and 4.8% of black women.

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

  •    —At 60 to 69 years of age, data not available for men and 7.4 for women.

  •    —At 70 to 79 years of age, 7.4 for men and 10.4 for women.

  •    —At ?80 years of age, 2.0 for men and 6.4 for women.

• Among survivors of an MI, in 2005, 34.7% of BRFSS respondents participated in outpatient cardiac rehabilitation. The prevalence of cardiac rehabilitation was higher among older age groups (?50 years of age), among men versus women, among Hispanics, among those who were married, among those with higher education, and among those with higher levels of household income.³⁹

• A recent analysis of Medicare claims data revealed that only 13.9% of Medicare beneficiaries enroll in cardiac rehabilitation after an AMI, and only 31% enroll after CABG. Older persons, women, nonwhites, and individuals with comorbidities were less likely to enroll in cardiac rehabilitation programs.⁴⁰

Hospital Discharges and Ambulatory Care Visits

(See Table 4-1 and Chart 4-7.)

• From 1996 to 2006, the number of inpatient discharges from short-stay hospitals with CHD as the first-listed diagnosis decreased from 2 272 000 to 1 760 000 (NHDS, NCHS).

• In 2007, there were 14 722 000 ambulatory care visits with CHD as the first-listed diagnosis (NCHS, NAMCS, NHAMCS). The majority of these visits (69.0%) were for coronary atherosclerosis.⁴¹

• Most hospitalized patients >65 years of age are women. For MI, 28.4% of hospital stays for people 45 to 64 years of age were for women, but 63.7% of stays for those ?85 years of age were for women. Similarly, for coronary atherosclerosis, 32.7% of stays among people 45 to 64 years of age were for women; this figure increased to 60.7% of stays among those ?85 years of age. For nonspecific chest pain, women were more numerous than men among patients <65 years of age. Approximately 54.4% of hospital stays among people 45 to 64 years of age were for women. Women constituted 73.9% of nonspecific chest pain stays among patients ?85 years of age, higher than for any other condition examined. For AMI, one third more women than men died in the hospital: 9.3% of women died in the hospital compared with 6.2% of men.⁴²

Operations and Procedures

• In 2006, an estimated 1 313 000 inpatient PCI procedures, 448 000 inpatient bypass procedures, 1 115 000 inpatient diagnostic cardiac catheterizations, 114 000 inpatient implantable defibrillators, and 418 000 pacemaker procedures were performed for inpatients in the United States.⁴³

Cost

• The estimated direct and indirect cost of CHD for 2010 is $177.1 billion.

• In 2006, $11.7 billion was paid to Medicare beneficiaries for in-hospital costs when CHD was the principal diagnosis ($14 009 per discharge for AMI, $12 977 per discharge for coronary atherosclerosis, and $10 630 per discharge for other ischemic HD).^35,44

Acute Coronary Syndrome

ICD-9 codes 410, 411.

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

• A conservative estimate for the number of discharges with ACS from hospitals in 2006 is 733 000. Of these, an estimated 401 000 are male and 332 000 are female. This estimate is derived by adding the first-listed inpatient hospital discharges for MI (647 000) to those for UA (86 000; NHDS, NCHS).

• When secondary discharge diagnoses in 2006 were included, the corresponding number of inpatient hospital discharges was 1 365 000 unique hospitalizations for ACS; 765 000 were male, and 600 000 were female. Of the total, 810 000 were for MI alone, and 537 000 were for UA alone (18 000 hospitalizations received both diagnoses; NHDS, NCHS).

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

• STEMI

• NSTEMI

• UA

The percentage of ACS or MI cases with ST elevation varies in different registries/databases and depends heavily on the age of patients included and the type of surveillance used. According to the National Registry of Myocardial Infarction 4 (NRMI-4), ?29% of MI patients are STEMI patients.⁴⁵ The AHA Get With the Guidelines project found that 32% of the MI patients in the CAD module are STEMI patients (personal communication from AHA Get With the Guidelines staff, October 1, 2007). The study of the Global Registry of Acute Coronary Events (GRACE), which includes US patient populations, found that 38% of ACS patients have STEMI, whereas the second Euro Heart Survey on ACS (EHS-ACS-II) reported that ?47% of ACS patients have STEMI.⁴⁶

• Analysis of data from the GRACE multinational observational cohort study of patients with ACS found evidence of a change in practice for both pharmacological and interventional treatments in patients with either STEMI or non–ST-segment–elevation ACS (NSTE ACS). These changes have been accompanied by significant decreases in the rates of in-hospital death, cardiogenic shock, and new MI among patients with NSTE ACS. The use of evidence-based therapies and PCI interventions increased in the STEMI population. This increase was matched with a statistically significant decrease in the rates of death, cardiogenic shock, and HF or pulmonary edema.⁴⁷

• A study of patients with NSTE ACS treated at 350 US hospitals found that up to 25% of opportunities to provide American College of Cardiology (ACC)/AHA guideline–recommended care were missed in current practice. The composite guideline adherence rate was significantly associated with in-hospital mortality.⁴⁸

• A study of hospital process performance in 350 centers of nearly 65 000 patients enrolled in the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines) National Quality Improvement Initiative found that ACC/AHA guideline–recommended treatments were adhered to in 74% of eligible instances.⁴⁸

Angina Pectoris

ICD-9 413; ICD-10 I20. See Table 4-2; and Chart 4-5.

Prevalence

• A study of 4 national cross-sectional health examination studies found that among Americans 40 to 74 years of age, the age-adjusted prevalence of AP was higher among women than men. Increases in the prevalence of AP occurred for Mexican American men and women and African American women but were not statistically significant for the latter.⁴⁹

Incidence

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

• The annual rates per 1000 population of new episodes of AP for nonblack men are 28.3 for those 65 to 74 years of age, 36.3 for those 75 to 84 years of age, and 33.0 for those ?85 years of age. For nonblack women in the same age groups, the rates are 14.1, 20.0, and 22.9, respectively. For black men, the rates are 22.4, 33.8, and 39.5, and for black women, the rates are 15.3, 23.6, and 35.9, respectively (CHS, NHLBI).⁷

• On the basis of 1987 to 2001 data from the ARIC study of the NHLBI, the annual rates per 1000 population of new episodes of AP for nonblack men are 8.5 for those 45 to 54 years of age, 11.9 for those 55 to 64 years of age, and 13.7 for those 65 to 74 years of age. For nonblack women in the same age groups, the rates are 10.6, 11.2, and 13.1, respectively. For black men, the rates are 11.8, 10.6, and 8.8, and for black women, the rates are 20.8, 19.3, and 10.0, respectively.⁷

Mortality

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

Cost

For women with nonobstructive CHD enrolled in the Women’s Ischemia Syndrome Evaluation (WISE) study of the NHLBI, the average lifetime cost estimate was ?$770 000 and ranged from $1.0 to $1.1 million for women with 1-vessel to 3-vessel CHD.⁵⁰

Prevalence

• An estimated 6 400 000 Americans ?20 years of age have had a stroke (extrapolated to 2006 using NCHS/NHANES 2003 to 2006 data). Overall stroke prevalence during this period is an estimated 2.9% (see Table 5-1).

• According to data from the 2005 BRFSS (CDC), 2.7% of men and 2.5% of women ?18 years of age had a history of stroke. Among these, 2.3% were non-Hispanic white, 4.0% were non-Hispanic black, 1.6% were Asian/Pacific Islander, 2.6% were Hispanic (of any race), 6.0% were American Indian/Alaska Native, and 4.6% were admixed.¹

• Data from the 2008 survey of the CDC/BRFSS found that, overall, 2.6% of respondents had been told that they had a stroke. The highest prevalence was in Alabama and West Virginia (4.2%) and the lowest was in Colorado (1.8%).²

• Among American Indians/Alaska Natives ?18 years of age, the estimated prevalence of stroke based on the 2008 NHIS was 3.9% (estimate considered unreliable). Among blacks, the prevalence was 3.6%; among whites, it was 2.7%; and among Asians, it was 1.8% (NHIS, NCHS).³

• Among American Indians/Alaska Natives ?18 years of age, the estimated prevalence of stroke is considered unreliable in available data sources.

• The prevalence of silent cerebral infarction between 55 and 64 years of age is ?11%. This prevalence increases to 22% between 65 and 69 years of age, 28% between 70 and 74 years of age, 32% between 75 and 79 years of age, 40% between 80 and 85 years of age, and 43% at ?85 years of age. Application of these rates to 1998 US population estimates results in an estimated 13 million people with prevalent silent stroke.^4,5

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

Incidence

• Each year, ?795 000 people experience a new or recurrent stroke. Approximately 610 000 of these are first attacks, and 185 000 are recurrent attacks (GCNKSS, NINDS, and NHLBI; GCNKSS and NINDS data for 1999 provided July 9, 2008; estimates compiled by NHLBI). Of all strokes, 87% are ischemic, 10% are intracerebral hemorrhage, and 3% are subarachnoid hemorrhage strokes (GCNKSS, NINDS, 1999).⁷

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

• A study of nearly 18 000 middle-aged, predominantly white male participants in the Physicians’ Health Study found that the Southeast and Midwest had higher crude and age-standardized major CVD, total stroke, ischemic stroke, coronary revascularization, and CVD death incidence rates compared with the Northeast.⁸

• Each year, ?55 000 more women than men have a stroke (GCNKSS, NINDS).

• The stroke incidence rate is higher for men compared with women at younger ages, but not at older ages. The male-to-female incidence ratio was 1.25 in those 55 to 64 years of age, 1.50 in those 65 to 74 years of age, 1.07 in those 75 to 84 years of age, and 0.76 in those ?85 years of age (ARIC and CHS studies, NHLBI).⁷

• Data from the GCNKSS and NINDS show that the annual incidence of first-ever hospitalized stroke did not change significantly between 1993 to 1994 and 1999: 158 per 100 000 blacks continue to have a higher stroke incidence than whites, especially among young adults.⁹

• Blacks have a risk of first-ever stroke that is almost twice that of whites. The age-adjusted stroke incidence rates in people 45 to 84 years of age are 6.6 per 1000 population in black men, 3.6 in white men, 4.9 in black women, and 2.3 in white women (ARIC, NHLBI).⁷ On the basis of 1987 to 2001 data from the ARIC study sponsored by the NHLBI, stroke/TIA incidence rates (per 1000 person-years) are 2.4 for white men 45 to 54 years of age, 6.1 for white men 55 to 64 years of age, and 12.2 for white men 65 to 74 years of age. For white women in the same age groups, the rates are 2.4, 4.8, and 9.8, respectively. For black men in the same age groups, the rates are 9.7, 13.1, and 16.2, and for black women, the rates are 7.2, 10.0, and 15.0, respectively.⁷

• National statistics from death certificate data have long shown an increase in deaths attributed to stroke for blacks because of a higher stroke incidence compared with whites, although the case-fatality rate is similar between the 2 racial groups. Blacks <55 years of age seem to be at particularly high risk (2- to 5-fold higher than age-matched white subjects), but in elderly ages, this racial disparity is attenuated. This racial disparity in stroke incidence does not seem to be changing over time. Community socioeconomic status appeared to explain 39% of the excess stroke incidence risk in blacks in this study.¹⁰

