A Public Health Action Plan to Prevent Heart Disease and Stroke

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Section 1. Heart Disease and Stroke Prevention: Time for Action

Heart Disease and Stroke: Scope, Burden, Disparities, and a Forecast 

The Scope of "Heart Disease and Stroke"

Disorders of the circulation that affect the heart, brain, and other organs may be described in various terms, sometimes with specific technical meaning.^1,3 For clarity, the most important terms used in this plan are defined either in the text or in the glossary (see Appendix A). Some of the more common terms are defined in this section. 

"Heart disease and stroke" refers to the two major classes of circulatory conditions that are the main focus of the Action Plan. This usage, which was chosen for the title of the plan, corresponds with the terminology of Chapter 12, Heart Disease and Stroke of Healthy People 2010.² "Heart disease" most often refers to coronary heart disease (including heart attack and other effects of restricted blood flow through the arteries that supply the heart muscle) or to heart failure. Other times, this term refers to several conditions or all diseases affecting the heart (e.g., "heart disease deaths"). "Stroke" refers to a sudden impairment of brain function, sometimes termed "brain attack," that results from interruption of circulation to one or another part of the brain following either occlusion or hemorrhage of an artery supplying that area. 

"Cardiovascular health" (CVH) refers broadly to a combination of favorable health habits and conditions that protects against the development of cardiovascular diseases. "CVH promotion" is support and dissemination of these favorable habits and conditions. "Cardiovascular disease or diseases" (CVD), in turn, refers in principle to any or all of the many disorders that can affect the circulatory system. Here, CVD most often means coronary heart disease (CHD), heart failure, and stroke, taken together, which are the circulatory system disorders of the greatest public health concern in the United States today. However, CVD can also mean cerebrovascular disease, or disease of brain circulation. Throughout this plan, which is intended to address heart disease and stroke together, use of either CVH or CVD means both cardiovascular and cerebrovascular disease. More often, if less conveniently, the phrase "heart disease and stroke" means explicitly that both are included. 

Heart disease and stroke are mainly consequences of atherosclerosis and high blood pressure (hypertension).³ They are sometimes included in the broader category of atherosclerotic and hypertensive diseases (see The Knowledge Base for Intervention later in this section). Risk factors for heart disease and stroke have been well established for many years. Distinct from age, family history, and possible genetic determinants are modifiable risk factors that cause heart attacks and strokes, including high blood cholesterol, high blood pressure, smoking, and diabetes. Behaviors that contribute to development of risk factors, partly by causing obesity, include adverse dietary patterns and physical inactivity. Social and environmental conditions that may determine such behavioral patterns, in turn, include education and income, cultural influences, family and personal habits, and opportunities to make favorable choices. Policies—especially in the form of laws, regulations, standards, or guidelines—contribute to setting these and other social and environmental conditions. For example, dietary patterns result from the influences of food production policies, marketing practices, product availability, cost, convenience, knowledge, choices that affect health, and preferences that are often based on early–life habits. Because many aspects of behavior are clearly beyond the control of the individual, the scope of heart disease and stroke prevention, from the public health perspective, extends far beyond the individual or the patient. Thus, a comprehensive public health strategy for prevention must address the broader determinants of risk and disease burden as they affect both the population as a whole and particular groups of special concern, including those determinants that make healthier choices more likely.

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The Nation's CVD Burden

The nation's CVD burden can be described in many ways. Examples include the number and rate of deaths by age, sex, race or ethnicity, or place of residence; the number and percentage of the population with a specific CVD condition or risk factor; and estimates of economic costs, including direct health care expenditures and loss of income from early death or disability. Several federal agencies contribute data on these aspects of the burden, including CDC and its National Center for Health Statistics and NIH's National Heart, Lung, and Blood Institute and National Institute of Neurological Disorders and Stroke. Table 1 illustrates several measures of the CVD burden in the U.S. population as reported by the American Heart Association on the basis of these data sources.¹

The dominant change in CVD mortality in the United States in recent decades was a major decline in the annual rates of death for the population as a whole (i.e., age–adjusted death rates) for both CHD and stroke. These declines resulted in a substantial reduction in the numbers of deaths from these conditions that would have occurred for any particular age group (e.g., 45–54 years) under the previously higher rates. Despite these declines in rates, actual numbers of deaths from heart disease have changed little in 30 years and have actually increased within the past decade, especially for stroke.¹ This is mainly because more people are living longer, and rates are higher among successively older age groups. 

