The interstitial fluid is that part of the ECF that is outside the vascular and lymph systems, bathing the cells. About a third of the total body water is extracellular; the remaining two thirds is intracellular intracellular fluid. Inappropriate compartmentalization of the body fluids can result in edema Clinical Box 1—1.

Edema is the build up of body fluids within tissues. The increased fluid is This div only appears when the trigger link is hovered over. Otherwise it is hidden from view. About MyAccess If your institution subscribes to this resource, and you don't have a MyAccess Profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus. Sign in via OpenAthens. Sign in via Shibboleth. Clinical Sports Medicine Collection. Search Advanced search allows to you precisely focus your query.

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Doing so can lead to serious misinterpretation of time trends. Mortality data are presented according to the underlying cause of death. 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.


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The first set of statistics for each disease in this Update includes the number of deaths for which the disease is the underlying cause. High BP, or hypertension, increases the mortality risks of CVD and other diseases, and HF should be 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: In this publication, we have used national population estimates from the US Census Bureau for in the computation of morbidity data.

NCHS population estimates for were used in the computation of death rate data. The Census Bureau World Wide Web site 1 contains these data, as well as information on the file layout. 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.

Ambulatory care visit data include patient visits to physician offices and hospital outpatient departments and EDs. Ambulatory care visit data reflect the first-listed primary diagnosis. Morbidity illness and mortality death data in the United States have a standard classification system: 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. 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 ICDCM. 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 standard population by the direct method.

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 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 Because NHANES is conducted only in the noninstitutionalized population, we extrapolated the rates to the total US population in , 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 Numbers of visits to physician offices , hospital EDs , and hospital outpatient departments are for Except as noted, economic cost estimates are for For data on hospitalizations, physician office visits, and mortality, CVD is defined according to ICD codes given in Chapter 25 of the present document. This definition includes all diseases of the circulatory system, as well as congenital CVD.

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. Direct all media inquiries to News Media Relations at gro. 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: See Tables through and Charts through Prevalence unadjusted estimates for poor, intermediate, and ideal cardiovascular health for each of the 7 metrics of cardiovascular health in the American Heart Association goals, US children aged 12 to 19 years, National Health and Nutrition Examination Survey NHANES — available data as of June 1, Incidence of cardiovascular disease according to the number of ideal health behaviors and health factors.

Reprinted from Folsom et al 2 with permission of the publisher. Standardized to the age distribution of the US standard population. No children meet all 7 criteria. Age-standardized prevalence estimates of US adults meeting different numbers of criteria for ideal cardiovascular health, overall and by age and sex subgroups, National Health and Nutrition Examination Survey NHANES — available data as of June 1, No adults meet all 7 criteria.

Age-standardized prevalence estimates of US adults meeting different numbers of criteria for ideal cardiovascular health, overall and in selected race subgroups from National Health and Nutrition Examination Survey NHANES — available data as of June 1, US age-standardized death rates attributable to cardiovascular diseases, and Data derived from Heron et al 4 and Xu et al.

These data include coronary heart disease, heart failure, stroke, and hypertension. Data include congenital cardiovascular disease mortality. Data include those inpatients discharged alive, dead, or of unknown status. Data include estimated direct and indirect costs for Because of overlap across conditions, it is not possible to add these conditions to arrive at a total. 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 potential beneficial effects of healthy lifestyle factors and lower CVD risk factor burden on CVD outcomes and longevity.

See Table and Charts through US adults 33 to 45 years of age. Data derived from Loria et al. Mean values of carotid intima-media thickness IMT for different carotid artery segments in older adults, by race. Data derived from Manolio et al. Atherosclerosis, a systemic disease process in which fatty deposits, inflammation, cells, and scar tissue build up within the walls of arteries, is the underlying cause of the majority of clinical cardiovascular events.

Individuals who develop atherosclerosis tend to develop it in a number of different types of arteries large and small arteries and those feeding the heart, brain, kidneys, and extremities , although they may have much more in some parts of the body than others. In recent decades, advances in imaging technology have allowed for improved ability to detect and quantify atherosclerosis at all stages and in multiple different vascular beds. Two modalities, computed tomography CT of the chest for evaluation of coronary artery calcification CAC and B-mode ultrasound of the neck for evaluation of carotid artery intima-media thickness IMT , have been used in large studies with outcomes data and may help define the burden of atherosclerosis in individuals before they develop clinical events such as heart attack or stroke.