• The Brain Attack Surveillance in Corpus Christi (BASIC, NINDS) demonstrated an increased incidence of stroke among Mexican Americans compared with non-Hispanic whites in this community. The crude cumulative incidence was 168 per 10 000 in Mexican Americans and 136 per 10 000 in non-Hispanic whites. Specifically, Mexican Americans have a higher cumulative incidence for ischemic stroke at younger ages (45 to 59 years of age: relative risk [RR] 2.04; 95% CI, 1.55 to 2.69; 60 to 74 years of age: RR 1.58; 95% CI, 1.31 to 1.91), but not at older ages (?75 years of age: RR 1.12; 95% CI, 0.94 to 1.32). Mexican Americans also have a higher incidence of intracerebral hemorrhage and subarachnoid hemorrhage than non-Hispanic whites, adjusted for age, as well as a higher incidence of ischemic stroke and TIA at younger ages than non-Hispanic whites.¹¹

• Among 4507 American Indian participants without a prior stroke in the Strong Heart Study in 1989 to 1992, the age- and sex-adjusted incidence of stroke through 2004 was 6.79 per 100 person-years, with 86% of incident strokes being ischemic.¹²

• The age-adjusted incidence of first ischemic stroke per 100 000 was 88 in whites, 191 in blacks, and 149 in Hispanics, according to data from the Northern Manhattan Study (NOMAS, NINDS). Among blacks, compared with whites, the relative rate of intracranial atherosclerotic stroke was 5.85; extracranial atherosclerotic stroke, 3.18; lacunar stroke, 3.09; and cardioembolic stroke, 1.58. Among Hispanics (primarily Cuban and Puerto Rican), 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, 1.42.¹³

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

• Analysis of black and white patients in the WASID trial found that blacks were significantly more likely to have an ischemic stroke, brain hemorrhage or vascular death, or ischemic stroke alone than whites.¹⁵

• A review of published studies and data from clinical trials found that hospital admissions for intracerebral hemorrhage have increased by 18% in the past 10 years, probably because of increases in elderly people, many of whom lack adequate blood pressure control, and the increasing use of anticoagulants, thrombolytics, and antiplatelet agents. Mexican Americans, Latin Americans, African Americans, Native Americans, Japanese people, and Chinese people have higher incidences than do white Americans.¹⁶

Transient Ischemic Attack

• The prevalence of transient ischemic attack (TIA)—a temporary episode of neurologic dysfunction caused by reduced blood flow to the brain, spinal cord, or retina, without permanent death of brain tissue—increases significantly with older age.¹⁷

• The incidence of TIA in the United States has been estimated to be ?200 000 to 500 000 per year, with a population prevalence of 2.3%, which translates into ?5 million people.¹⁸

• Approximately half of all patients who experience a TIA fail to report it to their healthcare providers.¹⁹

• Approximately 15% of all strokes are heralded by a TIA.¹⁷

• One third of episodes characterized as TIAs according to the classic definition (ie, focal neurological deficits that resolve within 24 hours) would be considered infarctions on the basis of diffusion-weighted magnetic resonance imaging findings.²⁰

• In population-based studies, the age- and gender-adjusted incidence rates for TIA range from 68.2 to 83.0 per 100 000. Men and blacks have higher rates of TIA.^21,22

• After TIA, the 90-day risk of stroke is 3.0% to 17.3% and is highest within the first 30 days, with half occurring within the first 48 hours after a TIA.^22–25

• Within 1 year of TIA, about 12% to 13% of patients will die.^22,26

• 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%/year).²⁷

• 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.²⁸

Mortality

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

• Stroke accounted for ?1 of every 18 deaths in the United States in 2006. Approximately 53% of stroke deaths in 2006 occurred out of the hospital.²⁹ Stroke mortality in 2006 was 137 119; any-mention mortality in 2006 was ?232 000 (NHLBI; NCHS public use data files).³⁰

• Preliminary stroke mortality in 2007 was 133 990, and the preliminary death rate was 41.6.³¹

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

• Among persons 45 to 64 years of age, 8% to 12% of ischemic strokes and 37% to 38% of hemorrhagic strokes result in death within 30 days, according to the ARIC study of the NHLBI.³²

• In a study of persons ?65 years of age recruited from a random sample of Health Care Financing Administration Medicare Part B eligibility lists in 4 US communities, the 1-month case fatality rate was 12.6% for all strokes, 8.1% for ischemic strokes, and 44.6% for hemorrhagic strokes.³³

• From 1996 to 2006, the annual stroke death rate decreased 33.5%, and the actual number of stroke deaths declined 18.4%.(Appropriate comparability ratios were applied).³⁰

• Conclusions about changes in stroke death rates from 1980 to 2005:

  •    —There was a greater decline in stroke death rates in men than in women, with a male-to-female ratio decreasing from 1.11 to 1.03 (age adjusted).

  •    —There were greater declines in stroke death rates at ?65 years of age in men than in women compared with younger ages.³⁰

• More women than men die of stroke each year due to the larger number of elderly women. Women accounted for 60.6% of US stroke deaths in 2006. (AHA computation).