As a consequence, heart disease remains the nation's leading cause of death.¹ Stroke is the third leading cause of death, and both conditions are major causes of adult disability. The decline in rates of coronary heart disease mortality slowed from -3.3% a year in the 1980s to -2.7% a year in the 1990s, and the decline in overall rates of stroke mortality slowed markedly in contrast to the 1970s and 1980s.⁴ Meanwhile, the frequency of heart failure increased steadily during the last 25 years.³ Peripheral arterial disease continues to be a major predictor of CVD death.^1,3 In addition, the previous favorable trends were not uniform among racial and ethnic groups. For example, heart disease rates declined more slowly among blacks than whites.¹ These shifting trends are consistent with forecasts of the global burden of CVD over the next two decades and support the prediction that heart disease and stroke will persist as the leading causes of death and disability worldwide unless effective public health action is taken to prevent them.^5,6 

Two other points should be emphasized. First, sudden deaths from coronary heart disease that occur without hospitalization or in the absence of any previous medical history of coronary heart disease (250,000 each year) make the strongest case for prevention.¹ For some victims, no opportunity exists for treatment because their death is the first sign of CVD. Second, the annual cost of CVD to the nation is projected to exceed $351 billion in 2003.¹ This total includes direct health care costs (for hospital and nursing home care, physicians and other professionals, drugs and other medical durables, and home health care) and indirect costs (due to lost productivity from disability and death). This cost substantially exceeds comparable costs for all cancers ($202 billion) and for human immunodeficiency virus (HIV) infections ($28.9 billion) reported for 2002.¹ 

Such data confirm that the CVD epidemic is continuing in the United States and that it is a major component of our health care costs. Yet they do not convey the full impact of CVD. For example, cognitive impairment and dementia caused by underlying vascular disease of the brain (vascular cognitive impairment [VCI]) may occur in as many as 30% of stroke survivors, as well as in people without a clear history of stroke.⁷ These observations also apply to people with or without Alzheimer's disease. Such findings suggest that VCI is part of the CVD spectrum and should be included in estimates of both the CVD burden and the potential health and economic impact of prevention. These factors reinforce concerns that the aging of the U.S. population will make CVD an even greater burden than previously estimated in the next two decades.

The CVD burden can also be expressed in the personal stories of how it affects people and their families. Just one example is the sudden death from heart attack in June 2002 of the St. Louis Cardinals' star pitcher, Darryl Kile. Kile was 33 years old and is survived by his widow and three young children.⁸ This is a striking example of the increased number of victims of sudden cardiac death younger than age 35 in the past decade.1 With an estimated 12.9 million Americans living with heart disease and 4.7 million living with stroke, many people can recount the impact on their lives of becoming a victim of CVD. For millions of others who did not survive their first encounter with heart disease or stroke, only the family members or friends left behind can tell their stories.

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Disparities 

Health disparities have long been a special concern in setting national objectives, and Healthy People 2010 calls for the elimination of such disparities as one of its two overarching goals.² Disparities can exist among certain populations defined by sex, race or ethnicity, education or income, disability, place of residence, or sexual orientation. Sex–specific data are commonly available for CVD. In contrast to previous beliefs, CVD is clearly not an affliction primarily of men. In fact, it causes more deaths among women. In 2000, CVD was responsible for 505,661 deaths among U.S. women and 440,175 deaths among U.S. men. The higher numbers among women are partially due to the greater numbers of women in the oldest age groups, where CVD mortality is highest.¹ 

Major disparities in the burden of heart disease and stroke and their risk factors among different racial and ethnic groups are widely recognized. However, relevant data for some groups are scant or nonexistent because data have not been collected to address this concern adequately. To improve data collection, the federal government has promulgated standards for classifying race and ethnicity in federal data systems.⁹ 

Researchers have also explored and published data on the geographic variations in the burden of heart disease death—by state and by county— for both women and men in the five major racial and ethnic categories.^10,11 These publications include information on local economic resources and medical care resources in the different areas examined. Data on the geographic variations in stroke deaths were published in 2003.¹² 

Table 2 summarizes heart disease mortality differences by race and ethnicity in the United States. Table 3 presents similar data for stroke deaths for the most recent years available, 1999–2000.*¹² Both tables illustrate striking disparities in the excess mortality among blacks (for both women and men) compared with all other groups.

* In Tables 2 and 3, data for Hispanics are presented twice—once under the category of "Hispanic," which includes Hispanics of all racial identities (e.g., Hispanic blacks, Hispanic whites), and again under any of the four racial categories according to a person's racial identity. Consequently, data for the five groups are not mutually exclusive because "Hispanic" is considered a designation of ethnicity, not race.

Disparities in other areas have been published in Health, United States, 2002, an annual report on national trends in health statistics.¹³ This report also examines differences in health outcomes and risk factors for major racial and ethnic groups in the United States. Table 4 presents examples of these disparities, some of which relate specifically to heart disease and stroke, whereas others relate to overall health. Several key points about health disparities among different groups are evident in this table. First, the extent to which data are lacking for major population groups is evident. Second, for populations with adequate data, disparities are striking—particularly among African Americans—in terms of years of life lost to death from heart disease and cerebrovascular disease, prevalence of hypertension and obesity (women only), and poverty. Other noteworthy points are the low values of several indicators for Asians (including Native Hawaiians and Other Pacific Islanders); the excess years of life lost because of deaths from cerebrovascular disease and diabetes among American Indians or Alaska Natives; and the high prevalence in the Hispanic or Latino population of poverty, lack of health coverage, and obesity. The table also indicates that a substantial proportion of these three minority groups live in poverty or without health care coverage.

Although other data sources are available for some of these populations, they suffer several limitations. Some of these were outlined in a 1999 report that illustrated the insufficiencies of data on Asian American and Pacific Islander populations.¹⁴ These include a lack of data for subgroups with heterogeneous health characteristics, relatively small sample sizes, a lack of systematic data collection, a lack of longitudinal studies, a lack of population–based CVD data, and self–selection bias in sampling methods. Eliminating disparities requires adequate CVD data to establish the nature and extent of the disparities and to monitor changes. Clearly, data systems must be strengthened if disparities are to be addressed effectively. What we do know about existing disparities indicates that interventions must affect disadvantaged groups more than they do the population as a whole. The population–based health objectives for heart disease and stroke presented in Healthy People 2010 that could be improved in the short term have targets that are predominantly based on the criterion "better than the best"—that is, all groups are expected to achieve a better measure of health status by 2010 than that of the most favorable group at the baseline.² This implies that we should attain health improvements for all groups within the population, but that groups with poorer baseline status need to experience accelerated improvement, so that all groups will reach the same measures of better health by 2010. Attaining the targets for these objectives will require that the most effective programs, including those aimed at reducing the prevalence of CVD risk factors, reach the groups with the greatest CVD burden.

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A Forecast 

Over the next two decades, the number of Americans older than age 65 will increase dramatically, from approximately 34.7 million in 2000 to more than 53.2 million in 2020.15 By 2020, a total of 16.5% of Americans will be aged 65 or older, compared with 12.6% in 2000—an increase of nearly one–third. Proportions of minorities in the overall population are expected to increase from 12.9% to 14.0% for blacks, 4.1% to 6.1% for Asians, 0.9% to 1.0% for American Indians, and 11.4% to 16.3% for Hispanics. Heart disease deaths are projected to increase sharply between 2010 and 2030, and the population of heart disease survivors is expected to grow at a much faster rate than the U.S. population as a whole. Marked increases in numbers of stroke deaths are also predicted.¹⁶ These changes together will constitute a major increase in the nation's CVD burden, accompanied by increasing demands for related health care services, as well as increases in health care expenditures; lost income and productivity; and prevalence of disease, disability, and dependency. This forecast suggests that instead of increasing quality and years of healthy life, we may lose ground. Moreover, if recent trends continue, disparities may widen rather than be eliminated.⁴ The need for prevention has never been as great as it is today.

Next Section: Myths and Misconceptions

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Date last reviewed: 05/12/2006
Content source: Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion