# ![](media/image1.wmf){width="2.3986111111111112in" height="2.2930555555555556in"} {#section .Chapter-#}

# 12 {#section-1 .Chapter-#}

# Heart Disease and Stroke

Co-Lead Agencies: Centers for Disease Control and Prevention\
National Institutes of Health

### Contents {#contents .Heading-Special}

[Goal Page 12-3](#goal)

[Overview Page 12-3](#overview)

[Issues and Trends Page 12-3](#issues-and-trends)

[Disparities Page 12-5](#disparities)

[Opportunities Page 12-7](#opportunities)

[Interim Progress Toward Year 2000 Objectives Page
12-14](#interim-progress-toward-year-2000-objectives)

[Healthy People 2010---Summary of Objectives Page
12-15](#healthy-people-2010summary-of-objectives)

[Healthy People 2010 Objectives Page
12-16](#healthy-people-2010-objectives)

[Heart Disease Page 12-16](#heart-disease)

[Stroke Page 12-19](#stroke)

[Blood Pressure Page 12-20](#blood-pressure)

[Cholesterol Page 12-25](#cholesterol)

[Related Objectives From Other Focus Areas Page
12-29](#related-objectives-from-other-focus-areas)

[Terminology Page 12-30](#terminology)

[References Page 12-33](#references)

## Goal

**Improve cardiovascular health and quality of life through the
prevention, detection, and treatment of risk factors; early
identification and treatment of heart attacks and strokes; and
prevention of recurrent cardiovascular events.**

## Overview

Heart disease is the leading cause of death for all people in the United
States. Stroke is the third leading cause of death. Heart disease and
stroke continue to be major causes of disability and significant
contributors to increases in health care costs in the United States.[^1]

Epidemiologic and statistical studies have identified a number of
factors that increase the risk of heart disease and stroke. In addition,
clinical trials and prevention research studies have demonstrated
effective strategies to prevent and control these risk factors and
thereby reduce illnesses, disabilities, and deaths caused by heart
disease and stroke.

### Issues and Trends

Coronary heart disease (CHD) accounts for the largest proportion of
heart disease. About 12 million people in the United States have
CHD.Error: Reference source not found The CHD death rate peaked in the
mid-1960s and has declined in the general population over the past 35
years. This decline began in females in the 1950s and in males in the
1960s. Although absolute declines have been much greater in males than
in females, rates of decline also have been greater in males, but in
recent years they have been greater in females.

Since 1950, there has been a clear rise and fall in CHD death rates for
each racial and gender group. Although the age-adjusted death rate for
CHD continues to decline each year, declines in the unadjusted death
rate and in the number of deaths have slowed because of an increase in
the number of older people in the United States, who have higher rates
of CHD.

High blood cholesterol is a major risk factor for CHD that can be
modified. More than 50 million U.S. adults have blood cholesterol levels
that require medical advice and treatment.[^2] More than 90 million
adults have cholesterol levels that are higher than desirable. Experts
recommend that all adults aged 20 years and older have their cholesterol
levels checked at least once every 5 years to help them take action to
prevent or lower their risk of CHD.[^3] Lifestyle changes that prevent
or lower high blood cholesterol include eating a diet low in saturated
fat and cholesterol, increasing physical activity, and reducing excess
weight.Error: Reference source not found

About 4 million persons have cerebrovascular disease,Error: Reference
source not found a major form of which is stroke. About 600,000 strokes
occur each year in the United States, resulting in about 158,000 deaths.
Death rates for stroke are highest in the southeastern United States.
Like CHD death rates, stroke death rates have declined over the past 30
years. The decline accelerated in the 1970s for whites and African
Americans. The rate of decline, however, has slowed in recent years. The
overall decline has occurred mainly because of improvements in the
detection and treatment of high blood pressure
(hypertension).![](media/image2.wmf){width="4.499305555555556in"
height="4.081944444444445in"}

High blood pressure is known as the "silent killer" and remains a major
risk factor for CHD, stroke, and heart failure. About 50 million adults
in the United States have high blood pressure. High blood pressure also
is more common in older persons. Comparing the 1976--80 National Health
and Nutrition Examination Survey (NHANES II) and the 1988--91 survey
(NHANES III, phase 1) reveals an increase from 51 to 73 percent in the
proportion of persons who were aware that they had high blood
pressure.[^4]**^,^** [^5] Nevertheless, a large proportion of persons
with high blood pressure still are unaware that they have this
disorder.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found^**

The age composition of the U.S. population changed dramatically during
the 20th century and will continue to change during the 21st century. By
the end of the 1990s, one in every four persons was aged 50 years or
older. By 2030, about one in three will be aged 50 years or older. Most
significant has been the increase in the size of the population aged 65
years and older. In addition, the percentage of persons aged 85 years
and older has increased significantly. Heart disease and stroke deaths
rise significantly after age 65 years, accounting for more than 40
percent of all deaths among persons aged 65 to 74 years and almost 60
percent of those aged 85 years and older. In the 1980s and 1990s, heart
failure emerged as a major chronic disease for older adults.[^6]**^,^**
[^7]**^,^** [^8]**^,^** [^9] Almost 75 percent of the nearly 5 million
patients with heart failure in the United States are older than 65
years.Error: Reference source not found Hospitalization rates for heart
failure continue to increase significantly in those aged 65 years and
older.Error: Reference source not found

Atrial fibrillation (AF) affects close to 2 million people in the United
States. The number of existing cases of AF increases with age and is
more common in males than in females.[^10] Even though prevalence of AF
is greater in males than in females, the absolute number of males and
females with AF is about equal. About 70 percent of persons with AF are
between age 65 and 85 years. About 15 percent of strokes occur in
persons with AF.Error: Reference source not found Because females have a
longer life expectancy than males, the actual number of cases in elderly
females (older than 75 years) is greater than in elderly males. Cases of
AF may continue to rise as persons live longer and as more persons
survive a first heart attack.

Because national data systems will not be available in the first half of
the decade for tracking progress, two subjects of interest are not
addressed in this focus area's objectives. Representing a research and
data collection agenda for the coming decade, the topics are related to
provider counseling and increasing awareness of cardiovascular disease
(CVD) as the leading cause of death for all females. The first topic
covers instruction of high-risk patients and family members or
significant others in preparing appropriate heart attack and stroke
action plans for seeking rapid emergency care, including when to call
911 or the local emergency number. The second topic deals with
increasing awareness among all females that CVD is their leading cause
of death.

### Disparities

In general, the heart disease death rate has been consistently higher in
males than in females and higher in the African American population than
in the white population. In addition, over the past 30 years the CHD
death rate has declined differentially by gender and race. In the 1970s,
African American females experienced the greatest decline in CHD. This
steep decline leveled off in the 1980s, when rates of decline for white
males and females exceeded those for African American males and females,
and African American females had the lowest rate of decline.[^11] In the
1980s, males had a steeper rate of decline than females. Between 1980
and 1995, the percentage declines were greater in males than in females
and greater in whites than in African Americans. In 1995, the
age-adjusted death rate for heart disease was 42 percent higher in
African American males than in white males, 65 percent higher in African
American females than in white females, and almost twice as high in
males as in females.

Disparities also exist in treatment outcomes for patients who have heart
attacks. Females, in general, have poorer outcomes following a heart
attack than do males: 44 percent of females who have a heart attack die
within a year, compared with 27 percent of males. At older ages, females
who have a heart attack are twice as likely as males to die within a few
weeks.[^12] These differences are explained, in part, by the presence of
coexisting conditions such as high blood pressure, diabetes, and
congestive heart failure. After controlling for such factors, however,
studies indicate an association remains between female gender and death
following a heart attack. Complications are more frequent in females
than in males after coronary intervention procedures, such as
angioplasty or bypass surgery, are performed. Additional studies are
needed to evaluate specific interventions and determine whether
gender-specific interventions may be beneficial. In general, factors
such as age (older), gender (female), race or ethnicity, low
socioeconomic status, and prior medical conditions (previous heart
attack, history of angina or diabetes) have been associated with longer
prehospital delays in seeking care for symptoms of a heart attack.[^13]

The male-female disparity in stroke deaths widened from the 1970s until
the 1980s and then narrowed. Although stroke death rates have been
decreasing, the decline among African Americans has not been as
substantial as the decline in the total population. The racial
differences in the number of new cases of stroke and deaths due to
stroke are even greater than those found in CHD. Stroke deaths are
highest in African American females born before 1950 and in African
American males born after 1950. Among the racial and gender groups,
declines in the stroke death rate are smallest in African American
males. When adjusted for age, stroke deaths are almost 80 percent higher
in African Americans than in whites and about 17 percent higher in males
than in females. Moreover, age-specific stroke deaths are higher in
African Americans than in whites in all age groups up to age 84 years
and higher in males than in females throughout all adult age groups.

The number of existing cases of high blood pressure is nearly 40 percent
higher in African Americans than in whites (an estimated 6.4 million
African Americans have high blood pressure),[^14] and its effects are
more frequent and severe in the African American population.

Other racial and ethnic CHD and stroke data indicate that among U.S.
adults aged 20 years and older, the age-adjusted (year 2000) prevalence
of heart attacks is 5.2 percent for non-Hispanic white males and 2.0
percent for females; 4.3 percent for non-Hispanic black males and 3.3
percent for females; 4.1 percent for Mexican American males and 1.9
percent for females. Among American Indians aged 65 to 74 years the
rates (per 1,000) of new and recurrent heart attacks are 25.1 for males
and 9.1 for females. The average annual CHD incidence rate (per 1,000)
in Japanese American males living in Hawaii was 4.6 for ages 45 to 49
years, 6.0 for ages 50 to 54 years, 7.2 for ages 55 to 59 years, 8.8 for
ages 60 to 64 years, and 10.5 for ages 65 to 68 years.Error: Reference
source not found

For stroke, other data show that the estimated age-adjusted (2000
standard) prevalence of stroke for persons aged 20 years and older in
the United States was 2.2 percent for non-Hispanic white males and 1.5
percent for females; for non-Hispanic blacks, 2.5 percent for males and
3.2 percent for females; and for Mexican Americans, 2.3 percent for
males and 1.3 percent for females. The rates (per 1,000) of new and
recurrent strokes in American Indians aged 65 to 74 years are 15.2 for
males and 7.9 for females. The average annual incidence rates (per
1,000) of stroke in Japanese American males increased with advancing age
from 45 to 49 years to 65 to 68 years at the initial examination: 2.1 to
8.2 for total stroke, 1.5 to 6.6 for thromboembolic stroke, and 0.4 to
1.0 for intracerebral hemorrhage.Error: Reference source not found

### Opportunities

**Primary prevention.** Heart disease and stroke share several risk
factors, including high blood pressure, cigarette smoking, high blood
cholesterol, and overweight. Physical inactivity and diabetes are
additional risk factors for heart disease. (See Focus Area 5. Diabetes.)
The lifetime risk for developing CHD is very high in the United States:
one of every two males and one of every three females aged 40 years and
under will develop CHD sometime in their life. Primary prevention,
specifically through lifestyle interventions that promote heart-healthy
behaviors, is a major strategy to reduce the development of heart
disease or stroke.[^15]**^,^** [^16]**^,^** [^17]**^,^** [^18]**^,^**
[^19]

A number of studies have shown that lifestyle interventions can help
prevent high blood pressure and reduce blood cholesterol levels. For
high blood pressure, these interventions include increasing the level of
aerobic physical activity, maintaining a healthy weight, limiting the
consumption of alcohol to moderate levels for those who drink, reducing
salt and sodium intake, and eating a reduced-fat diet high in fruits,
vegetables, and low-fat dairy food. Moreover, studies show that a diet
low in saturated fat, dietary cholesterol, and total fat---with physical
activity and weight control---can lower blood cholesterol
levels.[^20]**^,^** [^21]**^,^** [^22]

Overweight and obesity are growing public health problems, affecting
adults, adolescents, and children. Overweight and obesity affect a large
proportion of the U.S. population---55 percent of adults. These persons
are at increased risk of illness from high blood pressure, high blood
cholesterol and other lipid disorders, type 2 diabetes, CHD, stroke, and
other diseases. Efforts to prevent overweight and obesity by promoting
heart-healthy behaviors---beginning in childhood---are needed to help
reverse the trend. Balancing calorie intake with physical activity is
critical. Research in the 1990s showed that a wide range of physical
activities are beneficial to health and that everyone can benefit from
physical activity. Even when physical activity is less than vigorous, it
can still produce health benefits, including a decreased risk of
CHD.[^23]**^,^** [^24]**^,^** [^25]**^,^** [^26] (See Focus Area 19.
Nutrition and Overweight.)

Nonetheless, increasing the level of physical activity remains a
challenge. Furthermore, according to the 1996 surgeon general's report
on physical activity and health,[^27] the percentage of people who say
they engage in no leisure-time physical activity is higher among females
than males, among African Americans and Hispanics than whites, among
older adults than younger adults, and among the less affluent than the
more affluent. (See Focus Area 22. Physical Activity and Fitness.)

Progress on smoking cessation will play a critical role in achieving the
Healthy People 2010 objective for heart disease reduction. Smoking
cessation has major and immediate health benefits for men and women of
all ages. For example, people who quit smoking before age 50 years have
half the risk of dying in the next 15 years, compared with people who
continue to smoke.[^28]

Studies have shown that risk factors for heart disease and stroke
develop early in life: atherosclerosis already is present in late
adolescence, diabetes in overweight children is on the rise, and
hypertension can begin in the early teens.[^29]**^,^** [^30] Tobacco use
also begins in adolescence; therefore, primary prevention efforts should
be expanded in elementary and secondary schools and at the college
level. Nationwide mass media campaigns, community-based programs, and
other communication efforts should be expanded to give groups better
access to information and programs. These programs should promote
heart-healthy behaviors at the community level as well as detect and
treat existing risk factors.

**Risk factor detection and treatment.** Screening for risk factors,
particularly for high blood pressure and high blood cholesterol, is an
important step in identifying individuals whose risk factors may be
undiagnosed and referring them to ongoing care. A host of studies has
shown that dietary and pharmacologic therapy can reduce CHD and stroke
risk factors, especially high blood pressure and high blood cholesterol.
These interventions, coupled with other lifestyle changes, such as
stopping smoking, increasing physical activity, and maintaining a
healthy weight, can be even more effective in lowering the risk of a
heart attack or\
stroke.[^31]**^,^** [^32]**^,^** [^33]**^,^** [^34]

Research showing the importance of blood pressure to health led to the
introduction by the National Heart, Lung, and Blood Institute (NHLBI) of
the National High Blood Pressure Education Program (NHBPEP) in
1972.[^35] NHBPEP is the first large-scale public outreach and education
campaign to reduce high blood pressure. Its promotion of the detection,
treatment, and control of high blood pressure has been credited with
influencing the dramatic increase in the public's understanding of
hypertension and its role in heart attacks and strokes, as well as
related declines in deaths. The percentage of people who were able to
control their high blood pressure through lifestyle changes and through
antihypertensive drug therapy rose from about 16 percent in 1971--72 to
about 65 percent in 1988--94.Error: Reference source not found About 90
percent of all adults now have their blood pressure measured at least
once every 2 years. Average blood pressure levels have fallen by 10 to
12 mmHg since the advent of NHBPEP.[^36] A slowly changing issue has
been the recognition of systolic blood pressure as a more important
predictor of CHD than diastolic blood pressure, especially in older
adults.[^37]**^,^** [^38]

Research reported in the 1980s showed for the first time that lowering
high blood cholesterol significantly reduces the risk for heart attacks
and heart attack deaths. This research led to the creation of the
National Cholesterol Education Program (NCEP) in 1985.[^39] Clinical
trials have proved that lowering cholesterol in persons with and without
existing CHD reduces illness and death from CHD and even reduces overall
death rates. Since NCEP was launched, the percentage of persons who have
had their cholesterol checked has more than doubled, from 35 percent in
1983 to 75 percent in 1995.[^40] Consumption of saturated fat, total
fat, and cholesterol declined during the 1980s and 1990s, average blood
cholesterol levels in adults dropped from 213 mg/dL in 1978 to 203 mg/dL
in 1991 (age adjusted to 1980 population), and the prevalence of high
blood cholesterol requiring medical advice and treatment fell from 36
percent to 29 percent.Error: Reference source not found These results
reflect the impact of NCEP's population and high-risk strategies for
lowering cholesterol.![](media/image3.wmf){width="4.752083333333333in"
height="5.865277777777778in"}

The NHLBI Obesity Education Initiative, in cooperation with the National
Institute of Diabetes and Digestive and Kidney Diseases, released in
1998 the first Federal guidelines on the identification, evaluation, and
treatment of overweight and obesity in adults.[^41] These clinical
practice guidelines are designed to help physicians in their
identification and treatment of overweight and obesity, a growing public
health problem. Persons who are overweight or obese are at increased
risk of illness from high blood pressure, lipid disorders, type 2
diabetes, CHD, stroke, gallbladder disease, osteoarthritis, sleep apnea
and other respiratory problems, and certain cancers. The total cost
attributable to obesity-related diseases in the United States is nearly
\$100 billion annually. The guidelines present a new approach to the
assessment of overweight and obesity and establish principles of safe
and effective weight loss. According to the guidelines, the assessment
of overweight involves three key measures---body mass index (BMI), waist
circumference, and risk factors for diseases and conditions associated
with obesity. The definitions in the guidelines are based on research
that relates body mass index to the risk of death and illness, with
overweight defined as a BMI of 25 to 29.9 and obesity as a BMI of 30 and
above.Error: Reference source not found

As BMI levels rise, the average blood pressure and total cholesterol
levels increase, and average high-density lipoprotein (HDL) (good
cholesterol) levels decrease. Males in the highest obesity category have
more than twice the risk of high blood pressure, high blood cholesterol,
or both, compared to males of normal weight. Females in the highest
obesity category have four times the risk of either or both of these
risk factors, compared to normal weight females. Therefore, the
guidelines recommend weight loss to reduce high total cholesterol, raise
low levels of HDL, reduce high blood pressure, and reduce elevated blood
glucose in overweight persons who have two or more risk factors and in
obese persons. Overweight persons without other risk factors are advised
to prevent further weight gain.

The clinical practice guideline on smoking cessation issued by the
Agency for Health Care Policy and Research (now the Agency for
Healthcare Research and Quality) clearly shows that a variety of
interventions are effective and concludes that improvements in cessation
will require active participation of health care systems.[^42]

These national education efforts have changed the way people think about
their health. More people than ever are having their blood pressure and
their cholesterol levels checked and are taking action to keep them
under control. Individuals are aware of preventive measures and health
promotion behaviors that can reduce their risk of developing CHD- and
stroke-related illnesses. In addition, improved pharmacologic therapies
are available to treat and control major CHD risk factors, such as high
blood pressure, high blood cholesterol, and obesity. These therapies
however, may be underutilized by health care providers.

**Early identification and treatment.** Each year in the United States,
about 1.1 million persons experience a heart attack (acute myocardial
infarction \[AMI\]). In 1996, 476,000 persons died from heart
attacks---about 51 percent were males and 49 percent were females. More
than half of these deaths occurred suddenly, within 1 hour of symptom
onset, outside the hospital.Error: Reference source not found**^,^**
[^43] For those patients who survive a heart attack, delay in treatment
can mean increased damage to the heart muscle and poorer outcomes.

The benefits of rapid identification and treatment of heart attacks are
clear. Early treatment of heart attack patients reduces heart-muscle
damage, improves heart muscle function, and lowers the heart attack
death rate.[^44]**^,^** [^45]

Controlled trials of clot-dissolving (thrombolytic) agents used during
the acute phase of a heart attack have demonstrated the benefits of
opening the affected coronary artery and reestablishing blood flow. The
results from these trials have been incorporated into the current
treatment model for early intervention during the acute phase of a heart
attack.Error: Reference source not found Patients who receive
clot-dissolving agents in the first and second hours after the onset of
heart attack symptoms experience significant reductions in disability
and death when compared to patients who are treated in the third to
sixth hours.[^46] Even patients who are treated between 6 and 12 hours
after the onset of symptoms show modest but significant benefits when
compared to patients whose treatment is delayed more than 12 hours.[^47]
Other acute interventions for heart attack patients include balloon
angioplasty, coronary stenting, and coronary artery bypass
surgery.Error: Reference source not found**^,^** [^48] The importance of
early treatment has generated a growing interest in detecting the
earliest warning, or "prodromal," symptoms of a heart attack, thus
providing the lead time needed to treat heart attack patients as quickly
and effectively as possible.[^49]

As with heart attacks, deaths from stroke can be reduced or delayed by
preventing and controlling risk factors and using the most effective
therapies in a timely manner. Functional limitations can be minimized
when patients are treated with clot-dissolving therapy within 3 hours of
a thrombotic stroke.[^50] As therapies have become increasingly more
effective, delays in treatment initiation and lack of implementation of
therapies pose major barriers to improving outcomes. Thus far, efforts
to provide appropriate access to timely and optimal care to patients
with acute coronary syndromes and thrombotic stroke generally are not
organized into a unified, cohesive system in communities across the
United States.[^51]

Early access to emergency health care services is also a critical
determinant of outcome for victims of out-of-hospital cardiac arrest.
For out-of-hospital cardiac arrest where bystanders are present, a key
factor is minimizing the time from the moment the collapse is recognized
to the delivery of a short burst of electrical current. Collapse
recognition occurs when a bystander notices that the affected individual
is unresponsive, has slowed or stopped breathing, or lacks a detectable
pulse.Error: Reference source not found As soon as the emergency is
recognized, the bystander should call 911 or the local emergency number.
Cardiopulmonary resuscitation (CPR) is critical and should begin
immediately. The sooner CPR and defibrillation are given to a person in
cardiac arrest or ventilation is given for respiratory arrest, the
greater the chances of survival.[^52] (See Focus Area 1. Access to
Quality Health Services.)

Despite evidence that effective treatment depends on rapid response to
the patient, only a minority of individuals who can benefit from
defibrillatory shock or thrombolytic agents are treated early enough for
them to work.[^53] The public health challenge is to develop and
maintain programs for easier identification and treatment of individuals
with AMI and out-of-hospital cardiac arrest.

Counseling by health care providers could help to increase awareness of
the symptoms and signs of a heart attack or stroke and the appropriate
actions to take, such as accessing emergency medical services. It also
can help reduce and control factors that increase the risk of a heart
attack or a stroke. To focus resources where they might derive the
greatest benefit, education should be, at a minimum, aimed at reducing
delays in seeking treatment for those individuals who are at high risk
for a future cardiovascular event---for example, those with existing CHD
and multiple CHD risk factors.

**Cardiovascular disease (CVD) recurrence.** Patients with CHD,
atherosclerotic disease of the aorta or peripheral arteries, or carotid
artery disease are at high risk for heart attack and CHD
death.[^54]**^,^** [^55] About 50 percent of all heart attacks and at
least 70 percent of CHD deaths occur in individuals with prior symptoms
of CVD.[^56]**^,^** [^57] The risk for heart attack and death among
persons with established CHD (or other atherosclerotic disease) is five
to seven times higher than among the general population.Error: Reference
source not found

Risk factor control can greatly reduce the risk of subsequent
cardiovascular problems in patients with CHD. For example, clinical
trials have proved that lowering low-density lipoprotein (LDL)
cholesterol levels in CHD patients dramatically reduces heart attacks,
CHD and CVD deaths, and total deaths.[^58]**^,^** [^59]**^,^** [^60]
Clinical trials have also demonstrated that lowering blood pressure in
such patients reduces CVD endpoints (such as heart disease, stroke,
heart attacks, and coronary artery disease) and deaths from all
causes.[^61]**^,^** [^62]**^,^** [^63] Adequate control of risk factors
in the 12 million adults with CHD could reduce the overall rate of heart
attacks and CHD deaths in the United States by over 20 percent. Many CHD
patients, however, are not getting the aggressive risk factor management
they need.

Clinical trials also show that therapeutic interventions can relieve
symptoms, reduce deaths, reduce the number of rehospitalizations, and
improve the quality of life for older adults with heart failure. Despite
the development and promotion of clinical practice guidelines,
physicians are continuing to underutilize recommended therapies. As the
number of older adults who experience heart failure rises (expected to
double by about 2040), these guidelines will need to be incorporated
into clinical practice.[^64]**^,^** [^65]

**Adherence and compliance.** There currently exist a number of
well-established recommendations for preventing and treating
cardiovascular disease and its associated risk factors.[^66]**^,^**
[^67]**^,^** [^68] However, the potential benefits to be gained from
applying these science-based recommendations often are not realized
because of the multiple factors involved in adherence to such
recommendations. The ability or willingness of the patient to carry out
a treatment program successfully is of critical importance.

Experience with the long-term management of asymptomatic CHD risk
factors such as hypertension indicates that a sizable number of patients
do not successfully carry out their prescribed treatment regimen. The
reasons vary: the patient may choose not to have the initial
prescription filled, may successfully initiate therapy only to abandon
it after a few weeks or months, or may comply with only part of the
regimen and thus fail to achieve optimal control. Continued efforts are
needed to better understand the determinants of adherence to ensure that
patients stay with their prescribed therapy.[^69]**^,^** [^70] Also,
health care providers and the health care systems in which they work are
critical factors in determining whether established interventions are
prescribed and patients adequately educated and monitored for
therapeutic response.[^71]**^,^** [^72] Finally, support from the
patient's community and greater use of technology such as the Internet
also have an increasingly important role in promoting long-term
adherence to lifestyle and pharmacologic regimens. Achieving long-term
control of CHD risk factors requires that the same interest and
attention given to initial evaluation and treatment decisions also be
given to long-term management issues.

**Future efforts.** Population studies and public outreach are two of
the most important areas of future research. Advanced technology allows
researchers to screen persons noninvasively and painlessly for signs of
developing atherosclerosis. Eventually, when their role in medical
practice has been better delineated, noninvasive methods (such as
magnetic resonance imaging and ultrasound) may be used to determine the
number of persons in the population who have heart disease or are at
risk of developing heart disease.

Many people know what a desirable cholesterol level is, what their blood
pressure should be, and that these factors relate to a risk of heart
disease and stroke. The average person can expect to live 5.5 years
longer today than he or she did 30 years ago, and nearly 4 years of that
gain in life expectancy can be attributed to progress against CVD,
including CHD and stroke. However, much remains to be done to ensure
that all segments of the population share in these benefits. Although
national health data on African Americans and Hispanics have been
collected since the early 1980s, data on heart disease and stroke risk
factors are sparse for other population groups, including American
Indians, Alaska Natives, Native Hawaiians, Asians, and Pacific
Islanders. Adequate national data on all these populations will enable
researchers to examine racial and ethnic differences more fully.

Public outreach and community health intervention efforts, such as those
that encourage persons to lower their high blood pressure or to get
their cholesterol checked or to help people stop smoking, are important
parts of health care in the United States. Culturally and linguistically
appropriate counseling by health care providers is important to those
efforts. New coalitions between health care providers and individual
communities are forming to focus on the prevention and management of
chronic CVD throughout all stages of life. Emerging areas of research
include the effect of socioeconomic status on health and access to care;
health status in rural populations, which often have low income and
education levels; and quality of life as a criterion for evaluating
treatment. With the knowledge gained through these efforts, communities
will be able to use well-tested health promotion, disease prevention,
and early management strategies to lower their costs and begin to extend
the benefits of improved health to all persons in the United
States.[^73]

## Interim Progress Toward Year 2000 Objectives

Extensive progress has been made in reducing deaths from and risk
factors for heart disease and stroke, but significant challenges remain.
Between 1987 and 1996, the age-adjusted death rate for CHD declined by
22.2 percent, and for stroke, it declined by 13.2 percent. Despite these
achievements, the Healthy People 2000 objectives on CHD and stroke did
not reach the year 2000 targets, and the disparities between African
Americans and whites were not reduced.

However, progress occurred in reducing high blood cholesterol and
controlling high blood pressure. Average total cholesterol declined from
213 mg/dL in 1976--80 to 203 mg/dL in 1988--94, and the prevalence of
high blood cholesterol declined from 26 percent to 19 percent, thereby
achieving the year 2000 target. In the same time period, control rates
among persons who have high blood pressure increased from 11 percent to
29 percent. However, levels fell short of year 2000 targets. The
age-adjusted prevalence of overweight or obesity increased from 26
percent in 1976--80 to 35 percent in 1988--94.

The percentage of the population who engaged in light to moderate
physical activity remained stable at around 22 percent between 1985 and
1995. Caloric intake from fat as a percentage of total calories consumed
declined from 36 percent in 1976--80 to 34 percent in 1988--94, but fell
short of the target of 30 percent. Smoking among adults declined
steadily from the mid-1960s through the late 1980s, and has leveled off
in the 1990s. In 1998, median adult smoking prevalence for all 50 States
and the District of Columbia was 22.9 percent---25.3 percent for men and
21.0 percent for women.**^Error:\ Reference\ source\ not\ found^**

Note: Unless otherwise noted, data are from the Centers for Disease
Control and\
Prevention, National Center for Health Statistics, Healthy People 2000
Review, 1998--99.

## Healthy People 2010---Summary of Objectives

### Heart Disease and Stroke {#heart-disease-and-stroke-1 .Heading-Special-Sub}

**Goal:** Improve cardiovascular health and quality of life through the\
prevention, detection, and treatment of risk factors; early
identification and treatment of heart attacks and strokes; and
prevention of recurrent\
cardiovascular events.

  ----------------- ------------- -------------------------------------------------------------
  **Number**        **Objective   
                    Short Title** 

  **Heart Disease**               

  12-1                            Coronary heart disease (CHD) deaths

  12-2                            Knowledge of symptoms of heart attack and importance\
                                  of calling 911

  12-3                            Artery-opening therapy

  12-4                            Bystander response to cardiac arrest

  12-5                            Out-of-hospital emergency care

  12-6                            Heart failure hospitalizations

  **Stroke**                      

  12-7                            Stroke deaths

  12-8                            Knowledge of early warning symptoms of stroke

  **Blood                         
  Pressure**                      

  12-9                            High blood pressure

  12-10                           High blood pressure control

  12-11                           Action to help control blood pressure

  12-12                           Blood pressure monitoring

  **Cholesterol**                 

  12-13                           Mean total blood cholesterol levels

  12-14                           High blood cholesterol levels

  12-15                           Blood cholesterol screening

  12-16                           LDL-cholesterol level in CHD patients
  ----------------- ------------- -------------------------------------------------------------

## Healthy People 2010 Objectives

### Heart Disease

12-1. Reduce coronary heart disease deaths.

**Target:** 166 deaths per 100,000 population.

**Baseline:** 208 coronary heart disease deaths per 100,000 population
in 1998 (age adjusted to the year 2000 standard population).

**Target setting method:** 20 percent improvement.

**Data source:** National Vital Statistics System (NVSS), CDC, NCHS.

Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **Total Population, 1998**                     | **Coronary Heart    |
|                                                | Disease Deaths**    |
+================================================+=====================+
|                                                | Rate per 100,000    |
+------------------------------------------------+---------------------+
| ######### TOTAL                                | 208                 |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | 126                 |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | 123                 |
+------------------------------------------------+---------------------+
| > Asian                                        | DNC                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DNC                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 252                 |
+------------------------------------------------+---------------------+
| > White                                        | 206                 |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | 145                 |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | 211                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 257                 |
+------------------------------------------------+---------------------+
| > White                                        | 208                 |
+------------------------------------------------+---------------------+
| **Gender**                                     |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 165                 |
+------------------------------------------------+---------------------+
| > Male                                         | 265                 |
+------------------------------------------------+---------------------+
| **Education level** (aged 25 to 64 years)      |                     |
+------------------------------------------------+---------------------+
| > Less than high school                        | 96                  |
+------------------------------------------------+---------------------+
| > High school graduate                         | 80                  |
+------------------------------------------------+---------------------+
| > At least some college                        | 38                  |
+------------------------------------------------+---------------------+
| **Disability status**                          |                     |
+------------------------------------------------+---------------------+
| > Persons with disabilities                    | DNC                 |
+------------------------------------------------+---------------------+
| > Persons without disabilities                 | DNC                 |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Age adjusted to the year 2000 standard population.

Note: The table above may have continued from the previous page.

12-2. (Developmental) Increase the proportion of adults aged\
20 years and older who are aware of the early warning symptoms and signs
of a heart attack and the importance of accessing rapid emergency care
by calling 911.

**Potential data source:** National Health Interview Survey (NHIS), CDC,
NCHS.

12-3. (Developmental) Increase the proportion of eligible\
patients with heart attacks who receive artery-opening therapy within an
hour of symptom onset.

**Potential data source:** National Registry of Myocardial Infarction,
National Acute Myocardial Infarction Project, HCFA.

12-4. (Developmental) Increase the proportion of adults aged\
20 years and older who call 911 and administer\
cardiopulmonary resuscitation (CPR) when they witness\
an out-of-hospital cardiac arrest.

**Potential data source:** National Health Interview Survey (NHIS), CDC,
NCHS.

12-5. (Developmental) Increase the proportion of eligible\
persons with witnessed out-of-hospital cardiac arrest who\
receive their first therapeutic electrical shock within 6 minutes after
collapse recognition.

**Potential data source:** Medical Expenditure Panel Survey (MEPS),
AHRQ.

12-6. Reduce hospitalizations of older adults with congestive heart
failure as the principal diagnosis.

Target and baseline:

+-----------+-----------------------------+-------------+-------------+
| Objective | Reduction in                | 1997\       | 2010\       |
|           | Hospitalizations of Older   | Baseline    | Target      |
|           | Adults With Congestive      |             |             |
|           | Heart Failure as the        |             |             |
|           | Principal Diagnosis         |             |             |
+===========+=============================+=============+=============+
|           |                             | #######     |             |
|           |                             | # Per 1,000 |             |
|           |                             |  Population |             |
+-----------+-----------------------------+-------------+-------------+
| *         | Adults aged 65 to 74 years  | 13.2        | 6.5         |
| *12-6a.** |                             |             |             |
+-----------+-----------------------------+-------------+-------------+
| *         | Adults aged 75 to 84 years  | 26.7        | 13.5        |
| *12-6b.** |                             |             |             |
+-----------+-----------------------------+-------------+-------------+
| *         | Adults aged 85 years and    | 52.7        | 26.5        |
| *12-6c.** | older                       |             |             |
+-----------+-----------------------------+-------------+-------------+

**Target setting method:** Better than the best.

**Data source:** National Hospital Discharge Survey (NHDS), CDC, NCHS.

Note: The table below may continue to the following page.

+--------------------------+-------------+-------------+-------------+
| **Adults With Congestive | **Heart     |             |             |
| Heart Failure as         | Failure     |             |             |
| Principal Diagnosis,     | Hospita     |             |             |
| 1997**                   | lizations** |             |             |
+==========================+=============+=============+=============+
|                          | **12-6a.\   | **12-6b.\   | **12-6c.\   |
|                          | Aged\       | Aged\       | Aged\       |
|                          | 65 to 74    | 75 to 84    | 85 Years    |
|                          | Years**     | Years**     | and Older** |
+--------------------------+-------------+-------------+-------------+
|                          | Rate per    |             |             |
|                          | 1,000       |             |             |
+--------------------------+-------------+-------------+-------------+
| > **TOTAL**              | 13.2        | 26.7        | 52.7        |
+--------------------------+-------------+-------------+-------------+
| **Race and ethnicity**   |             |             |             |
+--------------------------+-------------+-------------+-------------+
| > American Indian or     | DSU         | DSU         | DSU         |
| > Alaska Native          |             |             |             |
+--------------------------+-------------+-------------+-------------+
| > Asian or Pacific       | DSU         | DSU         | DSU         |
| > Islander               |             |             |             |
+--------------------------+-------------+-------------+-------------+
| > Asian                  | DNC         | DNC         | DNC         |
+--------------------------+-------------+-------------+-------------+
| > Native Hawaiian and    | DNC         | DNC         | DNC         |
| > other Pacific Islander |             |             |             |
+--------------------------+-------------+-------------+-------------+
| > Black or African       | 20.0        | 21.4        | 47.0        |
| > American               |             |             |             |
+--------------------------+-------------+-------------+-------------+
| > White                  | 9.9         | 21.4        | 41.8        |
+--------------------------+-------------+-------------+-------------+
|                          |             |             |             |
+--------------------------+-------------+-------------+-------------+
| > Hispanic or Latino     | DSU         | DSU         | DSU         |
+--------------------------+-------------+-------------+-------------+
| > Not Hispanic or Latino | DSU         | DSU         | DSU         |
+--------------------------+-------------+-------------+-------------+
| > Black or African\      | DSU         | DSU         | DSU         |
| > American               |             |             |             |
+--------------------------+-------------+-------------+-------------+
| > White                  | DSU         | DSU         | DSU         |
+--------------------------+-------------+-------------+-------------+
| ###### Gender            |             |             |             |
+--------------------------+-------------+-------------+-------------+
| > Female                 | 11.5        | 25.0        | 50.2        |
+--------------------------+-------------+-------------+-------------+
| > Male                   | 15.3        | 29.2        | 58.8        |
+--------------------------+-------------+-------------+-------------+
| ###### Education level   |             |             |             |
+--------------------------+-------------+-------------+-------------+
| > Less than high school  | DNC         | DNC         | DNC         |
+--------------------------+-------------+-------------+-------------+
| > High school graduate   | DNC         | DNC         | DNC         |
+--------------------------+-------------+-------------+-------------+
| > At least some college  | DNC         | DNC         | DNC         |
+--------------------------+-------------+-------------+-------------+
| #                        |             |             |             |
| ###### Disability status |             |             |             |
+--------------------------+-------------+-------------+-------------+
| > People with            | DNC         | DNC         | DNC         |
| > disabilities           |             |             |             |
+--------------------------+-------------+-------------+-------------+
| > People without         | DNC         | DNC         | DNC         |
| > disabilities           |             |             |             |
+--------------------------+-------------+-------------+-------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

### Stroke

12-7. Reduce stroke deaths.

**Target:** 48 deaths per 100,000 population.

**Baseline:** 60 deaths from stroke per 100,000 population occurred in
1998\
(age adjusted to the year 2000 standard population).

**Target setting method:** 20 percent improvement.

**Data source:** National Vital Statistics System (NVSS), CDC, NCHS.

Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **Total Population, 1998**                     | **Stroke Deaths**   |
+================================================+=====================+
|                                                | Rate per 100,000    |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 60                  |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | 38                  |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | 51                  |
+------------------------------------------------+---------------------+
| > Asian                                        | DNC                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DNC                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 80                  |
+------------------------------------------------+---------------------+
| > White                                        | 58                  |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | 39                  |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | 60                  |
+------------------------------------------------+---------------------+
| > Black or African American                    | 82                  |
+------------------------------------------------+---------------------+
| > White                                        | 58                  |
+------------------------------------------------+---------------------+
| **Gender**                                     |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 58                  |
+------------------------------------------------+---------------------+
| > Male                                         | 60                  |
+------------------------------------------------+---------------------+
| **Education level** (aged 25 to 64 years)      |                     |
+------------------------------------------------+---------------------+
| > Less than high school                        | 22                  |
+------------------------------------------------+---------------------+
| > High school graduate                         | 17                  |
+------------------------------------------------+---------------------+
| > At least some college                        | 8                   |
+------------------------------------------------+---------------------+
| **Disability status**                          |                     |
+------------------------------------------------+---------------------+
| > Persons with disabilities                    | DNC                 |
+------------------------------------------------+---------------------+
| > Persons without disabilities                 | DNC                 |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Age adjusted to the year 2000 standard population.

Note: The table above may have continued from the previous page.

12-8. (Developmental) Increase the proportion of adults\
who are aware of the early warning symptoms and\
signs of a stroke.

**Potential data source:** National Health Interview Survey (NHIS), CDC,
NCHS.

### Blood Pressure

12-9. Reduce the proportion of adults with high blood pressure.

**Target:** 16 percent.

**Baseline:** 28 percent of adults aged 20 years and older had high
blood pressure in 1988--94 (age adjusted to the year 2000 standard
population).

**Target setting method:** Better than the best.

**Data source:** National Health and Nutrition Examination Survey
(NHANES), CDC, NCHS.

+------------------------------------------------+---------------------+
| **Adults Aged 20 Years and Older, 1988--94     | **High Blood\       |
| (unless noted)**                               | Pressure**          |
+================================================+=====================+
|                                                | Percent             |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 28                  |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | DSU                 |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | DSU                 |
+------------------------------------------------+---------------------+
| > Asian                                        | DNC                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DNC                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 40                  |
+------------------------------------------------+---------------------+
| > White                                        | 27                  |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | DSU                 |
+------------------------------------------------+---------------------+
| > Mexican American                             | 29                  |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | 28                  |
+------------------------------------------------+---------------------+
| > Black or African American                    | 40                  |
+------------------------------------------------+---------------------+
| > White                                        | 27                  |
+------------------------------------------------+---------------------+
| **Gender**                                     |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 26                  |
+------------------------------------------------+---------------------+
| > Male                                         | 30                  |
+------------------------------------------------+---------------------+
| **Family income level**                        |                     |
+------------------------------------------------+---------------------+
| > Poor                                         | 32                  |
+------------------------------------------------+---------------------+
| > Near poor                                    | 30                  |
+------------------------------------------------+---------------------+
| > Middle/high income                           | 27                  |
+------------------------------------------------+---------------------+
| **Disability status**                          |                     |
+------------------------------------------------+---------------------+
| > Persons with disabilities                    | 32 (1991--94)       |
+------------------------------------------------+---------------------+
| > Persons without disabilities                 | 27 (1991--94)       |
+------------------------------------------------+---------------------+
| **Select populations**                         |                     |
+------------------------------------------------+---------------------+
| > Persons with diabetes                        | DNA                 |
+------------------------------------------------+---------------------+
| > Persons without diabetes                     | DNA                 |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Age adjusted to the year 2000 standard population.

12-10. Increase the proportion of adults with high blood pressure whose
blood pressure is under control.

**Target:** 50 percent.

**Baseline:** 18 percent of adults aged 18 years and older with high
blood pressure had it under control in 1988--94 (age adjusted to the
year 2000 standard\
population).

**Target setting method:** Better than the best.

**Data source:** National Health and Nutrition Examination Survey
(NHANES), CDC, NCHS.

Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **Adults Aged 18 Years and Older With High     | **Blood Pressure    |
| Blood Pressure, 1988--94 (unless noted)**      | Controlled**        |
+================================================+=====================+
|                                                | Percent             |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 18                  |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | DSU                 |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | DSU                 |
+------------------------------------------------+---------------------+
| > Asian                                        | DNC                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DNC                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 19                  |
+------------------------------------------------+---------------------+
| > White                                        | 18                  |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | DSU                 |
+------------------------------------------------+---------------------+
| > Mexican American                             | 13                  |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | DNA                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 19                  |
+------------------------------------------------+---------------------+
| > White                                        | 18                  |
+------------------------------------------------+---------------------+
| **Gender**                                     |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 28                  |
+------------------------------------------------+---------------------+
| > Male                                         | 13                  |
+------------------------------------------------+---------------------+
| **Family income level**                        |                     |
+------------------------------------------------+---------------------+
| > Poor                                         | 25                  |
+------------------------------------------------+---------------------+
| > Near poor                                    | 20                  |
+------------------------------------------------+---------------------+
| > Middle/high income                           | 16                  |
+------------------------------------------------+---------------------+
| **Disability status** (aged 20 years and       |                     |
| older)                                         |                     |
+------------------------------------------------+---------------------+
| > Persons with disabilities                    | 24 (1991--94)       |
+------------------------------------------------+---------------------+
| > Persons without disabilities                 | 16 (1991--94)       |
+------------------------------------------------+---------------------+
| **Select populations**                         |                     |
+------------------------------------------------+---------------------+
| > Persons with diabetes                        | DNA                 |
+------------------------------------------------+---------------------+
| > Persons without diabetes                     | DNA                 |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Age adjusted to the year 2000 standard population.

Note: The table above may have continued from the previous page.

12-11. Increase the proportion of adults with high blood\
pressure who are taking action (for example, losing weight, increasing
physical activity, or reducing sodium\
intake) to help control their blood pressure.

**Target:** 95 percent.

**Baseline:** 82 percent of adults aged 18 years and older with high
blood pressure were taking action to control it in 1998 (age adjusted to
the year 2000 standard population).

**Target setting method:** Better than the best.

**Data source:** National Health Interview Survey (NHIS), CDC, NCHS.

Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **Adults Aged 18 Years and Older With\         | **Taking Action\    |
| High Blood Pressure, 1998 (unless noted)**     | To Control Blood    |
|                                                | Pressure**          |
+================================================+=====================+
|                                                | Percent             |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 82                  |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | DSU                 |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | 76                  |
+------------------------------------------------+---------------------+
| > Asian                                        | 75                  |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DSU                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 86                  |
+------------------------------------------------+---------------------+
| > White                                        | 80                  |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | 74                  |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | 83                  |
+------------------------------------------------+---------------------+
| > Black or African American                    | 87                  |
+------------------------------------------------+---------------------+
| > White                                        | 81                  |
+------------------------------------------------+---------------------+
| **Gender**                                     |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 83                  |
+------------------------------------------------+---------------------+
| > Male                                         | 80                  |
+------------------------------------------------+---------------------+
| **Family income level**                        |                     |
+------------------------------------------------+---------------------+
| > Poor                                         | 80                  |
+------------------------------------------------+---------------------+
| > Near poor                                    | 79                  |
+------------------------------------------------+---------------------+
| > Middle/high income                           | 81                  |
+------------------------------------------------+---------------------+
| ###### Disability status                       |                     |
+------------------------------------------------+---------------------+
| > Persons with activity limitations            | 84 (1994)           |
+------------------------------------------------+---------------------+
| > Persons without activity limitations         | 76 (1994)           |
+------------------------------------------------+---------------------+
| **Geographic variation**                       |                     |
+------------------------------------------------+---------------------+
| > Urban                                        | 83                  |
+------------------------------------------------+---------------------+
| > Rural                                        | 80                  |
+------------------------------------------------+---------------------+
| **Select populations**                         |                     |
+------------------------------------------------+---------------------+
| > Persons with diabetes                        | DNA                 |
+------------------------------------------------+---------------------+
| > Persons without diabetes                     | DNA                 |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Age adjusted to the year 2000 standard population.

Note: The table above may have continued from the previous page.

12-12. Increase the proportion of adults who have had their blood
pressure measured within the preceding 2 years and can state whether
their blood pressure was normal or high.

**Target:** 95 percent.

**Baseline:** 90 percent of adults aged 18 years and older had their
blood pressure measured in the past 2 years and could state whether it
was normal or high in 1998 (age adjusted to the year 2000 standard
population).

**Target setting method:** Better than the best.

**Data source:** National Health Interview Survey (NHIS), CDC, NCHS.

+------------------------------------------+---------------------------+
| **Adults Aged 18 Years and Older, 1998   | **Had Blood Pressure\     |
| (unless noted)**                         | Measured in Past 2 Years  |
|                                          | and Knew Whether It Was   |
|                                          | Normal or High**          |
+==========================================+===========================+
|                                          | Percent                   |
+------------------------------------------+---------------------------+
| > **TOTAL**                              | 90                        |
+------------------------------------------+---------------------------+
| **Race and ethnicity**                   |                           |
+------------------------------------------+---------------------------+
| > American Indian or Alaska Native       | 89                        |
+------------------------------------------+---------------------------+
| > Asian or Pacific Islander              | 86                        |
+------------------------------------------+---------------------------+
| > Asian                                  | 86                        |
+------------------------------------------+---------------------------+
| > Native Hawaiian and other Pacific      | 86                        |
| > Islander                               |                           |
+------------------------------------------+---------------------------+
| > Black or African American              | 92                        |
+------------------------------------------+---------------------------+
| > White                                  | 90                        |
+------------------------------------------+---------------------------+
|                                          |                           |
+------------------------------------------+---------------------------+
| > Hispanic or Latino                     | 84                        |
+------------------------------------------+---------------------------+
| > Not Hispanic or Latino                 | 91                        |
+------------------------------------------+---------------------------+
| > Black or African American              | 92                        |
+------------------------------------------+---------------------------+
| > White                                  | 91                        |
+------------------------------------------+---------------------------+
| **Gender**                               |                           |
+------------------------------------------+---------------------------+
| > Female                                 | 92                        |
+------------------------------------------+---------------------------+
| > Male                                   | 87                        |
+------------------------------------------+---------------------------+
| **Education level** (aged 25 years and   |                           |
| older)                                   |                           |
+------------------------------------------+---------------------------+
| > Less than high school                  | 84                        |
+------------------------------------------+---------------------------+
| > High school graduate                   | 90                        |
+------------------------------------------+---------------------------+
| > At least some college                  | 93                        |
+------------------------------------------+---------------------------+
| **Disability status**                    |                           |
+------------------------------------------+---------------------------+
| > Persons with activity limitations      | 90 (1994)                 |
+------------------------------------------+---------------------------+
| > Persons without activity limitations   | 84 (1994)                 |
+------------------------------------------+---------------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Age adjusted to the year 2000 standard population.

### Cholesterol

12-13. Reduce the mean total blood cholesterol levels among adults.

**Target:** 199 mg/dL (mean).

**Baseline:** 206 mg/dL was the mean total blood cholesterol level for
adults\
aged 20 years and older in 1988--94 (age adjusted to the year 2000
standard\
population).

**Target setting method:** Better than the best.

**Data source:** National Health and Nutrition Examination Survey
(NHANES), CDC, NCHS.

+------------------------------------------------+---------------------+
| **Adults Aged 20 Years and Older, 1988--94     | **Mean Cholesterol  |
| (unless noted)**                               | Level**             |
+================================================+=====================+
|                                                | mg/dL               |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 206                 |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | DSU                 |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | DSU                 |
+------------------------------------------------+---------------------+
| > Asian                                        | DNC                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DNC                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 204                 |
+------------------------------------------------+---------------------+
| > White                                        | 206                 |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | DSU                 |
+------------------------------------------------+---------------------+
| > Mexican American                             | 205                 |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | 206                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 204                 |
+------------------------------------------------+---------------------+
| > White                                        | 206                 |
+------------------------------------------------+---------------------+
| **Gender**                                     |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 207                 |
+------------------------------------------------+---------------------+
| > Male                                         | 204                 |
+------------------------------------------------+---------------------+
| **Family income level**                        |                     |
+------------------------------------------------+---------------------+
| > Poor                                         | 205                 |
+------------------------------------------------+---------------------+
| > Near poor                                    | 204                 |
+------------------------------------------------+---------------------+
| > Middle/high income                           | 206                 |
+------------------------------------------------+---------------------+
| **Disability status**                          |                     |
+------------------------------------------------+---------------------+
| > Persons with disabilities                    | 208 (1991--94)      |
+------------------------------------------------+---------------------+
| > Persons without disabilities                 | 204 (1991--94)      |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Age adjusted to the year 2000 standard population.

12-14. Reduce the proportion of adults with high total blood\
cholesterol levels.

**Target:** 17 percent.

**Baseline:** 21 percent of adults aged 20 years and older had total
blood\
cholesterol levels of 240 mg/dL or greater in 1988--94 (age adjusted to
the\
year 2000 standard population).

**Target setting method:** Better than the best.

**Data source:** National Health and Nutrition Examination Survey
(NHANES), CDC, NCHS.

Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **Adults Aged 20 Years and Older, 1988--94     | **Total Blood\      |
| (unless noted)**                               | Cholesterol Level   |
|                                                | of 240 mg/dL or     |
|                                                | Greater**           |
+================================================+=====================+
|                                                | Percent             |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 21                  |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | DSU                 |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | DSU                 |
+------------------------------------------------+---------------------+
| > Asian                                        | DNC                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DNC                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 19                  |
+------------------------------------------------+---------------------+
| > White                                        | 21                  |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | DNC                 |
+------------------------------------------------+---------------------+
| > Mexican American                             | 18                  |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | DNA                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 19                  |
+------------------------------------------------+---------------------+
| > White                                        | 21                  |
+------------------------------------------------+---------------------+
| **Gender**                                     |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 22                  |
+------------------------------------------------+---------------------+
| > Male                                         | 19                  |
+------------------------------------------------+---------------------+
| **Education level**                            |                     |
+------------------------------------------------+---------------------+
| > Less than high school                        | 22                  |
+------------------------------------------------+---------------------+
| > High school graduate                         | 22                  |
+------------------------------------------------+---------------------+
| > At least some college                        | 19                  |
+------------------------------------------------+---------------------+
| ###### Disability status                       |                     |
+------------------------------------------------+---------------------+
| > Persons with disabilities                    | 24 (1991--94)       |
+------------------------------------------------+---------------------+
| > Persons without disabilities                 | 19 (1991--94)       |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Age adjusted to the year 2000 standard population.

Note: The table above may have continued from the previous page.

12-15. Increase the proportion of adults who have had their blood
cholesterol checked within the preceding 5 years.

**Target:** 80 percent.

**Baseline:** 67 percent of adults aged 18 years and older had their
blood\
cholesterol checked within the preceding 5 years in 1998 (age adjusted
to the year 2000 standard population).

**Target setting method:** Better than the best.

**Data source:** National Health Interview Survey (NHIS), CDC, NCHS.

Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **Adults Aged 18 Years and Older, 1998 (unless | **Blood Cholesterol |
| noted)**                                       | Checked in Past 5   |
|                                                | Years**             |
+================================================+=====================+
|                                                | Percent             |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 67                  |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | 58                  |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | 68                  |
+------------------------------------------------+---------------------+
| > Asian                                        | 69                  |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | 65                  |
+------------------------------------------------+---------------------+
| > Black or African American                    | 67                  |
+------------------------------------------------+---------------------+
| > White                                        | 67                  |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | 59                  |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | 68                  |
+------------------------------------------------+---------------------+
| > Black or African American                    | 67                  |
+------------------------------------------------+---------------------+
| > White                                        | 70                  |
+------------------------------------------------+---------------------+
| **Gender**                                     |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 70                  |
+------------------------------------------------+---------------------+
| > Male                                         | 64                  |
+------------------------------------------------+---------------------+
| **Education level** (aged 25 years and older)  |                     |
+------------------------------------------------+---------------------+
| > Less than high school                        | 58                  |
+------------------------------------------------+---------------------+
| > High school graduate                         | 69                  |
+------------------------------------------------+---------------------+
| > At least some college                        | 78                  |
+------------------------------------------------+---------------------+
| ###### Disability status                       |                     |
+------------------------------------------------+---------------------+
| > Persons with activity limitations            | 72 (1993)           |
+------------------------------------------------+---------------------+
| > Persons without activity limitations         | 66 (1993)           |
+------------------------------------------------+---------------------+
| **Geographic variation**                       |                     |
+------------------------------------------------+---------------------+
| > Urban                                        | 68                  |
+------------------------------------------------+---------------------+
| > Rural                                        | 63                  |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Age adjusted to the year 2000 standard population.

Note: The table above may have continued from the previous page.

12-16. (Developmental) Increase the proportion of persons with coronary
heart disease who have their LDL-cholesterol level treated to a goal of
less than or equal to 100 mg/dL.

**Potential data source:** National Health and Nutrition Examination
Survey (NHANES), CDC, NCHS.

## Related Objectives From Other Focus Areas

1\. Access to Quality Health Services

1-3. Counseling about health behaviors

1-7. Core competencies in health provider training

1-10. Delay or difficulty in getting emergency care

1-11. Rapid prehospital emergency care

4\. Chronic Kidney Disease

4-2. Cardiovascular disease deaths in persons with chronic kidney
failure

7\. Educational and Community-Based Programs

7-2. School health education

7-5. Worksite health promotion programs

7-8. Satisfaction with patient education

7-10. Community health promotion programs

7-11. Culturally appropriate and linguistically competent community
health\
promotion programs

7-12. Older adult participation in community health promotion activities

11\. Health Communication

11-1. Households with Internet access

11-2. Health literacy

11-4. Quality of Internet health information sources

11-6. Satisfaction with health care providers' communication skills

19\. Nutrition and Overweight

19-1. Healthy weight in adults

19-2. Obesity in adults

19-3. Overweight or obesity in children and adolescents

19-5. Fruit intake

19-6. Vegetable intake

19-8. Saturated fat intake

19-9. Total fat intake

19-11. Calcium intake

19-16. Worksite promotion of nutrition education and weight management

22\. Physical Activity and Fitness

22-1. No leisure-time physical activity

22-2. Moderate physical activity

22-3. Vigorous physical activity

22-6. Moderate physical activity in adolescents

22-7. Vigorous physical activity in adolescents

22-11. Television viewing

22-13. Worksite physical activity and fitness

22-14. Community walking

22-15. Community bicycling

23\. Public Health Infrastructure

23-1. Public health employee access to Internet

23-3. Use of geocoding in health data systems

23-10. Continuing education and training by public health agencies

23-16. Data on public health expenditures

27\. Tobacco Use

27-1. Adult tobacco use

27-2. Adolescent tobacco use

27-3. Initiation of tobacco use

27-4. Age at first use of tobacco

27-5. Smoking cessation by adults

27-10. Exposure to environmental tobacco smoke

27-16. Tobacco advertising and promotion targeting adolescents and young
adults

27-17. Adolescent disapproval of smoking

## Terminology

(A listing of acronyms and abbreviations used in this publication
appears in Appendix H.)

**Angina** **(angina pectoris)**: A pain or discomfort in the chest that
occurs when some part of the heart does not receive enough blood. Angina
is a common symptom of coronary heart disease. It often recurs in a
regular or characteristic pattern. However, it may first appear as a
very severe episode or as frequently recurring bouts. When an
established stable pattern of angina changes sharply---for example, it
may be provoked by far less exercise than in the past, or it may appear
at rest---it is referred to as unstable angina.

**Angioplasty:** A nonsurgical procedure used to treat blockages in
blood vessels, particularly the coronary arteries that feed the heart.
Also known as percutaneous transluminal coronary angioplasty (PTCA). An
inflatable balloon or other device on a thin tube (catheter), fed
through blood vessels to the point of blockage, is used to open the
artery.

**Anticoagulants:** Drugs that delay the clotting (coagulation) of
blood. When a blood vessel is plugged up by a clot and an anticoagulant
is given, it tends to prevent new clots from forming or the existing
clot from enlarging. An anticoagulant does not dissolve an existing
blood clot.

**Arrhythmia:** A change in the regular beat or rhythm of the heart. The
heart may seem to skip a beat, or beat irregularly, or beat very fast or
very slowly.

**Atherosclerosis:** A type of hardening of the arteries in which
cholesterol and other substances in the blood are deposited in the walls
of arteries, including the coronary arteries that supply blood to the
heart. In time, narrowing of the coronary arteries by atherosclerosis
may reduce the flow of oxygen-rich blood to the heart.

**Atrial fibrillation (AF):** The most common sustained irregular heart
rhythm encountered in clinical practice. AF occurs when the two small
upper chambers of the heart (the atria) quiver instead of beating
effectively, and blood cannot be pumped completely out of them when the
heart beats, allowing the blood to pool and clot. If a piece of the
blood clot in the atria becomes lodged in an artery in the brain, a
stroke may result. AF is a risk factor for stroke and heart failure.

**Blood pressure:** The force of the blood pushing against the walls of
arteries. Blood pressure is given as two numbers that measure systolic
pressure (the first number, which measures the pressure while the heart
is contracting) and diastolic pressure (the second number, which
measures the pressure when the heart is resting between beats). Blood
pressures of 140/90 mmHg or above are considered high, while blood
pressures in the range of 130--139/85--89 are high normal. Less than
130/85 mmHg is normal.

**Body mass index (BMI):** Weight (in kilograms) divided by the square
of height (in meters), or weight (in pounds) divided by the square of
height (in inches) times 704.5. Because it is readily calculated, BMI is
the measurement of choice as an indicator of healthy weight, overweight,
and obesity.

**Cardiovascular disease (CVD):** Includes a variety of diseases of the
heart and blood vessels, coronary heart disease (coronary artery
disease, ischemic heart disease), stroke (brain attack), high blood
pressure (hypertension), rheumatic heart disease, congestive heart
failure, and peripheral artery disease.

**Cerebrovascular disease:** Affects the blood vessels supplying blood
to the brain. Stroke occurs when a blood vessel bringing oxygen and
nutrients to the brain bursts or is clogged by a blood clot. Because of
this rupture or blockage, part of the brain does not get the flow of
blood it needs, and nerve cells in the affected area die. Small
stroke-like events, such as transient ischemic attacks (TIAs), which
resolve in a day or less, are symptoms of cerebrovascular disease.

**Cholesterol:** A waxy substance that circulates in the bloodstream.
When the level of cholesterol in the blood is too high, some of the
cholesterol is deposited in the walls of the blood vessels. Over time,
these deposits can build up until they narrow the blood vessels, causing
atherosclerosis, which reduces the blood flow. The higher the blood
cholesterol level, the greater is the risk of getting heart disease.
Blood cholesterol levels of less than 200 mg/dL are considered
desirable. Levels of 240 mg/dL or above are considered high and require
further testing and possible intervention. Levels of 200--239 mg/dL are
considered borderline. Lowering blood cholesterol reduces the risk of
heart disease.

**Congestive heart failure (or heart failure):** A condition in which
the heart cannot pump enough blood to meet the needs of the body's other
organs. Heart failure can result from narrowed arteries that supply
blood to the heart muscle and from other factors. As the flow of blood
out of the heart slows, blood returning to the heart through the veins
backs up, causing congestion in the tissues. Often swelling (edema)
results, most commonly in the legs and ankles, but possibly in other
parts of the body as well. Sometimes fluid collects in the lungs and
interferes with breathing, causing shortness of breath, especially when
a person is lying down.

**Coronary heart disease (CHD):** A condition in which the flow of blood
to the heart muscle is reduced. Like any muscle, the heart needs a
constant supply of oxygen and nutrients that are carried to it by the
blood in the coronary arteries. When the coronary arteries become
narrowed or clogged, they cannot supply enough blood to the heart. If
not enough oxygen-carrying blood reaches the heart, the heart may
respond with pain called angina. The pain usually is felt in the chest
or sometimes in the left arm or shoulder. When the blood supply is cut
off completely, the result is a heart attack. The part of the heart
muscle that does not receive oxygen begins to die, and some of the heart
muscle is permanently damaged.

**Coronary stenting:** A procedure that uses a wire mesh tube (a stent)
to prop open an artery that recently has been cleared using angioplasty.
The stent remains in the artery permanently, holding it open to improve
blood flow to the heart muscle and relieve symptoms, such as chest pain.

**HDL (high-density lipoprotein) cholesterol:** The so-called good
cholesterol. Cholesterol travels in the blood combined with protein in
packages called lipoproteins. HDL is thought to carry cholesterol away
from other parts of the body back to the liver for removal from the
body. A low level of HDL increases the risk for CHD, whereas a high HDL
level helps protect against CHD.

**Heart attack (also called acute myocardial infarction):** Occurs when
a coronary artery becomes completely blocked, usually by a blood clot
(thrombus), resulting in lack of blood flow to the heart muscle and
therefore loss of needed oxygen. As a result, part of the heart muscle
dies (infarcts). The blood clot usually forms over the site of a
cholesterol-rich narrowing (or plaque) that has burst or ruptured.

**Heart disease:** The leading cause of death and a common cause of
illness and disability in the United States. Coronary heart disease and
ischemic heart disease are specific names for the principal form of
heart disease, which is the result of atherosclerosis, or the buildup of
cholesterol deposits in the coronary arteries that feed the heart.

**High blood pressure:** A systolic blood pressure of 140 mmHg or
greater or a diastolic pressure of 90 mmHg or greater. With high blood
pressure, the heart has to work harder, resulting in an increased risk
of a heart attack, stroke, heart failure, kidney and eye problems, and
peripheral vascular disease.

**Ischemic heart disease:** Includes heart attack and related heart
problems caused by narrowing of the coronary arteries and therefore a
decreased supply of blood and oxygen to the heart. Also called coronary
artery disease and coronary heart disease.

**LDL (low-density lipoprotein):** The so-called bad cholesterol. LDL
contains most of the cholesterol in the blood and carries it to the
tissues and organs of the body, including the arteries. Cholesterol from
LDL is the main source of damaging buildup and blockage in the arteries.
The higher the level of LDL in the blood, the greater is the risk for
CHD.

**Lipid:** Fat and fat-like substances such as cholesterol that are
present in blood and body tissues.

**Peripheral vascular disease:** Refers to diseases of any blood vessels
outside the heart and to diseases of the lymph vessels. It is often a
narrowing of the blood vessels that carry blood to leg and arm muscles.
Symptoms include leg pain (for example, in the calves) when walking and
ulcers or sores on the legs and feet.

**Stroke:** A form of cerebrovascular disease that affects the arteries
of the central nervous system. A stroke occurs when blood vessels
bringing oxygen and nutrients to the brain burst or become clogged by a
blood clot or some other particle. Because of this rupture or blockage,
part of the brain does not get the flow of blood it needs. Deprived of
oxygen, nerve cells in the affected area of the brain cannot function
and die within minutes. When nerve cells cannot function, the part of
the body controlled by these cells cannot function either.

## References

[^1]: National Heart, Lung, and Blood Institute (NHLBI). *Morbidity and
    Mortality: 1998 Chartbook on Cardiovascular, Lung, and Blood
    Diseases.* Bethesda, MD: Public Health Service (PHS), National
    Institutes of Health (NIH), NHLBI, October 1998.

[^2]: Sempos, C.T.; Cleeman, J.I.; Carroll, M.K.; et al. Prevalence of
    high blood cholesterol among U.S. adults: An update based on
    guidelines from the second report of the National Cholesterol
    Education Program Adult Treatment Panel. *Journal of the American
    Medical Association* 269:3009-3014, 1993.

[^3]: Expert Panel on Detection, Evaluation, and Treatment of High Blood
    Cholesterol in Adults. National Cholesterol Education Program:
    Second report of the Expert Panel on Detection, Evaluation, and
    Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel
    II). *Circulation* 89:1329-1445, 1994.

[^4]: The sixth report of the Joint National Committee on Prevention,
    Detection, Evaluation, and Treatment of High Blood Pressure.
    *Archives of Internal Medicine* 157(21):2413-2446, 1997.

[^5]: Burt, V.L.; Culter, J.A.; Higgins, M.; et al. Trends in the
    prevalence, awareness, treatment, and control of hypertension in the
    adult U.S. population. *Hypertension* 26:60-69, 1995.

[^6]: Centers for Disease Control and Prevention (CDC). Mortality from
    congestive heart failure---United States, 1980--1990. *Morbidity and
    Mortality Weekly Report* 43(5):77-78, 1994.

[^7]: Gillum, R.F. Epidemiology of heart failure in the United States.
    *American Heart Journal* 126:1042-1047, 1993.

[^8]: Lenfant, C. Fixing the failing heart. *Circulation* 95:771-772,
    1997.

[^9]: Croft, J.B.; Giles, W.H.; Pollard, R.A.; et al. National trends in
    the initial hospitalizations for heart failure. *Journal of the
    American Geriatrics Society* 45:270-275, 1997.

[^10]: American Heart Association (AHA). *2000 Heart and Stroke
    Statistical Update*. Dallas, TX: AHA, 2000.

[^11]: Huston, S.L.; Lengerich, E.J.; Conlisk, E.; et al. Trends in
    ischemic heart disease death rates for blacks and whites---United
    States, 1981--1995. *Morbidity and Mortality Weekly Review*
    47:945-949, 1998.

[^12]: Gillum, R.F.; Muscolino, M.F.; and Madans, J.A. Fatal MI among
    black men and women. *Annals of Internal Medicine* 127:111-118,
    1997.

[^13]: National Heart Attack Alert Program Coordination Committee.
    *Working Group Report on Educational Strategies To Prevent
    Prehospital Delay in Patients at High Risk for Acute Myocardial
    Infarction.* NIH Pub. No. 97-3787. Bethesda, MD: NIH, NHLBI, 1997.

[^14]: Burt, V.; Whelton, P.; and Roccella, E.J. Prevalence of
    hypertension in the U.S. adult population. *Hypertension*
    25:305-313, 1995.

[^15]: Stone, N.J. Primary prevention of coronary disease. *Clinical
    Cornerstone* 1(1):31-49, 1998.

[^16]: Benson, R.T., and Sacco, R.L. Stroke prevention: Hypertension,
    diabetes, tobacco, and lipids. *Neurologic Clinics* 18(2):309-319,
    2000.

[^17]: Paffenbarger, Jr., R.S.; Hyde, R.T.; Wing, A.; et al. The
    association of changes in physical activity levels and other
    lifestyle characteristics with mortality among men. *New England
    Journal of Medicine* 328:538-545, 1993.

[^18]: Blair, S.N.; Kampert, J.B.; Kohl, H.W.; et al. Influences of
    cardiopulmonary fitness and other precurors on cardiovascular
    disease and all-cause mortality in men and women. *Journal of the
    American Medical Association* 276:205-210, 1996.

[^19]: American Diabetes Association (ADA). *Diabetes 1996: Vital
    Statistics*. Alexandria, VA: ADA, 1996.

[^20]: He, J.; Whelton, P.K., Appel, L.J.; et al. Long-term effects of
    weight loss and dietary sodium reduction on incidence of
    hypertension. *Hypertension* 35(2):544-549, 2000.

[^21]: Leiter, L.A.; Abbott, D.; Campbell, N.R.; et al. Lifestyle
    modifications to prevent and control hypertension. 2.
    Recommendations on obesity and weight loss. Canadian Hypertension
    Society, Canadian Coalition for High Blood Pressure Prevention and
    Control, Laboratory Centre for Disease Control at Health Canada,
    Heart and Stroke Foundation of Canada. *Canadian Medical Association
    Journal* 160(Suppl. 9):S7-12, 1999.

[^22]: Hooper, L.; Summerbell, C.D.; Higgins, J.P.; et al. Reduced or
    modified dietary fat for prevention of cardiovascular disease.
    *Cochrane Database System Review* 2:CD002137, 2000.

[^23]: Pate, R.R.; Pratt, M.; Blair, S.N.; et al. Physical activity and
    public health: A recommendation from the Centers for Disease Control
    and Prevention and the American College of Sports Medicine. *Journal
    of the American Medical Association* 273:402-407, 1995.

[^24]: Physical activity and cardiovascular health. NIH Consensus
    Development Panel on Physical Activity and Cardiovascular Health.
    *Journal of the American Medical Association* 276(3):241-246, 1996.

[^25]: Dunn, A.L.; Marcus, B.H.; Kampert, J.B.; et al. Comparison of
    lifestyle and structured interventions to increase physical activity
    and cardiorespiratory fitness: A randomized trial. *Journal of the
    American Medical Association* 281:327-334, 1999.

[^26]: Manson, J.A.; Hu, F.; Rich-Edwards, J.W.; et al. A prospective
    study of walking as compared with vigorous exercise in the
    prevention of coronary heart disease in women. *New England Journal
    of Medicine* 341:650-658, 1999.

[^27]: U.S. Department of Health and Human Services (HHS). *Physical
    Activity and Health: A Report of the Surgeon General.* Atlanta, GA:
    HHS, CDC, National Center for Chronic Disease Prevention and Health
    Promotion (NCCDPHP), 1996.

[^28]: HHS. *The Health Benefits of Smoking Cessation. A Report of the
    Surgeon General.* HHS Pub. No. CDC 90-8416. Atlanta, GA: HHS, PHS,
    CDC, NCCDPHP, Office on Smoking and Health, 1990.

[^29]: Freedman, D.S.; Dietz, W.H.; Srinivasan, S.R.; et al. The
    relation of overweight to cardiovascular risk factors among children
    and adolescents: The Bogalusa Heart Study. *Pediatrics*
    103:1175-1182, 1999.

[^30]: Winkleby, M.; Robinson, T.; Sundquist, J.; et al. Ethnic
    variations in cardiovascular disease risk factors among children and
    young adults: Findings from the Third National Health and Nutrition
    Examination Survey (NHANES), 1998--1994. *Journal of the American
    Medical Association* 281(11):1006-1013, 1999.

[^31]: Leon, A.S.; Cornett, J.; Jacobs, Jr., D.R.; et al. Leisure time
    physical activity and risk of coronary heart disease and death: The
    Multiple Risk Factor Intervention Trial. *Journal of the American
    Medical Association* 258:2388-2395, 1987.

[^32]: O'Connor, G.T.; Hennekens, C.H.; Willett, W.H.; et al. Physical
    exercise and reduced risk of nonfatal myocardial infarction.
    *American Journal of Epidemiology* 142:1147-1156, 1995.

[^33]: Blair, S.N.; Kohl, III, H.W.; Barlow, C.E.; et al. Changes in
    physical fitness and all cause mortality: A prospective study of
    healthy and unhealthy men. *Journal of the American Medical
    Association* 273:1093-1098, 1995.

[^34]: Willett, W.H.; Dietz, W.H.; and Colditz, G.A. Primary care:
    Guidelines for healthy weight. *New England Journal of Medicine*
    341:427-434, 1999.

[^35]: Roccella, E.J., and Horan, M.J. The National High Blood Pressure
    Education Program: Measuring progress and assessing its impact.
    *Health Psychology* (Suppl. 7):237-303, 1998.

[^36]: National Center for Health Statistics (NCHS). *Health, United
    States, 1998.* Hyattsville, MD: HHS, CDC, NCHS, 1998.

[^37]: Kannel, W.B.; Dawber, T.R.; and McGee, D.L. Perspectives on
    systolic hypertension, the Framingham Study. *Circulation*
    61:1179-82, 1980.

[^38]: Systolic Hypertension in the Elderly Program (SHEP) Cooperative
    Research Group. Prevention of stroke by antihypertensive drug
    treatment in older persons with isolated systolic hypertension.
    Final results of the SHEP. *Journal of the American Medical
    Association* 265:3255-3264, 1991.

[^39]: Cleeman, J.I., and Lenfant, C. The National Cholesterol Education
    Program: Progress and prospects. *Journal of the American Medical
    Association* 280:2099-2104, 1998.

[^40]: NHLBI. Cholesterol Awareness Surveys. Press conference. Bethesda,
    MD: NHLBI, December 4, 1995.

[^41]: Clinical guidelines on the identification, evaluation, and
    treatment of overweight and obesity in adults: Evidence report.
    *Journal of Obesity Research* (Suppl. 2):51S-204S, 1998.

[^42]: HHS. *Smoking Cessation. Clinical Practice Guidelines No. 18.*
    HHS Pub. No. (AHCPR) 96-0692. Washington, DC: HHS, PHS, Agency for
    Health Care Policy and Research, 1996.

[^43]: Benson, V., and Marano, M.A. Current estimates from the National
    Health Interview Survey (NHIS), 1995. *Vital and Health Statistics*
    10(199):1-428, 1998.

[^44]: National Heart Attack Alert Program Coordinating Committee, 60
    Minutes to Treatment Working Group. Emergency Department: Rapid
    identification and treatment of patients with acute myocardial
    infarction. *Annals of Emergency Medicine* 23:311-329, 1994.

[^45]: Ryan, T.J.; Antman, E.M.; Brooks, N.H.; et al. 1999 update:
    ACC/AHA guidelines for the management of patients with acute
    myocardial infarction: A report of the American College of
    Cardiology/American Heart Association Task Force on Practice
    Guidelines (Committee on Management of Acute Myocardial Infarction).
    *Journal of the American College of Cardiology* 34:890-911, 1999.

[^46]: Boersma, E.; Maas, A.C.P.; Deckers, J.W.; et al. Early
    thrombolytic treatment in acute myocardial infarction: Reappraisal
    of the golden hour. *Lancet* 348:771-775, 1996.

[^47]: Betts, J.H. Late assessment of thrombolytic efficacy with
    altiplase (rt-PA) 6-24 hours after onset of acute myocardial
    infarction. *Australian New Zealand Journal of Medicine* 23:745-748,
    1993.

[^48]: Global Use of Strategies to Open Occluded Coronary Arteries in
    Acute Coronary Syndrome's (GUSTO IIb) Angioplasty Substudy
    Investigators. A clinical trial comparing primary coronary
    angioplasty with tissue plasminogen activator for acute myocardial
    infarction. *New England Journal of Medicine* 336:1621-1628, 1997.

[^49]: Bahr, R.D. Introduction: community message in acute myocardial
    ischemia. *Clinician* 14:1, 1996.

[^50]: National Institute of Neurological Disorders and Stroke, rt-PA
    Stroke Study Group. Tissue plasminogen activator for acute ischemic
    stroke. *New England Journal of Medicine* 333(24):1581-1587, 1995.

[^51]: ADA. Emergency Cardiovascular Care Programs. Chain of Survival.
    Links in the Chain.
    \<<http://www.proed.net/ecc/chain/links.htm>\>June 1999.

[^52]: National Heart Attack Alert Program Coordinating Committee,
    Access to Care Subcommittee. Access to timely and optimal care of
    patients with acute coronary syndromes---Community planning
    considerations: Report by the National Heart Attack Alert Program.
    *Journal of Thrombosis and Thrombolysis* 6:19-46, 1998.

[^53]: National Heart Attack Alert Program. *Patient/Bystander
    Recognition and Action: Rapid Identification and Treatment of Acute
    Myocardial Infarction.* NIH Pub. No. 93-3303 Bethesda, MD: NHLBI,
    NIH, 1993.

[^54]: Criqui, M.H.; Langer, R.D.; Fronek, A.; et al. Mortality over a
    period of 10 years in patients with peripheral arterial disease.
    *New England Journal of Medicine* 326(6):381-386, 1992.

[^55]: Salonen, J.T., and Salonen, R. Ultrasonographically assessed
    carotid morphology and the risk of coronary heart disease.
    *Arteriosclerosis and Thrombosis* 11(5):1245‑1249, 1991.

[^56]: Kannel, W.B., and Schatzkin, A. Sudden death: Lessons from
    subsets in population studies. *Journal of the American College of
    Cardiology* 5(Suppl. 6):141‑149B, 1985.

[^57]: Kuller, L.; Perper, J.; and Cooper, M. Demographic
    characteristics and trends in arteriosclerotic heart disease
    mortality: Sudden death and myocardial infarction. *Circulation*
    51(Suppl. 1):III‑1‑III-15, 1975.

[^58]: Scandinavian Simvastatin Survival Study Group. Randomized trial
    of cholesterol lowering in 4,444 patients with coronary heart
    disease: The Scandinavian Simvastat in Survival Study (4S). *Lancet*
    334:1383-1389, 1994.

[^59]: Sacks, F.M.; Pfeffer, M.A.; Moye, L.A.; et al., for the
    Cholesterol and Recurrent Events Trial Investigators. The effect of
    pravastatin on coronary events after myocardial infarction in
    patients with average cholesterol levels. *New England Journal of
    Medicine* 335:1001-1009, 1996.

[^60]: Long-Term Intervention with Pravastatin in Ischaemic Disease
    (LIPID) Study Group. Prevention of cardiovascular events and death
    with pravastatin in patients with coronary heart disease and a broad
    range of initial cholesterol levels. *New England Journal of
    Medicine* 339:1349-1357, 1998.

[^61]: Joint National Committee on Detection, Evaluation, and Treatment
    of High Blood Pressure. *The Sixth Report of the Joint National
    Committee on Detection, Evaluation, and Treatment of High Blood
    Pressure.* NIH Pub. No. 98-4080. Bethesda, MD: National High Blood
    Pressure Education Program, NIH, NHLBI, November 1998, 24-25.

[^62]: Psaty, B.M.; Smith, N.L.; Siscovick, D.S.; et al. Health outcomes
    associated with antihypertensive therapies used as first-line
    agents: A systematic review and meta-analysis. *Journal of the
    American Medical Association* 277:739-745, 1997.

[^63]: MacMahon, S., and Rodgers, A. The effect of blood pressure
    reduction in older patients: An overview of five randomized
    controlled trials in elderly hypertensives. *Clinical and
    Experimental Hypertension* 15(6):967-978, 1993.

[^64]: Packer, M.; Poole-Wilson, P.A.; Armstrong, P.W.; et al.
    Comparative effects of low and high doses of the
    angiotensin-converting enzyme inhibitor, lisinopril, on morbidity
    and mortality in chronic heart failure. ATLAS Study Group.
    *Circulation* 100(23):2312-2318, 1999.

[^65]: Chodoff, P.; Bischof, R.O.; Nash, D.B.; et al. AHCPR guidelines
    on heart failure: Comparison of a family medicine and an internal
    medicine practice with the guidelines and an educational
    intervention to modify behavior. *Clinical Performance Quality
    Health Care* 4(4):179-185, 1996.

[^66]: Haynes, R.B. Improving patient compliance in management of
    hypertension. In: Kaplan, N.M., and Ram, C.V., eds. *Individualized
    Therapy of Hypertension*. New York, NY: Marcel Dekker, Inc., 1995,
    257-273.

[^67]: Luscher, F.T.; Vetter, H.; Siegenthaler, W.; et al. Compliance in
    hypertension: Facts and concepts. *Journal of Hypertension* 3:3-9,
    1985.

[^68]: Dunbar-Jacob, J., and Stunkard, A.J. Adherence to diet and drug
    regimen. In: Levy, R.; Rifkind, B.; and Ernst, N.; eds. *Nutrition,
    Lipids, and* *Coronary Heart Disease.* New York, NY: Raven Press,
    1979, 391-423.

[^69]: Williams, G.H. Assessing patient wellness: New perspectives on
    quality of life and compliance. *American Journal of Hypertension*
    11:186S-191S, 1998.

[^70]: Roter, D.L.; Hall, J.A.; Merisca, R.; et al. Effectiveness of
    interventions to improve patient compliance. A meta-analysis.
    *Medical Care* 36:1138-1161, 1998.

[^71]: Houston, N.M.; Hill, M.; Kottke, T.; et al. The multilevel
    compliance challenge: Recommendations for a call to action. A
    statement for health care professionals. *Circulation* 95:1085-1090,
    1997.

[^72]: Stewart, M.A. Effective physician-patient communication and
    health outcomes: A review. *Canadian Medical Association Journal*
    152:1423, 1996.

[^73]: CDC. State-specific prevalence of current cigarette and cigar
    smoking adults---United States, 1998. *Morbidity and Mortality
    Weekly Report* 48(45), 1999.