Another commonly used method for detecting and quantifying atherosclerosis in the peripheral arteries is the ankle-brachial index ABI , which is discussed in Chapter Data on cardiovascular outcomes are starting to emerge for additional modalities that measure anatomic and functional measures of subclinical disease, including brachial artery reactivity testing, aortic and carotid magnetic resonance imaging, and tonometric methods of measuring vascular compliance or microvascular reactivity.

Further research may help to define the role of these techniques in cardiovascular risk assessment. There are still limited data demonstrating whether screening with these and other imaging modalities can improve patient outcomes or whether it only increases downstream medical care costs. A recently published report in a large cohort randomly assigned to coronary calcium screening or not showed such screening to result in an improved risk factor profile without increasing downstream medical costs. US adults 45 to 84 years of age.

Data derived from Bild et al. US adults 45 to 84 years of age reference group: Data derived from Detrano et al. Hazard ratios HRs for coronary heart disease events associated with coronary calcium scores: US adults reference group: Coronary heart disease events included nonfatal myocardial infarction and death attributable to coronary heart disease. Data derived from Greenland et al. A recent report in individuals who had baseline and repeat cardiac CT found that progression of CAC in predicting future all-cause mortality provided only incremental information over baseline score, demographics, and cardiovascular risk factors.

Mean values of carotid intima-media thickness IMT for different carotid artery segments in younger adults by race and sex Bogalusa Heart Study. Data derived from Urbina et al. CT angiography is widely used by cardiologists to aid in the diagnosis of CAD, particularly when other test results may be equivocal. It is also of interest because of its ability to detect and possibly quantitate overall plaque burden and certain characteristics of plaques that may make them prone to rupture, such as positive remodeling or low attenuation.

However, because of the limited outcome data in asymptomatic people, as well as the associated expense and risk of CT angiography including generally higher radiation levels than CT scanning to detect CAC , current guidelines do not recommend its use as a screening tool for assessment of cardiovascular risk in asymptomatic people.

ICD-9 to , See Tables and See Charts through Prevalence of coronary heart disease by age and sex National Health and Nutrition Examination Survey: Prevalence of low coronary heart disease risk, overall and by sex National Health and Nutrition Examination Survey: Ellipses indicate data not available. These data are based on self-reports. National Center for Health Statistics these data represent underlying cause of death only.

National Hospital Discharge Survey, National Center for Health Statistics data include those inpatients discharged alive, dead, or status unknown. AP indicates angina pectoris; NH, non-Hispanic; and ellipses, data not available. AP is chest pain or discomfort that results from insufficient blood flow to the heart muscle. Stable AP is predictable chest pain on exertion or under mental or emotional stress.

The incidence estimate is for AP without myocardial infarction. AP uncomplicated by a myocardial infarction or with no myocardial infarction Framingham Heart Study to — of the original cohort and to — of the Offspring Cohort, National Heart, Lung, and Blood Institute. National Hospital Discharge Survey, National Center for Health Statistics; data include those inpatients discharged alive, dead, or status unknown.

Annual rate of first heart attacks by age, sex, and race Atherosclerosis Risk in Communities Surveillance: National Heart, Lung, and Blood Institute. Estimated year coronary heart disease risk in adults 55 years of age according to levels of various risk factors Framingham Heart Study. HDL-C indicates high-density lipoprotein cholesterol. Data derived from Wilson et al. See Table and Chart Hospital discharges for coronary heart disease by sex United States: 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. Decisions about medical and interventional treatments are based on specific findings noted when a patient presents with ACS. Rate for women 45—54 years of age considered unreliable. These are included as a portion of total deaths attributable to CHD. See Tables and and Charts through Trends in carotid revascularization procedures.

Reproduced with permission from Goodney et al. NH indicates non-Hispanic; ellipses … indicate data not available. Age-specific percentages are extrapolated to the US population. Mortality data for white and black males and females include Hispanics. Data include those inpatients discharged alive, dead, or status unknown. Adapted from Goldstein et al. Stroke death rates, — Rates are spatially smoothed to enhance the stability of rates in counties with small populations.

International Classification of Diseases, 10th Revision codes for stroke: For prevalence and other information on any of these specific risk factors, refer to the specific risk factor chapters:. See Table for data on modifiable stroke risk factors. Among stroke or TIA patients with high-grade carotid stenosis, carotid endarterectomy has been the recommended treatment for the prevention of stroke, whereas carotid stenting has been proposed as a therapeutic option for patients at high risk for surgical revascularization.