• The 2006 overall death rate for stroke was 43.6 per 100 000. Death rates were 41.7 for white males, 67.1 for black males, 41.1 for white females, and 57.0 for black females.³⁰

• In 2006, death rates for stroke were 35.9 for Hispanic or Latino males and 32.3 for females, 39.8 for Asian or Pacific Islander males and 34.9 for females, and 25.8 for American Indian/Alaska Native males and 30.9 for females.³⁴

• From 1995 to 1998, age-standardized mortality rates for ischemic stroke, subarachnoid hemorrhage, and intracerebral hemorrhage were higher among blacks than whites. Death rates from intracerebral hemorrhage also were higher among Asians/Pacific Islanders than among whites. All minority populations had higher death rates from subarachnoid hemorrhage than did whites. Among adults 25 to 44 years of age, blacks and American Indians/Alaska Natives had higher risk ratios than did whites for all 3 stroke subtypes.³⁵

• In 2002, death certificate data showed that the mean age at stroke death was 79.6 years; however, males had a younger mean age at stroke death than females. Blacks, American Indians/Alaska Natives, and Asians/Pacific Islanders had younger mean ages than whites, and the mean age at stroke death was also younger among Hispanics than non-Hispanics.³⁶

• Age-adjusted stroke mortality rates began to level off in the 1980s and stabilized in the 1990s for both men and women, according to the Minnesota Heart Study. Women had lower rates of stroke mortality than did men throughout the period. Some of the improvement in stroke mortality may be the result of improved acute stroke care, but most is thought to be the result of improved detection and treatment of hypertension.³⁷

• A report released by the CDC in collaboration with the Centers for Medicare and Medicaid Services (CMS), the Atlas of Stroke Hospitalizations Among Medicare Beneficiaries, found that in Medicare beneficiaries, 30-day mortality rate varied by age: 9% in patients 65 to 74 years of age, 13.1% in those 74 to 84 years of age, and 23% in those ?85 years of age.³⁸

Stroke Risk Factors

(See Table 5-2 for data on modifiable stroke risk factors.)

• TIAs confer a substantial short-term risk of stroke, hospitalization for CVD events, and death. Of 1707 TIA patients evaluated in the ED of Kaiser Permanente Northern California, a large integrated healthcare delivery system, 180 (10%) experienced a stroke within 90 days. Ninety-one patients (5%) had a stroke within 2 days. Predictors of stroke included age >60 years, diabetes mellitus, focal symptoms of weakness or speech impairment, and TIA that lasted >10 minutes.³⁹

• BP is a powerful determinant of risk for both ischemic stroke and intercranial hemorrhage. Subjects with BP <120/80 mm Hg have approximately half the lifetime risk of stroke of subjects with hypertension.

• AF is a powerful risk factor for stroke, independently increasing risk ?5-fold throughout all ages. The percentage of strokes attributable to AF increases steeply from 1.5% at 50 to 59 years of age to 23.5% at 80 to 89 years of age.^40,41

• The risk of ischemic stroke associated with current cigarette smoking has been shown to be approximately double that of nonsmokers after adjustment for other risk factors (FHS, CHS, HHP, NHLBI).

• Age-specific incidence rates and rate ratios show that diabetes increases ischemic stroke incidence at all ages, but this risk is most prominent before 55 years of age in blacks and before 65 years of age in whites.⁴²

• In a recent ARIC/NHLBI study of a biracial population 45 to 64 years of age, with an average follow-up of 13.4 years, researchers found that blacks had a 3-fold higher multivariate-adjusted risk ratio of lacunar stroke than whites. In this middle-aged population, the top 3 risk factors based on the population-attributable fraction for lacunar stroke were hypertension (population-attributable fraction, 33.9%), diabetes mellitus (26.3%), and current smoking (22.0%).⁴³

• In the Framingham Offspring Study, 2040 individuals free of clinical stroke had an MRI scan to detect silent cerebral infarct (SCI). Prevalent SCI was associated with the Framingham Stroke Risk Profile score (OR, 1.27; 95% CI, 1.10 to 1.46), hypertension (OR, 1.56; 95% CI, 1.15 to 2.11), elevated plasma homocysteine (OR, 2.23; 95% CI, 1.42 to 3.51), AF (OR, 2.16; 95% CI, 1.07 to 4.40), carotid stenosis >25% (OR, 1.62; 95% CI, 1.13 to 2.34), and increased carotid intimal-medial thickness (OR, 1.65; 95% CI, 1.22 to 2.24).⁴⁴

• In the FHS of the NHLBI, in participants <65 years of age, the risk of developing stroke/TIA was 4.2-fold higher in those with symptoms of depression. After adjustment for components of the Framingham Stroke Risk Profile and education, similar results were obtained. In subjects ?65 years of age, use of antidepressant medications did not alter the risk associated with depressive symptoms. Identification of depressive symptoms at younger ages may have an impact on the primary prevention of stroke.⁴⁵

• Data from the HHP/NHLBI found that in Japanese men 71 to 93 years of age, low concentrations of high-density lipoprotein (HDL) cholesterol were more likely to be associated with a future risk of thromboembolic stroke than were high concentrations.⁴⁶

Female Sex as a Risk Factor for Stroke

• Analysis of NHANES 1999 to 2004 data found that women 45 to 54 years of age are more than twice as likely as men to have suffered a stroke. Women in the 45- to 54-year age group had a >4-fold higher likelihood of having had a stroke than women 35 to 44 years of age.⁴⁷

• Stroke is a major health issue for women, particularly for postmenopausal women, which raises the question of whether increased incidence is due to aging or to hormone status and whether hormone therapy affects risk.⁴⁸

• Among postmenopausal women who were generally healthy, the Women’s Health Initiative (WHI), a randomized trial of 16 608 women (95% of whom had no preexisting CVD), found that estrogen plus progestin increased ischemic stroke risk by 44%, with no effect on hemorrhagic stroke. The excess risk was apparent in all age groups, in all categories of baseline stroke risk, and in women with and without hypertension or prior history of CVD.⁴⁹

• In the WHI trial, among 10 739 women with hysterectomy, it was found that conjugate equine estrogen alone increased the risk of ischemic stroke by 55% and that there was no significant effect on hemorrhagic stroke. The excess risk of total stroke conferred by estrogen alone was 12 additional strokes per 10 000 person-years.⁵⁰

