Heart disease is the leading cause of death in the United States and the third leading cause of years of potential life lost before the age of 65. Ischemic heart disease (IHD)* accounts for 71% of all deaths due to heart disease and 27% of all mortality (1).

Data from the National Center for Health Statistics' mortality public-use data tapes for 1985 were used to analyze the incidence of premature mortality due to IHD. Deaths from IHD were stratified by gender for each of the 50 states and the District of Columbia. Age-adjusted IHD death rates for all ages combined were computed from state population estimates for 1984, the latest year for which age- and gender-specific estimates are available (2). In addition, rates of premature mortality due to IHD per 100,000 persons aged 35-64 were computed for each gender and state (Table 1, see page 320). To facilitate interpretation, the states were grouped relative to the national rate (less than 90%, 90%-110%, and greater than 110% of the national rate).

Age-adjusted IHD death rates for 1985 show similar geographic patterns for both men and women. States experiencing age-adjusted rates more than 10% above the national mean were located in the Northeast and Midwest. States with age-adjusted rates at least 10% below the national mean were around Chesapeake Bay; in the Rocky Mountain, Northwest, and Southwest regions of the country; and in Alaska and Hawaii.

Rates of premature mortality due to IHD in 1985 were also high in the parts of the Northeast and Midwest that experienced higher rates of age-adjusted IHD deaths (Figures 1 and 2). Additionally, several states in the Southeast and Appalachian regions experienced premature mortality from IHD that was more than 10% above the national mean. With the addition of California and Connecticut, areas with IHD premature mortality rates at least 10% below the national mean were similar to those with low age-adjusted IHD deaths. Reported by: Epidemiology Br, Div of Nutrition, Center for Health Promotion and Education, CDC. Editorial Note: Current geographic variations in premature IHD rates are probably associated with long-term trends in overall IHD deaths (3-8). Although each age, sex, racial, and geographic group has experienced significant declines in deaths from IHD, significant differences exist. In 1950, the West Coast ranked as high as the East Coast states, but in the 1960s, the rate in the west began to decline (6). By 1978, the highest rates clustered in the Appalachian and Northeastern regions. These regional trends in premature mortality due to IHD were similar for men and women as well as for blacks and whites.

Some of the current differences in state-specific IHD premature mortality rates may result from sociodemographic differences or population shifts over time. Blacks have higher rates of premature IHD (9). In addition, although blacks and whites had similar rates of decline in IHD deaths from 1968-1975, the rate of decline among white females and blacks of both genders from 1975 to 1985 has been half that of white men (10).

Finally, variations among states in IHD premature mortality rates may reflect geographic differences in the availability or effectiveness of interventions against IHD or in the prevalence of risk factors, such as cigarette smoking, high levels of serum cholesterol, high blood pressure, overweight, and low levels of physical activity. A review of available evidence suggests that reductions in serum cholesterol and in cigarette smoking are responsible for over half of the decline in overall IHD death rates over the last 2 decades (11).

Geographic variations in premature IHD, rather than age-adjusted IHD deaths for all ages combined, should direct epidemiologists and public-health practitioners in examining regional or state-specific patterns of risk factors known to contribute to premature mortality due to IHD. Furthermore, an examination of the environmental, behavioral, and social factors underlying these differences in risk factors might be beneficial. These investigations may provide insight into the most promising prevention strategies. References

1. National Center for Health Statistics. Vital statistics of the United States, 1984. Vol II: Mortality, Part A. Washington, DC: US Department of Health and Human Services, Public Health Service, 1987; DHHS publication no. (PHS)87-1122.

2. Bureau of the Census. County population estimates (experimental) by age, sex, and race: 1980, 1982, and 1984 (machine-readable data file). Washington, DC: Bureau of the Census, Data User Services Division, 1987.

3. Enterline PE, Stewart WH. Geographic patterns in deaths from coronary heart disease. Public Health Rep 1956;71:849-55.

4. Sauer HI, Enterline PE. Are geographic variations in death rates for the cardiovascular diseases real? J Chronic Dis 1959;10:513-24.

5. Friedman GD. Cigarette smoking and geographic variation in coronary heart disease mortality in the United States. J Chronic Dis 1967;20:769-79.

6. Leaverton PE, Feinleib M, Thom T. Coronary heart disease mortality in United States blacks, 1968-1978: interstate variation. Am Heart J 1984;108:732-7.

7. Levy RI. The decline in cardiovascular disease mortality. Annu Rev Public Health 1981; 2:49-70.

8. Ragland KE, Selvin S, Merrill DW. The onset of decline in ischemic heart disease mortality in the United States. Am J Epidemiol 1988;127:516-31.

9. Centers for Disease Control. Health, United States, 1987. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service; DHHS publication no. (PHS)88-1232.

10. Sempos C, Cooper R, Kovar MG, McMillen M. Divergence of the recent trends in coronary mortality for the four major race-sex groups in the United States. Am J Public Health (in press).

11. Goldman L, Cook EF. The decline in ischemic heart disease mortality rates: an analysis of the comparative effects of medical interventions and changes in lifestyle. Ann Intern Med 1984;101:825-36. *International Classification of Diseases, 9th Revision, codes 410-414.

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