Trends in carotid endarterectomy procedures United States: Hypertension Awareness, Treatment, and Control: HBP mortality in was 61 The death rate was See Tables through These data represent underlying cause of death only; data for white and black males and females include Hispanics. Inpatient mortality rate after all types of cardiac surgery was 4. Nevertheless, mortality risk varies substantially for different defect types, from 0. Fifty-five percent of operations were performed in males.

In unadjusted analysis, mortality after cardiac surgery was somewhat higher for males than for females 5. Congenital cardiovascular defects, also known as congenital heart defects, are structural problems that arise from abnormal formation of the heart or major blood vessels.

ICD-9 lists 25 congenital heart defects codes, of which 21 designate specified anatomic or hemodynamic lesions. Defects range in severity from tiny pinholes between chambers that may resolve spontaneously to major malformations that can require multiple surgical procedures before school age and may result in death in utero, in infancy, or in childhood. The common complex defects include the following:. Congenital heart defects are serious and common conditions that have significant impact on morbidity, mortality, and healthcare costs in children and adults.

The most commonly reported incidence of congenital heart defects in the United States is between 4 and 10 per , clustering around 8 per live births. Major defects may be apparent in the prenatal or neonatal period, but minor defects may not be detected until adulthood. Detection rates have increased since the advent of cardiac ultrasound. Because most estimates are available for new cases detected between birth and the first year of life, birth prevalence is the best proxy for incident congenital heart defects.

These are typically reported as cases per live births per year and do not distinguish between tiny defects that resolve without treatment and major malformations. To distinguish more serious defects, some studies also report new cases of sufficient severity to require an invasive procedure or that result in death within the first year of life. Despite the absence of true incidence figures, some data are available and are provided in Table The 32nd Bethesda Conference estimated that the total number of adults living with congenital HD in the United States in was Estimates of the distribution of lesions in the congenital heart defects population using available data vary with assumptions made.

If all those born were treated, there would be survivors with simple lesions, with moderate lesions, and with complex lesions; in addition, there would be 3 subjects alive with bicuspid aortic valves. The actual numbers surviving are projected to be between these 2 sets of estimates as of 1 decade ago. Mortality related to congenital cardiovascular defects in was Any-mention mortality related to congenital cardiovascular defects in was Although the most common congenital lesions were shunts, including patent ductus arteriosus, VSDs, and ASDs, TOF accounted for a higher proportion of in-hospital death than any other birth defect.

Between and , hospitalization rates increased by Hospital discharges for heart failure by sex United States: Hospital discharges include people discharged alive, dead, and status unknown. Resuscitation Outcomes Consortium Investigators, unpublished data, June 20, Out-of-hospital cardiac arrest is defined as a sudden and unexpected pulseless condition attributable to cessation of cardiac mechanical activity. 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.

For additional details on out-of-hospital and in-hospital arrest treatment and outcomes, please refer to Chapter 21, Quality of Care. National Center for Health Statistics; data represent underlying cause of death only. Mortality and any-mention mortality in this section are for Prevalence data are for Hospital discharge data for are based on ICD-9 codes.

Hospital discharges—28 , primary plus secondary diagnoses. Author manuscript; available in PMC May Go , MD, Donald M. Berry , MD, William B. Borden , MD, Dawn M. Kissela , MD, Steven J. Virani , MD, Nathan D. Author information Article notes Copyright and License information Disclaimer. AHA Statistical Update, cardiovascular diseases, epidemiology, risk factors, statistics, stroke. The publisher's final edited version of this article is available at Circulation. This article has been corrected. See other articles in PMC that cite the published article.

Summary Each year, the American Heart Association AHA , in conjunction with the Centers for Disease Control and Prevention, the National Institutes of Health, and other government agencies, brings together the most up-to-date statistics on heart disease, stroke, other vascular diseases, and their risk factors and presents them in its Heart Disease and Stroke Statistical Update.

The rates were From to , the rate of death attributable to CVD declined On the basis of mortality rate data, more than Americans die of CVD each day, an average of 1 death every 39 seconds. Coronary heart disease mortality in was It is estimated that an additional 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. Approximately of these are first attacks, and are recurrent attacks. On average, every 40 seconds, someone in the United States has a stroke.