• In postmenopausal women with known CHD, the Heart and Estrogen/Progestin Replacement Study (HERS), a secondary CHD prevention trial, found that a combination of estrogen plus progestin (conjugated equine estrogen [0.625 mg] and medroxyprogesterone acetate [2.5 mg]) hormone therapy did not reduce stroke risk.⁵¹

• The Women’s Estrogen for Stroke Trial (WEST) found that estrogen alone (1 mg of 17?-estradiol) in women with a mean age of 71 years also had no significant overall effect on recurrent stroke or fatality, but there was an increased rate of fatal stroke and an early increase in overall stroke rate in the first 6 months of therapy.⁵²

• Overall, randomized clinical trial data indicate that the use of estrogen plus progestin, as well as estrogen alone, increases stroke risk in postmenopausal, generally healthy women and provides no protection for women with established heart disease.^49,53

• An observational study of >37 000 women ?45 years of age participating in the Women’s Health Study suggests that a healthy lifestyle that consists of abstinence from smoking, low BMI, moderate alcohol consumption, regular exercise, and a healthy diet was associated with a significantly reduced risk of total and ischemic stroke, but not of hemorrhagic stroke.⁵⁴

• Analysis of data from the FHS found that women with menopause at 42 to 54 years of age and at ?55 years of age had lower stroke risk compared with those with menopause <42 years of age, even after adjustment for potential confounders. Women with menopause before 42 years of age had twice the stroke risk compared with all other women in different age groups.⁵⁵

Pregnancy as a Risk Factor for Stroke

• The risk of ischemic stroke or intracerebral hemorrhage during pregnancy and the first 6 weeks postpartum was 2.4 times greater than for nonpregnant women of similar age and race, according to the Baltimore-Washington Cooperative Young Stroke Study. The risk of ischemic stroke during pregnancy was not increased during pregnancy per se but was increased 8.7-fold during the 6 weeks postpartum. Intracerebral hemorrhage showed a small RR of 2.5 during pregnancy but increased dramatically to an RR of 28.3 in the 6 weeks postpartum. The excess risk of stroke (all types except subarachnoid hemorrhage) attributable to the combined pregnancy/postpregnancy period was 8.1 per 100 000 pregnancies.⁵⁶

• In the US Nationwide Inpatient Sample from 2000 to 2001, the rate of events per 100 000 pregnancies was 9.2 for ischemic stroke, 8.5 for intracerebral hemorrhage, 0.6 for cerebral venous thrombosis, and 15.9 for the ill-defined category of pregnancy-related cerebrovascular events, for a total rate of 34.2 per 100 000, not including subarachnoid hemorrhage. The risk was increased in blacks and among older women. Death occurred during hospitalization in 4.1% of women with these events and in 22% of survivors after discharge to a facility other than home.⁵⁷

Physical Inactivity as a Risk Factor for Stroke

• Higher levels of PA are associated with lower stroke risk. Results from the Physicians’ Health Study showed a 14% lower RR of stroke associated with vigorous exercise (exercise ?5 times per week) among men.⁵⁸ The Harvard Alumni Study showed that men who were highly physically active had an 18% lower RR of total stroke.⁵⁹ More recently, a clear inverse relationship between stroke incidence and increasing levels of combined work and leisure activity was shown in the EPIC-Norfolk study of 22 602 men and women, with a nearly 40% RR reduction in the most active category. In sex-stratified analysis, the trend was not significant in women.⁶⁰

• For women in the Nurses’ Health Study, RRs for total stroke from the lowest to the highest PA levels were 1.00, 0.98, 0.82, 0.74, and 0.66, respectively.⁶¹

• NOMAS (NINDS), which included white, black, and Hispanic men and women in an urban setting, showed a decrease in ischemic stroke risk associated with PA levels across all racial/ethnic and age groups and for each gender (OR 0.37).⁶²

• PA—whether in sports, during leisure time, or at work—was related to lower risk of ischemic stroke during follow-up of the ARIC/NHLBI cohort.⁶³

• A meta-analysis including 31 observational studies conducted mainly in the United States and Europe found that moderate and high levels of leisure-time and occupational PA was associated with lower risks of total stroke, hemorrhagic stroke, and ischemic stroke.⁶⁴

Awareness of Stroke Warning Signs and Risk Factors

• In the 2005 BRFSS among respondents in 14 states, 38.1% were aware of 5 stroke warning symptoms and would first call 9-1-1 if they thought that someone was having a heart attack or stroke. Awareness of all 5 stroke warning symptoms and calling 9-1-1 was higher among whites versus blacks and Hispanics (41.3%, 29.5%, and 26.8% respectively), women versus men (41.5% versus 34.5%), and persons with higher versus lower educational attainment (47.6% for persons with a college degree or more versus 22.5% for those who had not received a high school diploma). Among states, the same measure ranged from 27.9% (Oklahoma) to 49.7% (Minnesota).⁶⁵

• A study was conducted of patients admitted to an ED with possible stroke to determine their knowledge of the signs, symptoms, and risk factors of stroke. Of the 163 patients able to respond, 39% did not know a single sign or symptom. Patients ?65 years of age were less likely than those <65 years old to know a sign or symptom of stroke (28% versus 47%), and 43% did not know a single risk factor. Overall, almost 40% of patients did not know the signs, symptoms, and risk factors of stroke.⁶⁶

• A study of >2100 respondents to a random-digit telephone survey in Cincinnati, Ohio, in 2000 showed that 70% of respondents correctly named at least 1 established stroke warning sign (versus 57% in 1995), and 72% correctly named at least 1 established risk factor (versus 68% in 1995).^67,68 In the 1995 survey,⁶⁸ respondents ?75 years of age were less likely to correctly list 1 warning sign and to list 1 risk factor.

• Among patients recruited from the Academic Medical Center Consortium, the CHS, and United HealthCare, only 41% were aware of their increased risk for stroke. Approximately 74% recalled being told of their increased stroke risk by a physician, compared with 28% who did not recall this. Younger patients, depressed patients, those in poor current health, and those with a history of TIA were most likely to be aware of their risk.⁶⁹

• An AHA-sponsored random-digit dialing telephone survey was conducted in mid-2003. Only 26% of women >65 years of age reported being well informed about stroke. Correct identification of the warning signs of stroke was low among all age and racial/ethnic groups.⁷⁰

• Among participants in a study by the National Stroke Association, 2.3% reported having been told by a physician that they had had a TIA. Of those with a TIA, only 64% saw a physician within 24 hours of the event, only 8.2% correctly related the definition of TIA, and 8.6% could identify a typical symptom. Men, persons of color, and those with lower income and fewer years of education were less likely to be knowledgeable about TIA.²¹

• Insufficient awareness persists in the general medical community with regard to risk factors, warning signs, and prevention strategies for stroke. A survey of 308 internal medicine residency programs showed that only 46% required the study of neurology, whereas 97% required the study of cardiology. Under-representation of neurology training in internal medicine residency programs may lead to an under-recognition of stroke signs and symptoms by physicians and affect stroke outcome.⁷¹

• In 2004, 800 adults ?45 years of age were surveyed to assess their perceived risk for stroke and their history of stroke risk factors. Overall, 39% perceived themselves to be at risk. Younger age, current smoking, a history of diabetes, high BP, high cholesterol, heart disease, and stroke/TIA were independently associated with perceived risk for stroke. Respondents with AF were no more likely to report being at risk than were respondents without AF. Perceived risk for stroke increased as the number of risk factors increased; however, 46% of those with ?3 risk factors did not perceive themselves to be at risk.⁷²

• A study of patients who have had a stroke found that only 60.5% were able to accurately identify 1 stroke risk factor and that 55.3% were able to identify 1 stroke symptom. Patients’ median delay time from onset of symptoms to admission in the ED was 16 hours, and only 31.6% accessed the ED in <2 hours. Analysis showed that the appearance of nonmotor symptoms as the primary symptom and nonuse of the 9-1-1 system were significant predictors of delay >2 hours. Someone other than the patient made the decision to seek treatment in 66% of the cases.⁷³

• Spanish-speaking Hispanics are far less likely to know all heart attack symptoms and less likely to know all stroke symptoms than English-speaking Hispanics, non-Hispanic blacks, and non-Hispanic whites. Lack of English proficiency is strongly associated with lack of heart attack and stroke knowledge among Hispanics.⁷⁴

• In the Reasons for Geographic and Racial Differences in Stroke Study (REGARDS/NINDS), black participants were more aware than whites of their hypertension and more likely to be undergoing treatment if aware of their diagnosis, but among those treated for hypertension, they were less likely than whites to have their BP controlled. There was no evidence of a difference between the “stroke belt” and other regions in awareness of hypertension, but there was a trend for better treatment and BP control in the stroke belt region. The lack of substantial geographic differences in hypertension awareness and the trend toward better treatment and control in the stroke belt suggest that differences in hypertension management may not be a major contributor to the geographic disparity in stroke mortality.⁷⁵

Aftermath

Stroke is a leading cause of serious, long-term disability in the United States (Survey of Income and Program Participation [SIPP], a survey of the US Bureau of the Census).⁷⁶

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

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

  •    —The proportions of patients dead 1 year after a first stroke were as follows:

    •       ?At ?40 years of age: 21% of men and 24% of women.

    •       ?At 40 to 69 years of age: 14% of white men, 20% of white women, 19% of black men, and 19% of black women.

    •       ?At ?70 years of age: 24% of white men, 27% of white women, 25% of black men, and 22% of black women.

  •    —The proportions of patients dead within 5 years after a first stroke were as follows:

    •       ?At ?40 years of age: 47% of men and 51% of women.

    •       ?At 40 to 69 years of age: 32% of white men, 32% of white women, 34% of black men, and 42% of black women.

    •       ?At ?70 years of age: 58% of white men, 58% of white women, 49% of black men, and 54% of black women.

  •    —Of those who have a first stroke, the proportions with a recurrent stroke in 5 years were as follows:

    •       ?At 40 to 69 years of age: 13% of men and 22% of women.

    •       ?At ?70 years of age: 23% of men and 28% of women.

    •       ?At 40 to 69 years of age: 15% of white men, 17% of white women, 10% of black men, and 27% of black women.

    •       ?At ?70 years of age: 23% of white men, 27% of white women, 16% of black men, and 32% of black women.

  •    —The median survival times after a first stroke were:

    •       ?At 60 to 69 years of age: 6.8 years for men and 7.4 years for women.

    •       ?At 70 to 79 years of age: 5.4 years for men and 6.4 years for women.

    •       ?At ?80 years of age: 1.8 years for men and 3.1 years for women.

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

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

  •    —50% had some hemiparesis.

  •    —30% were unable to walk without some assistance.

  •    —26% were dependent in ADL.

  •    —19% had aphasia.

  •    —35% had depressive symptoms.

  •    —26% were institutionalized in a nursing home.

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

• After stroke, women have greater disability than men. A Michigan-based stroke registry found that 33% of women had moderate to severe disability (mRS ?4) at discharge, compared with 27% of men. In a study of 108 stroke survivors from FHS, 34% of women were disabled at 6 months (BI <60), compared with 16% of men. In the Kansas City Stroke Study, women had a 30% lower probability of achieving independence (BI ?95) by 6 months compared with men. In the Michigan registry, women had a 63% lower probability of achieving ADL independence (BI ?95) 3 months after discharge.^81–84

Hospital Discharges/Ambulatory Care Visits

• From 1996 to 2006, the number of inpatient discharges from short-stay hospitals with stroke as the first listed diagnosis declined from 956 000 to 889 000 (NHDS, NCHS). The decrease was observed in men and women ?65 years of age.⁸⁵

• In 2005, there was a hospitalization rate of 77.3 stays per 10 000 persons >45 years of age for cerebrovascular disease. There has been a decline in the hospitalization rate for different types of cerebrovascular disease between 1997 and 2005, with the exception of hemorrhagic stroke. Between 1997 and 2005, the hospitalization rate for ischemic stroke decreased by 34%, from 54.4 to 35.9 stays per 10 000 persons. The hospitalization rate for transient cerebral ischemia also decreased ?23% during this period. Similarly, the hospitalization rate for occlusion or stenosis of precerebral arteries steadily decreased by 30% between 1997 and 2005, from 18.4 to 12.8 stays per 10 000 persons. In contrast, the hospitalization rate for hemorrhagic stroke remained relatively stable during this period.⁸⁶

• Data from 2006 from the Hospital Discharge Survey of the NCHS showed that the average length of stay for discharges with stroke as the first-listed diagnosis was 4.9 days.⁸⁷

• In 2007, the number of ambulatory care visits with stroke as the first-listed diagnosis was 3 764 000 (NAMCS, NHAMCS/NCHS).⁸⁸

• In 2003, men and women accounted for roughly the same number of hospital stays for stroke in the 18- to 44-year age group. After 65 years of age, women were the majority. Among persons 65 to 84 years of age, 54.5% of stroke patients were women, whereas among the oldest age group, women constituted 69.7% of all stroke patients.⁸⁹

• A first-ever county-level Atlas of Stroke Hospitalizations Among Medicare Beneficiaries was released in 2008 by the CDC in collaboration with the Centers for Medicare and Medicaid Services. It found that the stroke hospitalization rate for blacks was 27% higher than for the US population in general, 30% higher than for whites, and 36% higher than for Hispanics. In contrast to whites and Hispanics, the highest percentage of strokes in blacks (42.3%) occurred in the youngest age group (65 to 74 years of age).³⁸

Stroke in Children

Stroke in children peaks in the perinatal period. In the NHDS/NCHS, from 1980 to 1998, the rate of stroke for infants <30 days old (per 100 000 live births per year) was 26.4, with rates of 6.7 for hemorrhagic stroke and 17.8 for ischemic stroke.⁹⁰

• A history of infertility, preeclampsia, prolonged rupture of membranes, and chorioamnionitis were found to be independent risk factors for radiologically confirmed perinatal arterial ischemic stroke in Kaiser Permanente of Northern California, a large integrated healthcare delivery system. The RR of perinatal stroke increased ?25-fold, with an absolute risk of 1 per 200 deliveries, when ?3 of the following antenatally determined risk factors were present: infertility, preeclampsia, chorioamnionitis, prolonged rupture of membranes, primiparity, oligohydramnios, decreased fetal movement, prolonged second stage of labor, and fetal heart rate abnormalities.⁹¹

• The overall incidence rate of all strokes in children <15 years of age was 6.4 per 100 000 in 1999, a nonsignificant increase compared with 1988. The 30-day case fatality rates were 18% in 1988 to 1989, 9% in 1993 to 1994, and 9% in 1999. The incidence of stroke in children has been stable over the past 10 years. The previously reported nationwide decrease in overall stroke mortality in children might be due to decreasing case fatality after stroke and not decreasing stroke incidence. It was conservatively estimated that ?3000 children and adults <20 years of age had a stroke in the United States in 2004.⁹²

• Stroke in childhood and young adulthood has a disproportionate impact on the affected patients, their families, and society compared with stroke at older ages. Outcome of childhood stroke was a moderate or severe deficit in 42% of cases.⁹³

• Boys have a 1.28-fold higher risk of stroke and a higher case-fatality rate for ischemic stroke than girls. Compared with the stroke risk of white children, black children have a higher RR of 2.12, Hispanics have a lower RR of 0.76, and Asians have a similar risk. The increased risk among blacks is not fully explained by the presence of sickle cell disease, nor is the excess risk among boys fully explained by trauma.⁹⁴

• Despite current treatment, 1 of 10 children with ischemic stroke will have a recurrence within 5 years.⁹⁵

• Cerebrovascular disorders are among the top 10 causes of death in children, with rates highest in the first year of life. Stroke mortality in children <1 year of age has remained the same over the past 40 years.⁹⁶

• From 1979 to 1998 in the United States, childhood mortality resulting from stroke declined by 58% overall, with reductions in all major subtypes.⁹⁷

  •    —Ischemic stroke decreased by 19%, subarachnoid hemorrhage by 79%, and intracerebral hemorrhage by 54%.

  •    —Black ethnicity was a risk factor for death resulting from all stroke types.

  •    —Male sex was a risk factor for death caused by subarachnoid hemorrhage and intracerebral hemorrhage, but not for death resulting from ischemic stroke.

• Sickle cell disease is the most important cause of ischemic stroke among black children. The Stroke Prevention Trial in Sickle Cell Anemia (STOP) demonstrated the efficacy of blood transfusions for primary stroke prevention in high-risk children with sickle cell disease in 1998. First-admission rates for stroke in California among persons <20 years of age with sickle cell disease showed a dramatic decline subsequent to the publication of the STOP study. For the study years 1991 to 1998, 93 children with sickle cell disease were admitted to California hospitals with a first stroke; 92.5% of these strokes were ischemic, and 7.5% were hemorrhagic. The first-stroke rate was 0.88 per 100 person-years during 1991 to 1998 compared with 0.50 in 1999 and 0.17 in 2000 (P<0.005 for trend).⁹⁸

Access to Stroke Care

• In 2008, there were 322 diplomates receiving initial certification in Vascular Neurology by the American Board of Psychiatry and Neurology.⁹⁹

• A 2004 survey conducted by the American Academy of Neurology revealed that 40% of the 6298 US neurologists responding considered cerebrovascular disease a focus practice area.¹⁰⁰

• In 2002, ?21% of US counties did not have a hospital, 31% lacked a hospital with an ED, and 77% did not have a hospital with neurological services.¹⁰¹

• The median time from stroke onset to arrival in an ED is between 3 and 6 hours, according to a study of at least 48 unique reports of prehospital delay time for patients with stroke, TIA, or stroke-like symptoms. The study included data from 17 countries, including the United States. Improved clinical outcome at 3 months was seen for patients with acute ischemic stroke when intravenous thrombolytic treatment was started within 3 hours of symptom onset.¹⁰²

• Of patients with ischemic stroke in the California Acute Stroke Pilot Registry, 23.5% arrived at the ED within 3 hours of symptom onset, and 4.3% received thrombolysis. If all patients had called 9-1-1 immediately, the expected overall rate of thrombolytic treatment within 3 hours would have increased to 28.6%. If all patients with known onset had arrived within 1 hour and had been optimally treated, 57% could have received thrombolytic treatment.¹⁰³

• Data from the Paul Coverdell National Acute Stroke Registry were analyzed from the 142 hospitals that participated in the 4 registry states. Among the >17 600 patients in the study, 66.1% were ?65 years of age. Women were older than men, and whites were older than blacks. Ischemic stroke (65%) was the most common subtype, followed by TIA (24%) and hemorrhagic stroke (9.7%). More patients were transported by ambulance than by other means (43.6%). Time of stroke symptom onset was recorded for 44.8% of the patients. Among these patients, 48% arrived at the ED within 2 hours of symptom onset. Significantly fewer blacks (42.4%) arrived within 2 hours of symptom onset than did whites (49.5%), and significantly fewer nonambulance patients (36.2%) arrived within 2 hours of symptom onset than did patients transported by ambulance (58.6%). The median arrival time for all patients with known time of onset was 2.0 hours. Sixty-five percent of patients who arrived at the ED within 2 hours of onset received imaging within 1 hour of ED arrival. Significantly fewer women (62%) received imaging within 1 hour of ED arrival than men.¹⁰⁴

• Patients with a discharge diagnosis of ischemic stroke were identified in 7 California hospitals participating in the California Acute Stroke Pilot Registry. Six points of care were tracked: thrombolysis, receipt of antithrombotic medications within 48 hours, prophylaxis for deep vein thrombosis, smoking cessation counseling, and prescription of lipid-lowering and antithrombotic medications at discharge. Overall, rates of optimal treatment improved for patients treated in year 2 versus year 1, with 63% receiving a perfect score in year 2 versus 44% in year 1. Rates improved significantly in 4 of the 6 hospitals and for 4 of the 6 interventions. A seventh hospital that participated in the registry but did not implement standardized orders showed no improvement in optimal treatment.¹⁰⁵

• A population-based study performed in a biracial population of 1.3 million in Ohio in 1993 and 1994 showed that 8% of all ischemic stroke patients presented to an ED within 3 hours and met other eligibility criteria for treatment with recombinant tissue plasminogen activator (rtPA). Even if time were not an exclusion criterion for use of rtPA, only 29% of all ischemic strokes in the population would have otherwise been eligible for rtPA.¹⁰⁶

Operations and Procedures

In 2006, an estimated 99 000 inpatient endarterectomy procedures were performed in the United States. Carotid endarterectomy is the most frequently performed surgical procedure to prevent stroke. (NHDS, NCHS)

Cost

The estimated direct and indirect cost of stroke for 2010 is $73.7 billion.

• In 2006, $3.9 billion ($7449 per discharge) was paid to Medicare beneficiaries discharged from short-stay hospitals for stroke.¹⁰⁷

• The mean lifetime cost of ischemic stroke in the United States is estimated at $140 048. This includes inpatient care, rehabilitation, and follow-up care necessary for lasting deficits. (All numbers were converted to 1999 dollars by use of the medical component of the Consumer Price Index.)¹⁰⁸

• In a study of stroke costs within 30 days of an acute event between 1987 to 1989 in the Rochester Stroke Study, the average cost was $13 019 for mild ischemic strokes and $20 346 for severe ischemic strokes (4 or 5 on the Rankin Disability Scale).¹⁰⁹

• Inpatient hospital costs for an acute stroke event account for 70% of first-year poststroke costs.¹⁰⁸

• The largest components of acute-care costs were room charges (50%), medical management (21%), and diagnostic costs (19%).¹¹⁰

• Death within 7 days, subarachnoid hemorrhage, and stroke while hospitalized for another condition are associated with higher costs in the first year. Lower costs are associated with mild cerebral infarctions or residence in a nursing home before the stroke.¹⁰⁹

• Demographic variables (age, sex, and insurance status) are not associated with stroke cost. Severe strokes (NIHSS score >20) cost twice as much as mild strokes, despite similar diagnostic testing. Comorbidities such as ischemic heart disease and AF predict higher costs.^110,111 The total cost of stroke from 2005 to 2050, in 2005 dollars, is projected to be $1.52 trillion for non-Hispanic whites, $313 billion for Hispanics, and $379 billion for blacks. The per capita cost of stroke estimates is highest in blacks ($25 782), followed by Hispanics ($17 201) and non-Hispanic whites ($15 597). Loss of earnings is expected to be the highest cost contributor in each race-ethnic group.⁹⁶