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Cardiovascular Disease

Between 1980 and 2009 the leading cause of death is heart disease.1

In 2009 599,413 people died from heart disease.1

Almost 1/3 of the deaths in people ages 65 and older are due to heart disease.1

Multiple epidemiological studies have confirmed that the following risk factors account for the majority of CAD cases:3,4

  • Cholesterol (as assessed by TC, LDL-C or apoB)
  • Cigarette smoking
  • HDL-C
  • Age (the major determinant of risk)
  • Male sex
  • Diabetes mellitus
  • Blood pressure
  • Family history of premature CAD (younger than 60 years of age)
  • Inflammatory biomarkers (especially hs-CRP)
  • Overweight and obesity

 

Other variables that increase risk include poor nutrition, caloric excess resulting in overweight and obesity, physical inactivity and psychological stress.

Percentage of all U.S. deaths caused by heart disease in 2008, listed by ethnicity.

Race or Ethnic Group % Deaths caused by heart disease
African Americans
24.4
American Indians or Alaska Natives
17.9
Asians or Pacific Islanders
23.2
Hispanics
20.7
Whites
25.1
All
24.9

*Adapted from National Vital Statistics Reports; vol 59 no 104

Although cardiovascular disease (CVD) is a disease of adulthood, risk factors for CVD are present in children and persist into adulthood. 

The 2008 overall rate of death attributable to cardiovascular disease was 244.8 per 100,000. Cardiovascular disease death rate by ethnicity and gender:

  • White Male: 287.2 per 100,000
  • Black Male: 390.4 per 100,000
  • White Female: 200.5 per 100,000
  • Black Female: 277.4 per 100,000.7

 

Major Risk Factors

Obesity: 1, 4, 3, 5, 17

Obesity in adults is associated with cardiovascular risk and obesity continues to be a growing public health problem. According to the 2003–2004 National Health and Nutrition Examination Survey, 17 percent of persons two to 19 years of age are overweight. The number of obese children and adolescents has tripled in the past 20 years.1

(There are significant racial and ethnic disparities in obesity prevalence among U.S. children and adolescents.) 4

In 2007-2008, the prevalence of obesity was significantly higher among Mexican-American adolescent boys (26.8%) than among non-Hispanic white adolescent boys (16.7%). In NHANES III (1988-1994) there was no significant difference in prevalence between Mexican-American and non-Hispanic white adolescent boys.

In a study that conducted systematic hypertension and overweight screening in multiethnic, school-aged children in public schools in the Houston, Texas metropolitan area.43 Of school-aged children (age range 10 –19 years), 20% had BMI >95th percentile. Within this population of 5000 children, the prevalence of overweight among Hispanic children was more than twice that of white children and 3 times that of Asian children. 3 This study confirmed the presence of an evolving epidemic of cardiovascular risk in youth. The prevalence of overweight and hypertension in children has increased dramatically, most notably among ethnic minorities.3

Dyslipidemia:

As of 2012 98.8 million Americans age 20 and older have total blood cholesterol levels of 200 milligrams per deciliter (mg/dL) or higher: 45.0 million men and 53.8 million women.5

Of these, 33.6 million have total blood cholesterol levels of 240 mg/dL or higher: 14.6 million men and 19.0 million women.5

Approximately 16% of U.S. adults have high serum total cholesterol levels17

Among Americans age 20 and older, the following have an LDL cholesterol of 130 mg/dL or higher:5

  • For non-Hispanic whites, 30.5 percent of men and 32.0 percent of women
  • For non-Hispanic blacks, 34.4 percent of men and 27.7 percent of women
  • For Mexican Americans, 41.9 percent of men and 31.6 percent of women

 

Percentages of people with high cholesterol in the United States by ethnicity:

Race or Ethnic Group Men (%) Women (%)
African Americans
9.7
13.3
Mexican Americans
16.9
14.0
Whites
13.7
16.9
All
13.5
16.2

* Adapted from: Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics—2012 update: a report from the American Heart Association. Circulation. Epub 2011 Dec 15.

According to the National Cholesterol Education Program Report on Blood Cholesterol Levels in Children and Adolescents, total cholesterol levels < 170 mg/dl are normal, 170-199 mg/dl are borderline and > 200 mg/dl are high.6

The 2003–2004 NHANES found that 10 percent of persons two to 19 years of age have serum total cholesterol levels greater than 200 mg per dL (5.18 mmol per L).9

Fatty streaks can be found in most children by age 10 and fibrous plaques in adolescent.8

While the significance of fatty streaks in the aorta is questionable, their presence along with fibrous plaques in the coronary vessels indicates severe and progressive atherosclerosis.8

The presence of three or four risk factors for CVD increased the prevalence of fatty streaks 8.5 fold and the prevalence of fibrous-plaque lesions in the coronary arteries 12 times.8

Hypertension:

An estimated 68 million adults have high blood pressure this is about 1 in 3 U.S. adults 11

Individuals with a systolic blood pressure of 120–139 mmHg or a diastolic blood pressure of 80–89 mmHg should be considered as pre-hypertensive and a systolic blood pressure of140-149 or a diastolic blood pressure of 90-99 is considered hypertensive.18

The Framingham Heart Study suggests that individuals who have normal blood pressure at age 55 have a 90 percent risk for developing hypertension in their lifetime. 12

There is a continuous, consistent, and independent of other risk factors relationship between BP and risk of CVD events. The higher the BP, the greater is the chance of heart attack, heart failure, stroke, and kidney disease. 18

Childhood hypertension is defined by a systolic or diastolic blood pressure at or above the 95th percentile when adjusted for sex, age, and height.14

In a recent study of more than 5,000 children close to 5 percent had persistent, elevated blood pressure. In this study they found the strongest risk factor for persistent elevated blood pressure was obesity. 15

It is now recommended that, children and adolescents with BP levels at 120/80 mmHg or above, but less than the 95th percentile, should be considered prehypertensive.16

Data on healthy adolescents demonstrate there is a positive and progressive correlation with increasing hypertension and BMI, and hypertension is detectable in about thirty percent of overweight children.19

The association between overweight and hypertension in children has been reported in a variety of ethnic and racial groups, finding higher blood pressures and/or higher prevalence of hypertension in overweight compared with lean children.15

Diabetes: (see also Type 2 Diabetes)

In 2008, an estimated 18,300,000 Americans had diagnosed diabetes mellitus, this is about 8.0% of the adult population.7

There have been studies that demonstrated that T2DM is a high-risk condition for CVD irrespective of the different degrees of BMI-defined body weight including normal weight.20

Almost 70% of people >65 years of age with diabetes die of some form of heart disease; 16% die of stroke.

Heart disease death rates among adults with diabetes are 2 to 4 times the rates for adults without diabetes.5

Among Americans age 20 and older, the following have physician-diagnosed diabetes:

  • For non-Hispanic whites, 6.8% of men and 6.5% of women.
  • For non-Hispanic blacks, 14.3% of men and 14.7% of women.
  • For Mexican Americans, 11.0% of men and 12.7% of women.5

 

Children who develop type 2 diabetes are typically overweight or obese and have a family history of the disease. Most are American Indian, black, Asian, or Hispanic/Latino.5

Each year, about 15,000 people under twenty years of age are diagnosed with Type 1 Diabetes. Healthcare providers are finding more and more children with type 2 diabetes.5

In study participants who had Type 2 Diabetes and normal weight, about 70% had metabolic syndrome, 80% had central abdominal obesity, about 60% had dyslipidaemia and hypertension was present in 45%. Approximately 65% had two or more co-existing risk factors. 20

Overweight children frequently have some degree of insulin resistance, which is a pre-diabetic condition.16

Metabolic Syndrome:

Metabolic syndrome is defined by NCEP-ATP III as having at least three of the following: hypertriglyceridemia, low HDL cholesterol levels, elevated fasting blood glucose levels, excessive waist circumference, or hypertension.10

Reports from studies that examined childhood data estimate that the insulin-resistance syndrome is present in 30 percent of children with BMI greater than the 95th percentile.21

The syndrome is most common in Mexican Americans, followed by non-Hispanic whites and non-Hispanic blacks.22 The increasing prevalence among children and adolescents has paralleled the rise in obesity. 14

Other Risk Factors

Low levels of Physical Activity: (See also Physical Activity)

Thirty-three percent of adults (>18 years of age) do not engage in leisure-time physical activity according to 2010 data from the NHIS.