From to , the stroke death rate fell In , 1 in 9 death certificates deaths in the United States mentioned heart failure. This amounts to an estimated 76 US adults with hypertension. The prevalence of hypertension is nearly equal between men and women. Table High Blood Pressure. Population Group Prevalence, All Ages Hospital Discharges, All Ages Estimated Cost, Both sexes 76 Open in a separate window. The percentage of the nonsmoking population with detectable serum cotinine indicating exposure to secondhand smoke declined from In , an estimated 18 Americans had diagnosed diabetes mellitus, representing 8.

An additional 7 had undiagnosed diabetes mellitus, and DM indicates diabetes mellitus; and NH, non-Hispanic. Table Overweight and Obesity. Ages 2—19 y Prevalence of Obesity in Children, — Among children 2 to 19 years of age, Mexican American boys and girls and African American girls are disproportionately affected. 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, degenerative joint disease, and many others.

The prevalence of diabetes mellitus is increasing dramatically over time, in parallel with the increases in prevalence of overweight and obesity. In , among adolescents in grades 9 through 12, 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 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 CVDs. Cardiovascular Procedure Utilization and Costs Chapter 22 provides data on trends and current usage of cardiovascular surgical and invasive procedures. The surveys used are: Medical Expenditure Panel Survey MEPS —data on specific health services that Americans use, how frequently they use them, the cost of these services, and how the costs are paid.

Nationwide Inpatient Sample of the Agency for Healthcare Research and Quality—hospital inpatient discharges, procedures, and charges. Disease Prevalence Prevalence is an estimate of how many people have a disease at a given point or period in time. 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. Mortality Mortality data are presented according to the underlying cause of death. Population Estimates In this publication, we have used national population estimates from the US Census Bureau for in the computation of morbidity data.

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. International Classification of Diseases Morbidity illness and mortality death data in the United States have a standard classification system: 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 standard population by the direct method.

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 from rates reported in a community- or hospital-based study or multiple studies. Cardiovascular Disease For data on hospitalizations, physician office visits, and mortality, CVD is defined according to ICD codes given in Chapter 25 of the present document. Race Data published by governmental agencies for some racial groups are considered unreliable because of the small sample size in the studies.

US Census Bureau population estimates. National Center for Health Statistics; International Classification of Diseases, Ninth Revision: Age standardization of death rates: Natl Vital Stat Rep. World Health Statistics Annual. World Health Organization; Percent BP ideal among adults, — Among US adults Chart , the age-standardized prevalence of ideal levels of cardiovascular health behaviors and factors currently varies from 0. In general, the prevalence of ideal levels of health behaviors and health factors is higher in US children than in US adults.

Age-standardized and age-specific prevalence estimates for ideal cardiovascular health and for ideal levels of each of its components are shown in Table The prevalence of ideal levels of all of the 7 health factors and health behaviors decreases dramatically from younger to older ages. Chart displays the prevalence estimates for the population of US children meeting different numbers of criteria for ideal cardiovascular health out of 7 possible. Half of US children ages 12 to 19 years meet 4 or fewer criteria for ideal cardiovascular health.

Charts and display the age-standardized prevalence estimates for the population of US adults meeting different numbers of criteria for ideal cardiovascular health out of 7 possible , overall and stratified by age groups, sex, and race. Women tend to have more metrics at ideal levels than do men Chart Chart displays the age-standardized percentages of US adults and percentages of children who have 5 or more of the metrics out of 7 possible at ideal levels. Whites have approximately twice the percentage of adults with 5 or more metrics with ideal levels as Mexican Americans.

Chart displays the age-standardized percentages of US adults meeting different numbers of criteria for poor and ideal cardiovascular health. Meeting the AHA Strategic Impact Goals is predicated on reducing the relative percentage of those with poor levels while increasing the relative percentage of those with ideal levels for each of the 7 metrics. The prevalence of risk factors and their awareness, treatment, and control are displayed in Table separately for those with and without self-reported CVD.

Death rates attributable to stroke, heart diseases HDs , and other cardiovascular causes were Prognosis of Ideal Cardiovascular Health Folsom et al 2 recently published the first examination of the community prevalence of ideal cardiovascular health and its association with incident CVD events in 12 white and African American participants of the ARIC study aged 45 to 64 years at baseline who were followed up for up to 20 years.

