**Indicator: Cardiovascular Disease Prevalence and Mortality (078)**

The broad category of cardiovascular disease (CVD) includes any disease
involving the heart and blood vessels. Coronary heart disease (CHD),
cerebrovascular disease (commonly known as stroke), and hypertension are
the major cardiovascular diseases (American Heart Association, 2003). In
addition to being a major risk factor for heart disease and stroke,
hypertension is a very commonly diagnosed disease that can also lead to
kidney damage and other health problems. Obesity, physical inactivity,
and sodium intake are all important risk factors for hypertension (NIH
2004). Since 1900, cardiovascular disease has been the leading cause of
death in the United States every year except 1918 (American Heart
Association, 2003). The U.S. age-adjusted mortality rate for CVD reached
a peak in 1950 (CDC, 1999). Between 1950 and 1999, the age-adjusted
mortality rate for CVD declined 60 percent. The major risk factors for
CVD include tobacco use, high blood pressure, high blood cholesterol,
diabetes, physical inactivity, and poor nutrition (CDC, 2004).

Environmental factors may also play a role in CVD morbidity and
mortality independent of other risk factors. However, susceptible
populations such as the elderly, smokers, and other high-risk
populations may be most impacted. For example, chronic exposure to
ambient airborne particulate matter has been shown in studies to be
associated with increased hospitalizations and mortality among older
individuals, largely due to cardiopulmonary and cardiovascular disease
(EPA, 2004). Environmental tobacco smoke (ETS) may also contribute to
CVD. Although the smoke to which a nonsmoker is exposed is less
concentrated than that inhaled by smokers, research has demonstrated
increased cardiovascular-related health risks associated with ETS (NCI
1999).

This indicator presents U.S. adult prevalence rates for coronary heart
disease, stroke, and hypertension; and mortality rates for CVD as a
whole as well as coronary heart disease, and stroke, and hypertension.
CVD prevalence data were compiled between 1997 and 2003 from the
National Center for Health Statistic's (NCHS) National Health Interview
Survey (NHIS). Mortality data were compiled between 1979 and 2002 using
the National Vital Statistics System (NVSS), maintained by NCHS. NHIS is
the principal source of information on the health of the civilian
non-institutionalized population of the United States and since 1960 has
been one of the major data collection programs of NCHS. The NVSS
registers virtually all deaths and births nationwide with data coverage
from 1933 to present and from all 50 States and the District of
Columbia.

**What the Data Show**

# *CVD Prevalence*

Among adults 18 years and older, the prevalence of heart disease and
stroke between 1997 and 2003 has remained essentially the same (Figure
078-1). In contrast, the prevalence of hypertension has shown a slow
rise increasing from 191.6 cases per 1,000 in 1999 to over 215.6 cases
per 1,000 in 2003.

Gender, race, and age differences in CVD prevalence exist. The
prevalence of CHD among males is consistently higher than females (70.3
cases per 1,000 compared with 45.7 cases per 1,000 for women in 2003).
In contrast, hypertension is more prevalent among women (225.5 cases per
1,000 for women compared with 204.8 for men in 2003). Among the racial
groups reported, Native American and Alaskan Natives consistently have
the highest prevalence of heart disease followed by whites, blacks, and
Asians. Asians also consistently had the lowest prevalence of stroke and
hypertension among the racial groups reported. In addition, the Hispanic
or Latino population had a much lower prevalence of the major
CVD-related diseases between 1999 and 2003 compared with the
non-Hispanic or Latino population.

# *CVD Mortality*

In 1998, the national age-adjusted CVD mortality rate was 352.0 per
100,000 compared to a rate of 541.0 per 100,000 in 1980 (Figure 078-2).
This decline appears to continue after 1999, with the rate dropping from
349.3 per 100,000 in 1999 to 317.4 per 100,000 in 2002. Both CHD and
stroke mortality rates have been declining in the United States. The
age-adjusted CHD mortality rate ranged from 345.2 per 100,000 in 1980 to
197.1 per 100,000 in 1998. For stroke mortality the age-adjusted rate
ranged from 97.1 per 100,000 in 1979 to 59.3 per 100,000 in 1998. The
age-adjusted mortality rate (2000 U.S. Standard Population) for CHD and
stroke in 2002 was 170.9 and 56.2 per 100,000, respectively, compared to
194.6 and 61.6 per 100,000, respectively, in 1999). Death rates from
hypertension remained essentially the same between 1999 and 2002.

Both CHD and stroke mortality have been declining over time in the 10
EPA Regions (Figures 078-3 and 078-4). In 1979, CHD and stroke
age-adjusted mortality rates (2000 U.S. Standard Population) ranged from
285.6 (Region 10) to 401.9 (Region 2) per 100,000 and 80.3 (Region 2) to
111.4 (Region 4) per 100,000, respectively. In 1998, CHD and stroke
mortality rates ranged 145.6 (Region 8) to 233.2 (Region 2) per 100,000
and 43.2 (Region 2) to 68.5 per (Region 10) 100,000, respectively. The
declining trends in CHD and stroke also appear to continue in the
1999-2002 period.

Differences exist in CVD mortality rates among gender, racial and age
groups. For example, in 2002, those aged 65 and older had the highest
CVD, CHD and stroke mortality (2,119.4, 1,135.9, and 393.2 per 100,000,
respectively) compared to younger age groups (e.g., in 2002, the
age-adjusted CVD, CHD, and stroke mortality rates for those 45-64 years
of age were 185.2, 108.5, and 23.8 per 100,000, respectively). Notable
differences in CVD and CHD mortality rates exist between males and
females, but not for stroke mortality. CHD mortality among males in 2002
was 220.4 per 100,000 compared to 133.6 per 100,000 for women. In 2002,
black males had the highest CVD mortality rate at 487.5 per 100,000
compared to white males (370.7 per 100,000), black females (363.8 per
100,000) and white females (262.8 per 100,000).

**Indicator Limitations**

-   The NHIS questionnaire underwent major changes in 1997, and the data
    presented focus on surveys conducted from 1997 to the most currently
    available release (2003). The redesigned NHIS is different in
    content, format, and mode of data collection from earlier versions
    of the survey. Due to changes in methodology, comparisons
    between1997--2003 NHIS estimates and pre-1997 NHIS data may not be
    valid.

-   Prevalence data reported in the NHIS are based on self-reported
    responses to specific questions pertaining to CVD-related illnesses.
    Self-reported data may underestimate the disease prevalence being
    measured.

-   All prevalence data are based on crude rates and are not
    age-adjusted. Therefore, the reported disease prevalence rates
    across time or within different race and gender subgroups may not
    reflect differences in the age distribution of the populations being
    compared.

-   CVD mortality rates are based on under-lying cause-of-death as
    entered on a death certificate by a physician. Some individuals may
    have had competing causes of death. "When more than one cause or
    condition is entered by the physician, the underlying cause is
    determined by the sequence of conditions on the certificate,
    provisions of the ICD, and associated selection rules and
    modifications" (CDC WONDER). Consequently, some misclassification of
    reported mortality might occur in individuals with competing causes
    of death.

-   CVD mortality rates reported previously for specified years may
    differ because new age-adjusted rates reflect the 2000 standard
    census population whereas earlier age-adjusted rates are based on
    different (e.g., 1990) standard population projections.

-   For some of the reported years , if the user selects a CDC WONDER
    query for the United States with data grouped by state, or selects a
    WONDER query for a specific state, CDC WONDER reports state
    population figures that do not add up to the national population
    reported by CDC WONDER. This is because the two different sets of
    populations come from different U.S. Census population estimates.
    (For all other years, these two sets of population data are the
    same.)

-   The International Classification of Diseases 9th Revision (ICD-9)
    codes were used to specify underlying cause of death for years
    1979 - 1998. Beginning in 1999, cause of death is specified with the
    International Classification of Diseases 10th Revision (ICD-10)
    codes. The two revisions differ substantially, and to prevent
    confusion about the significance of any specific disease code, data
    queries are separate.

**Data Sources**

National Center for Health Statistics (NCHS): Summary Health Statistics
for U.S. Adults: National Health Interview Survey, 1997 (205), 1998
(209), 1999 (Report 212), 2000 (Report 215), 2001 (Report 218), 2002
(Report 222), 2003 (Report 225).
<http://www.cdc.gov/nchs/products/pubs/pubd/series/sr10/ser10.htm>. See
Table 2.

CDC. CDC WONDER. Compressed Mortality File, Underlying Cause of Death.
[http://wonder.cdc.gov](http://wonder.cdc.gov/).

The complete web-link pathway from the CDC WONDER Home Page is:

 [Mortality---underlying cause of
death](http://wonder.cdc.gov/mortSQL.html)  [Mortality for 1999--2001
with ICD 10 codes](http://wonder.cdc.gov/mortICD10J.html)

ICD-10 codes I00--I78 are listed as major cardiovascular diseases

Note: ICD-9 codes 410-414, 429.2; ICD-10 codes I20--I25 are listed as
ischaemic heart diseases

Note: ICD-9 codes 430-434, 436-438; ICD-10 codes I60--I69 are listed as
cerebrovascular diseases

Note: ICD-10 codes 121-122 are listed as myocardial infarction (MI)

The raw numbers for each state were downloaded from the CDC WONDER
mortality database (http://wonder.cdc.gov). The raw numbers for each
state within a region were combined and age adjusted rates (2000 U.S.
Standard Population) were calculated.

NCHS. Deaths: Final Data for 2002. National Vital Statistics Reports.
53(5). October 12, 2004. Available at:
<http://www.cdc.gov/nchs/data/nvsr/nvsr53/nvsr53_05.pdf>.

**References**

American Heart Association. 2003. Heart Disease and Stroke Statistics --
2004 Update. Dallas, Texas: American Heart Association.

Center for Disease Control and Prevention (CDC). 1999. Decline in Deaths
from Heart Disease and Stroke, United States, 1990-1999, Washington, DC:
Center for Disease Control.

Center for Disease Control and Prevention (CDC). 2004. The Burden of
Chronic Diseases and

Their Risk Factors - National and State Perspectives. Department of
Health and Human Services. Accessed February 2, 2005.
<http://www.cdc.gov/nccdphp/burdenbook2004/pdf/burden_book2004.pdf>

Environmental Protection Agency. 2004. Particulate Matter (PM) Research.
Accessed February 2, 2005.
<http://www.epa.gov/pmresearch/pm_grant/04_necessity.html>

National Cancer Institute (NCI). 1999. Smoking and Tobacco Control
Monograph 10: Health Effects of Exposure to Environmental Tobacco Smoke.
August 1999. Accessed September 10, 2005.
<http://cancercontrol.cancer.gov/tcrb/monographs/10/m10_complete.pdf>

National Center for Health Statistics (NCHS): Summary Health Statistics
for U.S. Adults: National Health Interview Survey, 1997 (205), 1998
(209), 1999 (Report 212), 2000 (Report 215), 2001 (Report 218), 2002
(Report 222), 2003 (Report 225).
<http://www.cdc.gov/nchs/products/pubs/pubd/series/sr10/ser10.htm>. See
Table 2.

National Institute of Health (NIH). 2004. NIH News: The Increasing
Number of Adults with High Blood Pressure. August 23, 2004. Accessed
September 11, 2005.

<http://www.nhlbi.nih.gov/new/press/04-08-23.htm>