Among people age 18 and older, the following meet the 2008 Federal Physical Activity guide- lines:

  • Non-Hispanic whites only, 21.3%
  • Non-Hispanic blacks only, 17.2%
  • Hispanics or Latinos, 14.4%5

 

A greater proportion of black and Hispanic students used computers or watched television >3 hours per day than white students.5

Smoking:

During 2000 to 2004, cigarette smoking resulted in an estimated 443 000 premature deaths each year due to smoking-related illnesses, and about 49 000 of these deaths were due to secondhand smoke. In adults ≥35 years of age, a total of 32.7% of these deaths were related to CVD.5

From 1998 to 2010, US adults 18 years of age and older who were current cigarette smokers declined from 24.1% to 19.3%.5

Prevalence of current cigarette smoking in 2007 to 2009, among adults 18 years of age and older:

  • Asian women (5.4%)
  • Hispanic women (9.3%)
  • Asian men (15.4%)
  • Non-Hispanic black women (17.2%)
  • Hispanic men (17.9%)
  • American Indian or Alaska Native women (19.9%).
  • Non-Hispanic white women (21.0%)
  • Non-Hispanic black men (23.8%)
  • Non-Hispanic white men (24.1%)
  • American Indian or Alaska Native men (26.8%). 5

 

Overall, in 2007 to 2009 cigarette smoking was lease prevalent in Asian women and highest in American Indian and Alaska Native Men.

The prevalence of adolescent smoking is reported to be between 7.4 and 17.9 percent.23

Nationwide, 19.5% of students had smoked cigarettes on at least 1 day during the 30 days before the survey and Nationwide, 7.3% of students had smoked cigarettes on 20 or more days during the 30 days before the survey.

Nationwide, 26.0% of students had reported current cigarette use, current smokeless tobacco use, or current cigar use. Overall, the prevalence of current tobacco use was higher among male (29.8%) than female (21.8%) students.

Nationwide, 11.2% of students had ever smoked at least one cigarette every day for 30 days.

Family History:

Primary hypertension in childhood is usually characterized by mild or Stage 1 hypertension and is often associated with a positive family history of hypertension or cardiovascular disease (CVD).16

Research has shown that a parental or family history of myocardial infarction is an independent risk factor for cardiovascular disease.24

Dietary Habits:

Data from NHANES indicate that between 1971 and 2004, average total energy consumption among US adults increased 22% in women (from 1,542–1,886 kcal/d) and 10% in men (from 2,450–2,693 kcal/d).

Dietary habits affect multiple CV risk factors, including established risk factors (systolic and diastolic blood pressure, LDL cholesterol levels, HDL cholesterol levels, glucose levels, and obesity/ weight gain) and novel risk factors (e.g., inflammation, cardiac arrhythmias, endothelial cell function, triglyceride levels, lipoprotein[a] levels, and heart rate).5

  • A DASH dietary pattern with low sodium reduced systolic blood pressure by 7.1 mm Hg in adults without hypertension, and by 11.5 mm Hg in adults with hypertension.
  • For each 2% of calories from trans fat was associated with a 23% higher risk of coronary heart disease.
  • Each daily serving of fruits or vegetables was associated with a 4% lower risk of CHD and a 5% lower risk of stroke.
  • Greater whole grain intake (2.5 compared with 0.2 servings per day) was associated with a 21% lower risk of CVD events, with similar estimates for specific CVD outcomes such as heart disease, stroke and fatal CVD.5