There was a stepwise decrease in the year incidence of CVD events defined as stroke, HF, MI, or fatal coronary disease with greater numbers of health metrics at ideal levels. Age-, sex-, and race-adjusted CVD incidence rates per person-years were Thus, year CVD incidence rates for those with 6 ideal health metrics were one-tenth those of participants with 0 ideal health metrics. The pattern of outcomes across number of ideal health metrics was similar for African-Americans and whites.

Importantly, both ideal health behaviors and ideal health factors were associated in a stepwise fashion with lower CVD risk Chart Implications Taken together, these data continue to indicate the substantial progress that will need to occur for the AHA to achieve its Impact Goals over the next decade. If the goals can be met, there is evidence suggesting that CVD event rates could decrease significantly. To achieve improvements in cardiovascular health, all segments of the population will need to focus on improved cardiovascular health behaviors, in particular with regard to diet and weight, as well as on an increase in PA and further reduction of the prevalence of smoking.

More children, adolescents, and young adults will need to learn how to preserve their ideal levels of cardiovascular health factors and health behaviors into older ages. With regard to reducing the burden of CVD and stroke morbidity and mortality, renewed emphasis will be needed on treatment of acute events and secondary and primary prevention through treatment and control of risk factors.

As shown in Table , relatively modest changes in population levels of health factors could result in important changes in the prevalence of overall and ideal cardiovascular health. Further reductions in BP would mean even more people would achieve ideal levels. Such modest reductions could result from decreased salt intake at the population level of as little as 1 to 2 g per day, with significant projected decreases in CVD rates in US adults.

Defining and setting national goals for cardiovascular health promotion and disease reduction: Community prevalence of ideal cardiovascular health, by the American Heart Association definition, and relationship with cardiovascular disease incidence. J Am Coll Cardiol. Projected effect of dietary salt reductions on future cardiovascular disease. N Engl J Med. US maps corresponding to state death rates including the District of Columbia. Table Cardiovascular Diseases.

Among whites only, Among blacks or African Americans, Among Hispanics or Latinos, 8. Among American Indians or Alaska Natives, Among Native Hawaiians or other Pacific Islanders, The average annual rates of first cardiovascular events rise from 3 per men at 35 to 44 years of age to 74 per 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 attributable to CHD occur in men than in women, and a higher proportion of events attributable 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 population. Among women, it ranges from 9 to 15 per Median overall survival was 30 years for men and 36 years for women. Mortality data show that CVD I00—I99, Q20—Q28 as the listed underlying cause of death including congenital cardiovascular defects accounted for CVD any-mentions 1 deaths in constituted In every year since except , CVD accounted for more deaths than any other major cause of death in the United States.

In the same year period, the actual number of CVD deaths per year declined Among other causes of death in , cancer caused deaths; CLRD, ; accidents, ; and Alzheimer disease, 82 There were 40 deaths due to breast cancer in females in ; lung cancer claimed 70 in females. Death rates for females were One in 31 deaths in females was attributable to breast cancer, whereas 1 in 6.

For comparison, 1 in 4. If all forms of cancer were eliminated, the estimated gain could be 3 years. In older men, they were diseases of the heart No. Analysis of data from NCHS was used to determine the number of disease-specific deaths attributable to all non-optimal levels of each risk factor exposure, by age and sex. High dietary salt, low dietary omega-3 fatty acids, and high dietary trans fatty acids were the dietary risks with the largest estimated excess mortality effects. 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. In , 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. 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 , the rate of awareness of CVD as the leading cause of death had nearly doubled since , was significantly greater for whites than for blacks and Hispanics, and was independently correlated with increased 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. A total of 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. The prevalence of multiple risk factors ranged from Adults who reported being unable to work had the highest prevalence Data from the Chicago Heart Association Detection Project —, with an average follow-up of 31 years showed that in younger women 18—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. In men, the highest prevalence of obesity Black women with or without a high school education had a high prevalence of obesity Hypertension prevalence was high among blacks 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. CVD mortality at all ages tended to be highest in blacks. Total DM 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.

Furthermore, the prevalence of participants with elevated risk factors was higher in black subjects; after accounting for education and known CVD 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. These results suggest that the primary prevention of elevated risk factors might substantially impact the future incidence of CVD, and these beneficial effects would likely be applicable not only for white but also for black subjects.

Among those told that they had HD, Among those ever told that they had indicators of HD, Younger people 18—44 years of age were more likely A greater percentage of those 18 to 44 years of age had a healthy weight Non-Hispanic whites were more likely than Hispanics or non-Hispanic blacks to engage in moderate-to-vigorous PA Non-Hispanic whites were more likely to have maintained a healthy weight than were Hispanics or non-Hispanic blacks Hispanics were more likely to be nonsmokers Women were more likely than men to have maintained a healthy weight A greater percentage of adults with at least some college education had a healthy weight There was a greater percentage of nonsmokers among those with a college education Participants 18—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.

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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 and not the direction of the association. 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.

Addition of family history of premature CVD to a model that contained traditional risk factors provided modestly improved prognostic value in the FHS. Parental history of premature CHD is associated with increased burden of subclinical atherosclerosis in the coronary arteries and the abdominal aorta. The HealthStyles survey of people 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.

An accurate and complete family history may identify rare mendelian conditions such as hypertrophic cardiomyopathy HCM , long-QT syndrome, or familial hypercholesterolemia. However, in the majority of people 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 individuals 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 potential beneficial effects of healthy lifestyle factors and lower CVD risk factor burden on CVD outcomes and longevity.

Remaining lifetime risks for atherosclerotic CVD events were only 5. 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.

Heart Disease and Stroke Statistics— Update

During follow-up, those with low predicted lifetime risk also had less progression of coronary calcium. In another study, FHS investigators followed up 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. Factors associated with survival to the age of 85 years included female sex, lower SBP, 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 UA , HF, stroke, dementia, and cancer were nearly identical. Dietary recommendations, in general, and daily fruit intake recommendations, in particular, were least likely to be followed.

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—59 years of age. However, remaining lifetime risks for non-CVD death also increased dramatically with increasing CVD risk factor burden.

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These data help to explain the markedly greater longevity experienced by those who reach middle age free of major CVD risk factors. 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.

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. Hospital admissions that originated in the ED accounted for In , coronary artery disease CAD was estimated to be responsible for 1. There was no difference between men and women in hospitalizations for cardiac dysrhythmias. Circulatory disorders were the most frequent reason for admission to the hospital through the ED, accounting for Stroke and irregular heart beat ranked seventh and eighth, respectively.

Among current home healthcare patients in , Among patients discharged from hospice in , Operations and Procedures In , an estimated 7 inpatient cardiovascular operations and procedures were performed in the United States; 4. Summary health statistics for U. National Health Interview Survey, Vital Health Stat Health Characteristics of the Asian Adult Population: Forecasting the future of cardiovascular disease in the United States: National Heart, Lung, and Blood Institute; Strong Heart Study Data Book: A Report to American Indian Communities.

Prediction of lifetime risk for cardiovascular disease by risk factor burden at 50 years of age. Centers for Disease Control and Prevention. Decennial Life Tables for —91, Vol. Explaining the decrease in U. The preventable causes of death in the United States: J Womens Health Larchmt ; Awareness, knowledge, and perception of heart disease among adolescents. Eur J Cardiovasc Prev Rehabil. Favorable cardiovascular risk profile in young women and long-term risk of cardiovascular and all-cause mortality.

Low risk-factor profile and long-term cardiovascular and noncardiovascular mortality and life expectancy: State of disparities in cardiovascular health in the United States. Secular trends in cardiovascular disease risk factors according to body mass index in US adults [published correction appears in JAMA.

Absolute and attributable risks of cardiovascular disease incidence in relation to optimal and borderline risk factors: Atherosclerosis Risk in Communities Study. Agency for Healthcare Research and Quality; Mar, Adult Civilian Noninstitutionalized Population, Comparison of risk factors for cardiovascular mortality in black and white adults. Association between language and risk factor levels among Hispanic adults with hypertension, hypercholesterolemia, or diabetes. Parental history and myocardial infarction risk across the world: Parental cardiovascular disease as a risk factor for cardiovascular disease in middle-aged adults: Sibling cardiovascular disease as a risk factor for cardiovascular disease in middle-aged adults.

Development and validation of improved algorithms for the assessment of global cardiovascular risk in women: Parental occurrence of premature cardiovascular disease predicts increased coronary artery and abdominal aortic calcification in the Framingham Offspring and Third Generation cohorts. Family history of premature coronary heart disease and coronary artery calcification: Association of parental heart failure with risk of heart failure in offspring. Sudden death and myocardial infarction in first degree relatives as predictors of primary cardiac arrest.

Prevalence and progression of subclinical atherosclerosis in younger adults with low short-term but high lifetime estimated risk for cardiovascular disease: Cardiovascular risk factors predictive for survival and morbidity-free survival in the oldest-old Framingham Heart Study participants. J Am Geriatr Soc. Primary prevention of coronary heart disease in women through diet and lifestyle. S adults embraced most heart healthy behaviors in — Risk factor burden in middle age and lifetime risks for cardiovascular and non-cardiovascular death Chicago Heart Association Detection Project in Industry Am J Cardiol.

Mediterranean diet, lifestyle factors, and year mortality in elderly European men and women: Major coronary risk factors and death from coronary heart disease: Favorable cardiovascular risk profile in middle age and health-related quality of life in older age. Benefit of a favorable cardiovascular risk-factor profile in middle age with respect to Medicare costs. Agency for Healthcare Research and Quality; Feb, Hospital Stays for Circulatory Diseases, Agency for Healthcare Research and Quality; Sep, The National Hospital Bill: The Most Expensive Conditions, by Payer, Elixhauser A, Jiang HJ.

Agency for Healthcare Research and Quality; May, Hospitalizations for Women With Circulatory Disease, Elixhauser A, Owens P. Health Care Financing Review: Centers for Medicare and Medicaid Services; General cardiovascular risk profile for use in primary care: Subclinical Atherosclerosis See Table and Charts through CAC indicates coronary artery calcification.

Other components of the atherosclerotic plaque, including fatty eg, cholesterol-rich components and fibrotic components, often accompany CAC and may be present even in the absence of CAC.

Heart Disease and Stroke Statistics—2012 Update

Chart shows the prevalence of CAC by ethnicity and sex. The prevalence of CAC was lower in black men than in white men but was similar in black and white women at these ages. Chart shows the prevalence of CAC by sex and ethnicity. The prevalence and 75th percentile levels of CAC were highest in white men and lowest in black and Hispanic women.

Table shows the 75th percentile levels of CAC by sex and race at selected ages. These findings may have important implications for population screening for subclinical atherosclerosis. Using US Census block-group-level data, among women, higher odds of CAC were associated with higher neighborhood deprivation and lower neighborhood cohesion.

Among all men, neither neighborhood deprivation nor neighborhood cohesion was associated with CAC, whereas among men in deprived neighborhoods, low cohesion was associated with higher odds of CAC. CAC provided similar predictive value for coronary events in whites, Chinese, blacks, and Hispanics HRs ranging from 1. In another report of a community-based sample, not referred for clinical reasons, the South Bay Heart Watch examined CAC in adults average age 66 years with coronary risk factors, with a median of 7.

Increasing CAC scores further predicted risk in intermediate- and high-risk groups. In a study of healthy adults 60 to 72 years of age who were free of clinical CAD, predictors of the progression of CAC were assessed. Insulin resistance, in addition to the traditional cardiac risk factors, independently predicts progression of CAC. It is noteworthy, as recently demonstrated in MESA in participants with a median of 5. The contribution of CAC to risk prediction has also been observed in other cohorts, including both the Heinz Nixdorf Recall study 14 and the Rotterdam study.

CAC Progression and Risk A recent report in individuals who had baseline and repeat cardiac CT found that progression of CAC in predicting future all-cause mortality provided only incremental information over baseline score, demographics, and cardiovascular risk factors. Carotid IMT Background Carotid IMT measures the thickness of 2 layers the intima and media of the wall of the carotid arteries, the largest conduits of blood going to the brain.

Carotid IMT is thought to be an even earlier manifestation of atherosclerosis than CAC, because thickening precedes the development of frank atherosclerotic plaque. Carotid IMT methods are still being refined, so it is important to know which part of the artery was measured common carotid, internal carotid, or bulb and whether near and far walls were both measured. This information can affect the average-thickness measurement that is usually reported. Unlike CAC, everyone has some thickness to the layers of their arteries, but people who develop atherosclerosis have greater thickness.

Ultrasound of the carotid arteries can also detect plaques and determine the degree of narrowing of the artery they may cause. Although ultrasound is commonly used to diagnose plaque in the carotid arteries in people who have had strokes or who have bruits sounds of turbulence in the artery , guidelines are limited as to screening of asymptomatic people with carotid IMT to quantify atherosclerosis or predict risk. However, some organizations have recognized that carotid IMT measurement by B-mode ultrasonography may provide an independent assessment of coronary risk.

These men and women were healthy but overweight. The mean values of carotid IMT for the different segments are shown in Chart by sex and race.


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Men had significantly higher carotid IMT in all segments than women, and blacks had higher common carotid and carotid bulb IMTs than whites. Participants with greater numbers of adverse risk factors 0, 1, 2, 3, or more had stepwise increases in mean carotid IMT levels. In a subsequent analysis, the Bogalusa investigators examined the association of risk factors measured since childhood with carotid IMT measured in these young adults. These data highlight the importance of adverse risk factor levels in early childhood and young adulthood in the early development of atherosclerosis.

Chinese participants had the lowest carotid IMT, in particular in the internal carotid, of the 4 ethnic groups Chart Mean maximal common carotid IMT was 1. After a mean follow-up of 6. After adjustment for other risk factors, there was still a 2- to 3-fold greater risk for the top versus the bottom quintile. Conflicting data have been reported on the contribution of carotid IMT to risk prediction. There was a modest but statistically significant improvement in the area under the receiver operating characteristic curve, from 0.

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. Ten-year and lifetime risks for CVD were estimated for each participant, and the participants were stratified into 3 groups: The latter group had the highest burden and greatest progression of subclinical atherosclerosis.

These data confirm the importance of early exposure to risk factors for the onset and progression of subclinical atherosclerosis. CT Angiography CT angiography is widely used by cardiologists to aid in the diagnosis of CAD, particularly when other test results may be equivocal. Arterial tonometry offers the ability to directly and noninvasively measure central pulse wave velocity in the thoracic and abdominal aorta. Brachial flow-mediated dilation FMD is a marker for nitric oxide release from the endothelium that can be measured by ultrasound.

Recommendations have not been specific, however, as to which, if any, measures of vascular function may be useful for CVD risk stratification in selected patient subgroups. Because of the absence of significant prospective data relating these measures to outcomes, latest guidelines do not currently recommend measuring either FMD or arterial stiffness for cardiovascular risk assessment in asymptomatic adults. They found that as aortic pulse wave velocity increased, the risk of CHD was 1. The FHS measured several indices of arterial stiffness, including pulse wave velocity, wave reflection, and central pulse pressure.

Assessment of coronary artery disease by cardiac computed tomography: Impact of coronary artery calcium scanning on coronary risk factors and downstream testing: Defining normal distributions of coronary artery calcium in women and men from the Framingham Heart Study Am J Cardiol. Early adult risk factor levels and subsequent coronary artery calcification: Ethnic differences in coronary calcification: Do neighborhood socioeconomic deprivation and low social cohesion predict coronary calcification? Coronary calcium as a predictor of coronary events in four racial or ethnic groups.

Coronary artery calcium score combined with Framingham score for risk prediction in asymptomatic individuals [published correction appears in JAMA. Insulin resistance independently predicts the progression of coronary artery calcification. Impact of subclinical atherosclerosis on cardiovascular disease events in individuals with metabolic syndrome and diabetes: Coronary artery calcium score and risk classification for coronary heart disease prediction.

Coronary risk stratification, discrimination, and reclassification improvement based on quantification of subclinical coronary atherosclerosis: Coronary calcium score improves classification of coronary heart disease risk in the elderly: Progression of coronary artery calcium predicts all-cause mortality. Impact of multiple coronary risk factors on the intima-media thickness of different segments of carotid artery in healthy young adults the Bogalusa Heart Study Am J Cardiol.

Childhood cardiovascular risk factors and carotid vascular changes in adulthood: Carotid-artery intima and media thickness as a risk factor for myocardial infarction and stroke in older adults. Carotid ultrasound identifies high risk subclinical atherosclerosis in adults with low Framingham risk scores. J Am Soc Echocardiogr. Carotid intima-media thickness and presence or absence of plaque improves prediction of coronary heart disease risk: Is carotid intima media thickness useful for individual prediction of cardiovascular risk?

Ethnic differences in the relationship of carotid atherosclerosis to coronary calcification: Coronary artery calcification compared with carotid intima-media thickness in the prediction of cardiovascular disease incidence: Arterial stiffness and risk of coronary heart disease and stroke: