|
An Overview Of Cardiovascular Disease Burden In The United States
Cardiovascular disease (CVD) is the leading cause of death and a major cause of disability worldwide. In the United States, CVD accounted for 34.4 percent of the 2.4 million deaths in 2003 and remain a major cause of health disparities and rising health care costs. In 2006, health care spending and lost productivity from CVD exceeded $400 billion. The aging population, obesity epidemic, underuse of prevention strategies, and suboptimal control of risk factors could exacerbate the future CVD burden. Increased adherence to clinical and community-level guidelines and renewed emphasis on policy, environmental, and lifestyle changes will be crucial for its effective prevention and control.
WORLD WIDE, CARDIOVASCULAR DISEASE (CVD) is the leading cause of death and a major cause of disability and lost productivity in adults.1 In the United States, heart disease and stroke—the principal components of CVD—rank first and third, respectively, among the leading causes of death.2 The term CVD, as used in this paper, includes rheumatic fever (International Classification of Diseases, Tenth Revision [ICD-10] codes I00–I02 and I05–I09); hypertensive diseases (I10–I15); ischemic heart diseases (I20–I25); pulmonary heart disease and diseases of pulmonary circulation (I26–I28); other forms of heart disease (I30–I52); cerebrovascular diseases or stroke (I60–I69); diseases of arteries, arterioles, and capillaries (I70–I79); other diseases of veins, lymphatic vessels, and lymph nodes (I80–I89); other and unspecified disorders of the circulatory system (I95–I99); and congenital malformations or birth defects of the circulatory system (Q20–Q28).3 These diseases are common and occur in infants, children, and adults of both sexes, and they affect people of all races and ethnicities. The lifetime risk for a forty-year-old developing coronary heart disease is roughly 50 percent in men and 32 percent in women.4 In this paper we present an overview of the CVD burden in the United States using epidemiologic data on the magnitude and trends of CVD and their implications for policy and program development for cardiovascular health promotion and CVD prevention.
Prevalence and incidence. An estimated one in three U.S. adults (about 71.3 million) have one or more types of CVD.5 The prevalence increases with advancing age and varies within racial, ethnic, geographic, and sociodemographic groups. Among the 71.3 million adults with one or more forms of CVD, the most prevalent conditions are hypertension or high blood pressure (65 million), coronary heart disease (13.2 million), stroke (5.5 million), heart failure (5 million), and congenital heart defects (1 million).6 Exhibit 1  shows the prevalence of four major CVD categories.
Although advancing age is the most powerful risk factor for CVD, about 62 percent of adults living with CVD are younger than age sixty-five. In particular, men and women ages 55–64 are a special concern. In this age group, 52.0 percent of men and 56.5 percent of women live with one or more forms of CVD.7 Children and young adults also represent an important age group. Although the overall incidence of CVD in children and young adults is low (600 cases per year), sudden cardiac death accounts for one in five unexpected sudden deaths among children ages 1–13 and for one in three among those ages 14–21.8 Congenital heart defects, a common cause of infant death from birth defects, affect thousands of newborns each year.9
Mortality.
Heart disease and stroke are the first and third leading causes of death in the United States, respectively.10 These two disease categories accounted for 34.4 percent of the 2.4 million deaths in 2003 (Exhibit 2
The remarkable declines in the age-adjusted death rate from heart disease and stroke represent one of the greatest public health achievements of the twentieth century.16 Since 1940, the age-adjusted mortality rate has declined more than 56 percent for heart disease and more than 70 percent for stroke.17 Outpatient and emergency department visits for heart disease and stroke. Outpatient visits to physicians’ offices and admissions or discharges from emergency departments (EDs) represent another important measure of the burden of CVD. In 2003 alone, there were nearly 70.7 million outpatient physician office visits and 4.5 million ED admissions with a primary diagnosis of CVD.18 High blood pressure, acute and chronic heart failure, and chest pain (that may represent life-threatening conditions such as a heart attack) are among the chief reasons for outpatient physician office visits and ED admissions. For example, outpatient and ED data for 1999–2000 showed that essential hypertension alone accounted for 37.5 million combined ambulatory care visits and represented the leading cause of outpatient visits.19
Hospitalization for heart disease and stroke.
CVD remains a leading cause of admissions or discharges from short-stay hospitals and nursing homes. For example, in 2003 heart disease as a first-listed diagnosis was the highest-ranked disease category for hospital discharges and represented a 31 percent increase over discharges in 1979.20 In fact, analysis of hospital discharge data for 1979–2003 shows sizable increases in hospitalization (expressed as a percentage) for major CVD, including coronary heart disease (16 percent), stroke (29 percent), and chronic heart failure (174 percent).21 Between 1970 and 2000, the total number of stroke-related hospitalizations increased among people age sixty-five or older (372,000 in 1970 versus 711,000 in 2000), although rates of hospitalization remained stable (20.7 per 1,000 in 1970 versus 20.4 per 1,000 in 2000).22 Rates were similar for men and women during this period, while rates for blacks increased from 14.0 per 1,000 in 1970 to 20.6 per 1,000 in 2000 (Exhibit 3
Economic burden of CVD. CVD is the most costly disease in the United States.24 Using data from multiple sources, the American Heart Association has compiled a detailed table of 2006 estimates of the direct and indirect costs of heart diseases, coronary heart disease, stroke, hypertensive heart disease, heart failure, and total CVD.25 The estimated health care spending and lost productivity (direct and indirect costs) of total CVD exceed $400 billion (Exhibit 4 ). Data from the 2003 Healthcare Costs and Utilization Project (HCUP) also show that the mean charges for individual cardiovascular procedures are among the most expensive and include at least two procedures with mean charges of $118,656 (for heart valve procedure) and $103,680 (for implantable defibrillator).26
Cardiovascular health disparities. Disparities in cardiovascular health and health care are pervasive and well documented.27 Although much progress has been made, striking disparities persist in many aspects of cardiovascular care by race/ethnicity, age group, and state, as noted earlier.28 In spite of impressive declines in mortality, marked disparities in CVD mortality persist within and between population subgroups defined by race/ethnicity or age. For example, Akira Sekikawa and Lewis Kuller found as much as a 2.5-fold difference in CHD mortality between black and white women ages 45–54, and a threefold difference among similarly aged white and black women by state.29 Similarly striking disparities in stroke mortality exist between blacks and whites and among blacks by state.30
Exhibit 5
Compared with white adults, hospitalization rates for hypertension in 2000 were six times higher among black adults ages 18–44, more than five times higher among blacks ages 45–64, and nearly three times higher among blacks age sixty-five and older.33 Hospitalization rates for angina and congestive heart failure were also much higher among blacks than among whites.34 Sex disparities in cardiovascular health care and mortality are also pervasive, although recent data show some major improvements. For example, Jeffrey Pearcy and Kenneth Keppel have shown that from 1989 to 1998, disparities in CVD mortality decreased based on sex but were largely unchanged based on race/ethnicity.35
Several important positive trends have been documented for CVD in the past century. The dramatic declines in age-adjusted mortality from heart disease, stroke, and total cardiovascular diseases and the major declines in population mean blood pressure and cholesterol levels represent key examples. Nevertheless, there are many powerful adverse patterns in CVD epidemiology that hold the potential for unraveling many of the public health achievements of the past century. Chief among these adverse trends is the graying of America. Advancing age is the most powerful risk factor for CVD; therefore, the aging of the U.S. population and the demographic changes projected for 2020 and beyond will have a major impact on the prevalence of and cost of care for CVD.36 Second, the continuing epidemics of childhood obesity and of obesity and type 2 diabetes in adults represent major public health challenges likely to increase the morbidity and mortality from CVD.37 In barely four decades, from 1963–1965 to 1999–2002, the prevalence of overweight nearly quadrupled (from 4.6 percent to 16.1 percent) in adolescents ages 12–19 and more than tripled (from 4.2 percent to 15.8 percent) in children ages 6–11. Among children ages 5–11, data from the Bogalusa Heart Study have shown that 27.1 percent now have one or more risk factors for heart disease and that an additional 6.9 percent have two or more risk factors.38 Taken together, these epidemiological findings are great cause for alarm. Third, the declining prevalence of adults with no known major CVD risk factors is another important concern. Using data from the Behavioral Risk Factor Surveillance System (BRFSS), we demonstrated that the proportion of adults with no self-reported major CVD risk factors declined from 42 percent in 1991 to 36 percent in 2001.39 The decline was noted in both men and women in nearly all states, racial/ethnic populations, age groups, and education levels.40 In addition, the self-reported prevalence of CVD risk factors (high blood pressure, high cholesterol, diabetes, and obesity) among U.S. adults increased, whereas the prevalence of smoking remained nearly the same during that decade.41 The recent reports of increasing prevalence of metabolic syndrome, a marker of CVD risk-factor clustering, also suggest that the prevalence of low CVD risk factor profiles is decreasing.42 The actual prevalence of truly low-risk people (those with favorable levels of measured blood cholesterol and blood pressure who do not smoke and do not have diagnosed diabetes, myocardial infarction, or electrocardiographic abnormalities) has been estimated at about 5–10 percent, much lower than self-reported in BRFSS data and most likely declining.43 Fourth, the increasing use of expensive diagnostic and therapeutic procedures is another important issue. Over the past two to three decades, the total number of inpatient diagnostic and therapeutic procedures have increased dramatically. For example, from 1979 to 2003, total inpatient operations and procedures for CVD increased 470 percent, and the volume of cardiac catheterizations alone increased 373 percent.44 The mean charges for these procedures have also increased greatly.45 These trends are highlighted not to suggest impropriety or inappropriate use of operations and procedures but to emphasize the potential impact that effective programs for preventing CVD can have on health care costs and resource use.
The social, environmental, and biological determinants and risk factors for CVD are well established.46 Safe and effective interventions are available for primordial, primary, and secondary prevention and control of CVD. Although adherence to established practice guidelines that promote these best practices is suboptimal, there is evidence that it is improving and that improved adherence has an effect on survival and quality of life.47 In fact, life-table analyses on the elimination of specific causes of death suggest that the gains from effective prevention and control of CVD would exceed those of any other cause of death: Life expectancy would rise by almost seven years, but only three years if cancer were eliminated as a cause of death.48 The gains in life expectancy predicted from the elimination of CVD is not surprising considering the important role that CVD plays as the leading cause of death. A similarly large impact on the reduction and eventual elimination of health disparities might also be seen because CVD contributes greatly to health disparities, particularly among people with fewer years of education and among African Americans.49 The availability of drug and nondrug strategies that could reduce cardiovascular events provides hope that CVD can be eliminated. The prevalence of many cardiovascular risk factors is declining in the United States, although increases in some risk factors are present, particularly among some population subgroups.50 Smoking prevalence continues to decline, and U.S. cigarette sales continue to fall.51 Declines in total cholesterol levels observed between 1960 and the early 1990s and in levels of low-density lipoprotein (LDL) cholesterol from the late 1970s to early 1990s in the United States continue.52 These advances are tempered by increases in the prevalence of hypertension, obesity, and diabetes.53 Although additional evidence is needed, the simultaneous reduction of four cardiovascular risk factors (LDL cholesterol, blood pressure, serum homocysteine, and platelet function) using one combination pill (so-called polypill) administered to people with existing CVD and everyone age fifty-five and older without any screening and without requiring risk factors to be measured has the potential to reduce ischemic heart disease events and strokes.54 Also, data from one study using an evidence-based recipe (Polymeal) that includes wine, fish, dark chocolate, fruits, vegetables, garlic, and almonds suggest the potential to reduce CVD events and increase life expectancy.55 Although intriguing, these findings and their policy implications remain controversial and deserve systematic evaluation. Nevertheless, the epidemiological data provide support for renewed emphasis on both individual level as well as populationwide strategies, including policy and environmental changes for cardiovascular health promotion and the aggressive prevention, treatment, and control of CVD risk factors in all settings including schools, worksites, health care providers, and the community at large. CARDIOVASCULAR DISEASES, principally heart disease and stroke, rank first and third, respectively, among the leading causes of death in the United States. They are also a leading cause of morbidity and are partly responsible for persisting and sometimes marked disparities in life expectancy and overall health. The rising hospitalization rate for major CVD and marked increase in inpatient operations and procedures also contributes greatly to rising health care costs. As the U.S. population ages and adverse trends of major risk factors including the epidemics of obesity and type 2 diabetes continue, CVD will take on even greater clinical, public health, and economic importance. The time has come for epidemiological data to play an even greater role in informing the development, implementation, and evaluation of cardiovascular health care policies. Applying the best available science through increased adherence to established clinical and community-level guidelines; comprehensive worksite health promotion programs; and renewed emphasis on supportive policy, environmental, and lifestyle changes beginning in infants, children, and young adults will be crucial for achieving the national Healthy People 2010 goals for CVD.56
George Mensah (GMensah{at}cdc.gov) is chief medical officer, Office of the Director, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, in Atlanta, Georgia. David Brown is an epidemiologist in the Division of Adult and Community Health in that center. The findings and conclusions in this paper are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.
This article has been cited by other articles:
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Top
The CVD Burden And...
Cardiovascular Disease And Cause...
