Executive Summary: Heart Disease and Stroke Statistics—2013 Update

The 2013 Update Expands Data Coverage of the Epidemic of Poor Cardiovascular Health Behaviors and Their Antecedents and Consequences

• Adjusted population attributable fractions for cardiovascular disease (CVD) mortality were as follows¹: 40.6% (95% confidence interval [CI], 24.5–54.6) for high blood pressure; 13.7% (95% CI, 4.8–22.3) for smoking; 13.2% (95% CI, 3.5–29.2) for poor diet; 11.9% (95% CI, 1.3–22.3) for insufficient physical activity; and 8.8% (95% CI, 2.1–15.4) for abnormal glucose levels.

• Despite 4 decades of progress, in 2011, among Americans ≥18 years of age, 21.3% of men and 16.7% of women continued to be cigarette smokers. In 2011, 18.1% of students in grades 9 through 12 reported current cigarette use.

• The percentage of the nonsmoking population with detectable serum cotinine (indicating exposure to secondhand smoke) declined from 52.5% in 1999 to 2000 to 40.1% in 2007 to 2008, with declines higher for those 3 to 11 years of age (–53.6%) and those 12 to 19 years of age (–46.5%) than for those 20 years of age and older (–36.7%).

• 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 2011, among adolescents in grades 9 through 12, 17.7% of girls and 10.0% of boys 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 7 days per week.

• Thirty two percent of adults reported engaging in no aerobic leisure-time physical activity.

• Data from the National Health and Nutrition Examination Survey (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).

• The increases in calories consumed during this time period are attributable primarily to greater average carbohydrate intake, in particular, 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 estimated prevalence of overweight and obesity in US adults (≥20 years of age) is 154.7 million, which represents 68.2% of this group in 2010. Fully 34.6% 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.

• Among children 2 to 19 years of age, 31.8% are overweight and obese (which represents 23.9 million children) and 16.9% are obese (12.7 million children). Mexican American boys and girls and African American girls are disproportionately affected. Over the past 3 decades, the prevalence of obesity in children 6 to 11 years of age has increased from ≈4% to >20%.

• 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 mellitus, CVD end points (including coronary heart disease, stroke, and heart failure), and numerous other health conditions, including asthma, cancer, end-stage renal disease, degenerative joint disease, and many others.

Prevalence and Control of Cardiovascular Health Factors and Risks Remains an Issue for Many Americans

• An estimated 31.9 million adults ≥20 years of age have total serum cholesterol levels ≥240 mg/dL, with a prevalence of 13.8%.

• Based on 2007 to 2010 data, 33.0% of US adults ≥20 years of age have hypertension. This represents 78 million US adults with hypertension. The prevalence of hypertension is nearly equal between men and women. African American adults have among the highest prevalence of hypertension (44%) in the world.

• Among hypertensive adults, ≈82% are aware of their condition and 75% are using antihypertensive medication, but only 53% of those with documented hypertension have their condition controlled to target levels.

• In 2010, an estimated 19.7 million Americans had diagnosed diabetes mellitus, representing 8.3% of the adult population. An additional 8.2 million had undiagnosed diabetes mellitus, and 38.2% 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 mellitus in the United States.

• The prevalence of diabetes mellitus 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).

Rates of Death Attributable to CVD Have Declined, but the Burden of Disease Remains High

• The 2009 overall rate of death attributable to CVD (International Classification of Diseases, 10th Revision, codes I00–I99) was 236.1 per 100 000. The rates were 281.4 per 100 000 for white males, 387.0 per 100 000 for black males, 190.4 per 100 000 for white females, and 267.9 per 100 000 for black females.

• From 1999 to 2009, the relative rate of death attributable to CVD declined by 32.7%. Yet in 2009, CVD (I00–I99; Q20–Q28) still accounted for 32.3% (787 931) of all 2 437 163 deaths, or 1 of every 3 deaths in the United States.

• On the basis of 2009 death rate data, >2150 Americans die of CVD each day, an average of 1 death every 40 seconds. About 153 000 Americans who died of CVD (I00–I99) in 2009 were <65 years of age. In 2009, 34% of deaths attributable to CVD occurred before the age of 75 years, which is well before the average life expectancy of 78.5 years.

• Coronary heart disease alone caused ≈1 of every 6 deaths in the United States in 2009. In 2009, 386 324 Americans died of coronary heart disease. Each year, an estimated ≈635 000 Americans have a new coronary attack (defined as first hospitalized myocardial infarction or coronary heart disease death) and ≈280 000 have a recurrent attack. It is estimated that an additional 150 000 silent first myocardial infarctions occur each year. Approximately every 34 seconds, 1 American has a coronary event, and approximately every 1 minute, an American will die of one.

• From 1999 to 2009, the relative rate of stroke death fell by 36.9% and the actual number of stroke deaths declined by 23.0%. Yet each year, ≈795 000 people continue to experience a new or recurrent stroke (ischemic or hemorrhagic). Approximately 610 000 of these are first attacks, and 185 000 are recurrent attacks. In 20ss09, stroke caused ≈1 of every 19 deaths in the United States. On average, every 40 seconds, someone in the United States has a stroke and dies of one approximately every 4 minutes.

• In 2009, 1 in 9 death certificates (274 601 deaths) in the United States mentioned heart failure. Heart failure was the underlying cause in 56 410 of those deaths in 2009. The number of any-mention deaths attributable to heart failure was approximately as high in 1995 (287 000) as it was in 2009 (275 000). Additionally, hospital discharges for heart failure remained essentially unchanged from 2000 to 2010, with first-listed discharges of 1 008 000 and 1 023 000, respectively.

The 2013 Update Provides Critical Data About 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 CVD risk factors and conditions. The Statistical Update provides these critical data in several sections.

Quality-of-Care Metrics for CVDs

Quality data are available from the AHA’s “Get With The Guidelines” programs for coronary artery disease and heart failure and from the American Stroke Association/AHA’s “Get With The Guidelines” program for acute stroke. Similar data from the Veterans Healthcare Administration, national Medicare and Medicaid data, and Acute Coronary Treatment and Intervention Outcomes Network (ACTION)–“Get With The Guidelines” Registry data are also reviewed. These data show impressive adherence to guideline recommendations for many, but not all, metrics of quality of care for these hospitalized patients. Data are also reviewed on screening for CVD risk factor levels and control.

Cardiovascular Procedure Use and Costs

• The total number of inpatient cardiovascular operations and procedures increased 28%, from 5 939 000 in 2000 to 7 588 000 in 2010 (National Heart, Lung, and Blood Institute computation based on National Center for Health Statistics annual data).

• The total direct and indirect cost of CVD and stroke in the United States for 2009 is estimated to be $312.6 billion. This figure includes health expenditures (direct costs, which include the cost of physicians and other professionals, hospital services, prescribed medications, home health care, and other medical durables) and lost productivity that results from morbidity and premature mortality (indirect costs).

• By comparison, in 2008, the estimated cost of all cancer and benign neoplasms was $228 billion ($93 billion in direct costs, $19 billion in morbidity indirect costs, and $116 billion in mortality indirect costs). CVD costs more than any other diagnostic group.

The AHA, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current data available in the Statistics Update.

Finally, it must be noted that this annual Statistical Update is the product of an entire year’s worth of effort by dedicated professionals, volunteer physicians and scientists, and outstanding AHA staff members, without whom publication of this valuable resource would be impossible. Their contributions are gratefully acknowledged.

Alan S. Go, MD

Melanie B. Turner, MPH

On behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee

Note: Population data used in the compilation of NHANES prevalence estimates are for the latest year of the NHANES survey being used. Extrapolations for NHANES prevalence estimates are based on the census resident population for 2010 because this is the most recent year of NHANES data used in the Statistical Update.