References

  1. Kochanek KD, Xu JQ, Murphy SL, et al. Deaths: Preliminary data for 2009. National vital statistics reports; vol 59 no 4. Hyattsville, MD: National Center for Health Statistics. 2011.
  2. Smith SC, Jr, Allen J, Blair SN, et al. AHA/ACC. National Heart, Lung, and Blood Institute AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update: Endorsed by the National Heart, Lung, and Blood Institute. Circulation. 2006;113:2363–72.
  3. Yusuf S, Hawken S, Ounpuu S, et al. INTERHEART Study Investigators Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): Case-control study. Lancet. 2004;364:937–52
  4. Miniño AM, Murphy SL, Xu J, Kochanek KD. Deaths: Final data for 2008. National Vital Statistics Reports; vol 59 no 10. Hyattsville, MD: National Center for Health Statistics. 2011.
  5. Roger VL, Go AS, Lloyd-Jones DM, Benjamin EJ, Berry JD, Borden WB, Bravata DM, Dai S, Ford ES, Fox CS, Fullerton HJ, Gillespie C, Hailpern SM, Heit JA, Howard VJ, Kissela BM, Kittner SJ, Lackland DT, Lichtman JH, Lisabeth LD, Makuc DM, Marcus GM, Marelli A, Matchar DB, Moy CS, Mozaffarian D, Mussolino ME, Nichol G, Paynter NP, Soliman EZ, Sorlie PD, Sotoodehnia N, Turan TN, Virani SS, Wong ND, Woo D, Turner MB; on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2012 update: a report from the American Heart Association. Circulation. 2012: published online before print December 15, 2011, 10.1161/CIR.0b013e31823ac046.
  6. The National Cholesterol Education Program (1991) Report of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents. Bethesda, MD: National Heart, Lung, and Blood Institute.
  7. Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics—2012 update: a report from the American Heart Association. Circulation. Epub 2011 Dec 15.
  8. Hickman TB, Briefel RR, Carroll MD, Rifkind BM, Cleeman JI, Maurer KR, & Johnson CL. (1998) Distributions and trends of serum lipid levels among United States children and adolescents ages 4-19 years: data from the Third National Health and Nutrition Examination Survey. Preventive Medicine 27: 879-890.
  9. Ogden  CL, et al.  Prevalence of overweight and obesity in the United States, 1999–2004.  JAMA.  2006;295(13):1549–1555.
  10. Executive summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III).  JAMA.  2001;285(19):2486–2497.
  11. CDC. Vital signs: prevalence, treatment, and control of hypertension—United States, 1999-2002 and 2005-2008. MMWR. 2011;60(4):103-8.
  12. Vasan RS, Beiser A, Seshadri S, et al. Residual lifetime risk for developing hypertension in middle-aged women and men: The Framingham Heart Study. JAMA. 2002;287:1003-10. F
  13. Lewington S, Clarke R, Qizilbash N, et al. Age-specific relevance of usual blood pressure to vascular mortality: A meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002;360:1903-13.
  14. Spiotta RT, Luma GB. Evaluating obesity and cardiovascular risk factors in children and adolescents. Am. Fam. Physician 2008; 78: 1052–8.
  15. Sorof  JM, et al.  Overweight, ethnicity, and the prevalence of hypertension in school-aged children.  Pediatrics.  2004;113(3 pt 1):475–482.
  16. NHBPEP Working Group. The fourth report on the diagnosis, evaluation and treatment of high blood presssure in children and adolescents. Pediatrics 2004;114:555–576.
  17. Schober SE, Carroll MD, Lacher DA, Hirsch R. High serum total cholesterol—an indicator for monitoring cholesterol lowering efforts; U.S. adults, 2005–2006. NCHS data brief no 2, Hyattsville, MD: National Center for Health Statistics. 2007.
  18. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr., Jones DW, Materson BJ, Oparil S, Wright JT Jr., Roccella EJ, National High Blood Pressure Education Program Coordinating Committee. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. Hypertension. 2003; 42: 1206–1252.
  19. Sorof J, Daniels S. Obesity hypertension in children: A problem of epidemic proportions. Hypertension 2002;40:441–7.
  20. S.H. Song and C.A. Hardisty. Type 2 diabetes mellitus: a high-risk condition for cardiovascular disease irrespective of the different degrees of obesity. QJM (2008) 101(11): 875-879 first published online September 6, 2008 doi:10.1093/qjmed/hcn109
  21. Cook S, Weitzman M, Auinger P, Nguyen M, Dietz WH. Prevalence of a metabolic syndrome phenotype in adolescents: Findings from the third National Health and Nutrition Examination Survey, 1988–1994. Arch Pediatr Adolesc Med 2003;157:821–7.
  22. Duncan  GE, et al.  Prevalence and trends of a metabolic syndrome phenotype among U.S. adolescents, 1999–2000.  Diabetes Care.  2004;27(10):2438–2443.
  23. Finkelstein  DM, et al.  Social status, stress, and adolescent smoking.  J Adolesc Health.  2006;39(5):678–685.
  24. Shea S, Ottman R, Gabrieli C, et al. Family history as an independent risk factor for coronary artery disease. J Am Coll Cardiol. 1984; 4: 793–801.

Health Disparities

Outside