U.S. Department of Health and Human Services

Centers for Disease Control and Prevention

A Public Health Action Plan

to Prevent Heart Disease and Stroke

Executive Summary and Overview
The special contributions of the following partners to development of A Public

Health Action Plan to Prevent Heart Disease and Stroke, through representation in

the Working Group or Expert Panels, are gratefully acknowledged:

American Heart Association/American Stroke Association

Association of State and Territorial Health Officials (ASTHO)

Association of State and Territorial Directors of Health Promotion and Public Health 

Education (ASTDHPPHE), ASTHO

Cardiovascular Health Council, Chronic Disease Directors, ASTHO

Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS)

Chronic Disease Directors (CDD), ASTHO

Health Canada

Heart and Stroke Foundation of Canada

International Stroke Society

National Association of County and City Health Officials

National Heart, Lung, and Blood Institute, National Institutes of Health (NIH), HHS

National Institute of Neurological Disorders and Stroke, NIH, HHS

National Stroke Association

Office of Disease Prevention and Health Promotion, Office of Public Health and Science, HHS

Prevention Research Centers Program, CDC, HHS

World Health Organization

For more information or for free copies of this publication or the complete Action Plan

E-mail: ccdinfo@cdc.gov

Telephone: 1-888-232-2306 (toll free inside the United States)

Write: National Center for Chronic Disease Prevention and Health Promotion

Division of Adult and Community Health

4770 Buford Highway NE, MS K-45

Atlanta, GA 30341-3717

Web site: www.cdc.gov/cvh (contains the complete Action Plan)

Suggested Citation

US Department of Health and Human Services. A Public Health Action Plan to Prevent Heart

Disease and Stroke: Executive Summary and Overview. Atlanta, GA: US Department of Health

and Human Services, Centers for Disease Control and Prevention; 2003.

Updated July 2003.
A Public Health 

Action Plan to Prevent 

Heart Disease and Stroke

Executive Summary and Overview
ii
A MESSAGE FROM THE SECRETARY

We at the U.S. Department of Health and Human Services are committed

to improving the health of America. With the release of A Public Health

Action Plan to Prevent Heart Disease and Stroke, we will tackle one of the

most formidable public health challenges of this century—reducing the

burden of heart disease and stroke.

Heart disease and stroke are among the nation’s leading causes of death

and disability, projected to cost more than $351 billion in 2003. Heart

disease and stroke can affect anyone without regard to age, race, ethnicity,

sex, or income level. And as our population ages, these largely preventable

conditions are projected to increase.

This nation has the tools to substantially reduce the devastating impact

that heart disease and stroke have on individuals, their families, and the

nation’s economy. We can take significant steps toward a heart-healthy

and stroke-free America through several actions. These include early 

and continuous health education that focuses on prevention and healthy

lifestyle choices; medical services that provide the most effective drugs

and therapies without disparity; and environmental policies in schools,

work sites, and communities that promote good nutrition, regular 

physical activity, and abstinence from smoking.

The Action Plan offers a new promise of success. Quite simply, this plan

gives health practitioners and policy makers a framework for developing 

a health care system that equally supports treatment and prevention. This

plan is a collaborative effort designed to guide the nation in taking action,

strengthening capacity, evaluating impact, advancing policy, and engaging

in partnerships to reverse the epidemic of heart disease and stroke.

I thank the many public and private health, social service, faith, and 

community professionals who pooled their talents to develop the Action

Plan—our landmark, long-term guide for improving the nation’s heart

and stroke health. But a plan is not enough. Your personal commitment

is essential to accomplishing this massive national effort. I call on all

Americans to join me and to learn what you can do to make a difference.

Tommy G. Thompson

Secretary of Health and Human Services

U.S. Department of Health and Human Services

iii
iv
v

A MESSAGE FROM THE DIRECTORS

OF CDC AND NIH

A Public Health Action Plan to Prevent Heart Disease and Stroke is a call 

to action for tackling one of our nation’s foremost challenges—to 

prevent and control chronic diseases. 

To meet the challenge, the Centers for Disease Control and Prevention

(CDC) and the National Institutes of Health (NIH) are charged with

providing leadership to reduce heart disease and stroke, using Healthy

People 2010 objectives as their guide. The CDC and the NIH gratefully

acknowledge the many individuals from such areas as public health 

practice, academia, and voluntary health organizations, whose dedicated

efforts have produced the Action Plan. By implementing this plan

through collaborations with these and other partners, we can make the

nation’s public health system more effective in protecting the health and 

enhancing the daily lives of all Americans. 

Our national goal for preventing and controlling heart disease and 

stroke requires prevention, detection, and treatment of risk factors; 

early identification and treatment of heart attacks and strokes; and 

prevention of recurrent cardiovascular events. The Action Plan presents a

framework for public health action that addresses each of these requirements, from preventing risk factors to assuring accessible, high-quality

care for patients with these conditions. The success of this comprehensive public health strategy will also contribute to meeting the overarching goals of Healthy People 2010, which are to increase quality and years

of healthy life and to eliminate health disparities.

Our greatest challenges often represent our greatest opportunities. The

challenge is formidable—turning the tide on our nation’s leading causes

of death and major contributors to disability and dependency. We must

not underestimate the commitment needed. By making this commitment

and fully implementing the Action Plan, the public health community,

along with present and future partners, will improve our nation’s health.

We invite each of you to join us in making this plan a reality.

Julie Louise Gerberding, MD, MPH

Director, Centers for Disease Control and Prevention

Elias A. Zerhouni, MD

Director, National Institutes of Health
vi
vii

CONTENTS

A Message from the Secretary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii

A Message from the Directors of CDC and NIH . . . . . . . . . . . . . . . v

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

A Comprehensive Public Health Strategy . . . . . . . . . . . . . . . . . . . . . . . . 3

The Challenge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

The Public Health Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

The Action Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Fundamental Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Summary Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
viii
1

Executive Summary

EXECUTIVE SUMMARY

Purpose of the plan: To chart a course for the Centers for Disease Control and

Prevention (CDC) and collaborating public health agencies, with all interested

partners and the public at large, to help in promoting achievement of national

goals for preventing heart disease and stroke over the next two decades—through

2020 and beyond.

Heart disease and stroke are among the nation’s leading causes of death

and major causes of disability, projected to cost more than $351 billion in

2003. In the next two decades, these conditions can be expected to increase

sharply as this country’s “baby boom” generation ages. The current disease

burden, recent trends, and growing disparities among certain populations

reinforce this projection.

Yet these conditions are largely preventable. As expressed in the Steps to 

a HealthierUS initiative from Secretary of Health and Human Services

Tommy G. Thompson, the long-term solution for our nation's health

care crisis requires embracing prevention as the first step. To reverse the

epidemic of heart disease and stroke through increasingly effective prevention, action is needed now.

A Public Health Action Plan to Prevent Heart Disease and Stroke addresses 

this urgent need for action. Key partners, public health experts, and heart

disease and stroke prevention specialists came together to develop targeted

recommendations and specific action steps toward achievement of this

goal, through a process convened by CDC and its parent agency, the U.S.

Department of Health and Human Services (HHS).

CDC and public health partners will provide national leadership to assure

meaningful progress in implementing the plan. This includes bringing the

public health community together with new and existing partners representing every interested segment of society. An important aspect of this

process is continuing coordination between CDC and the National

Institutes of Health (NIH), HHS, which is the co-lead agency with CDC

for the heart disease and stroke focus area of Healthy People 2010.

Today, support for public health programs to prevent heart disease and

stroke remains low, constituting less than 3% of the aggregate budget of

our state public health agencies. Despite substantial public health gains in

recent years, the failure to halt and reverse the epidemic has been extremely costly. Numbers of victims and health care expenses will only escalate

unless the epidemic is reversed.

Fortunately, a new promise of success exists today. We have knowledge

from decades of research and experience, especially because of the contributions of NIH and the American Heart Association. We also have a

growing commitment to prevention, exemplified by the Secretary's Steps to

a HealthierUS initiative. And we have the potential collaboration of many

major national partners.
Public Health Action Plan to Prevent Heart Disease and Stroke

2

The Action Plan represents a comprehensive public health strategy to assist

in addressing the Healthy People 2010 goal of improving cardiovascular

health through the prevention, detection, and treatment of risk factors;

early identification and treatment of heart attacks and strokes; and prevention of recurrent cardiovascular events. This strategy depends on a

balanced investment in all available intervention approaches, from policy

and environmental changes designed to prevent risk factors to assurance

of quality care for the victims of heart disease and stroke, and it includes

education to support individual efforts to prevent or control risk factors.

To successfully implement the plan, two fundamental requirements must

be met. First, we must communicate to the public at large and to policy

makers the urgent need and unprecedented opportunity to prevent heart

disease and stroke. Second, we must transform the nation’s public health

infrastructure to provide leadership and to develop and maintain effective partnerships and collaborations to support the needed actions.

The five essential components of this plan are taking action, strengthening

capacity, evaluating impact, advancing policy, and engaging in regional and

global partnerships. In these five areas, 22 recommendations and supporting action steps are proposed for implementation over the course of this

long-term plan. In summary form, these recommendations are as follows:

• Develop new policies in accordance with advances in science and implement new intervention programs in a timely manner in multiple settings,

for all age groups, for whole populations, and especially for high-risk

groups, on a scale sufficient to have measurable impacts.

• Strengthen public health agencies and create training opportunities,

model standards, and resources for continuous technical support for these

agencies and their partners.

• Enhance data sources and systems to monitor key indicators relevant to

heart disease and stroke prevention and to systematically evaluate policy

and program interventions.

• Foster research on policies and public health programs aimed at preventing atherosclerosis and high blood pressure, especially at the community

level. Continue to evaluate the public health role of genetic and other

biomarkers of risk. Develop innovative ways to evaluate public health

interventions, particularly those related to policy and environmental

change and population-wide health promotion.

• Work with regional and global partners to reap the full benefit of sharing

knowledge and experience in heart disease and stroke prevention with

these partners.

The next step is to develop a detailed implementation plan—first setting

priorities, then assessing the potential alignment of proposed action steps

with the interests of individual partners, adopting short- and long-term

time lines, and formulating feasible approaches for evaluation. CDC is

committed to providing leadership and support to convene these ongoing

efforts, inviting all interested partners to collaborate in action areas 

congruent with their own interests.
3

OVERVIEW

Heart disease and stroke are epidemic in the United States and elsewhere.1,2 In the next two decades, these largely preventable conditions are

projected to increase sharply in numbers as this country’s “baby boom”

generation ages.3,4 The message is urgent—action is needed now to

reverse the epidemic of heart disease and stroke.

A Comprehensive Public Health Strategy

Effective action will require a comprehensive public health strategy 

and a sustained commitment to its implementation. A Public Health 

Action Plan to Prevent Heart Disease and Stroke addresses these requirements. CDC invited participants to develop the plan, in keeping with its

responsibility for undertaking activities to help move the nation toward

achievement of the goal for heart disease and stroke prevention under

Healthy People 2010.5

This followed designation of CDC as co-lead agency for this focus 

area, joining the National Institutes of Health (NIH), which had sole

responsibility for this area previously. NIH, with CDC and other partners,

participated in the Working Group that guided the planning process. In

addition, public health experts and heart disease and stroke prevention

specialists in the United States and abroad were asked to participate in the

Working Group, one of five Expert Panels, or a National Forum. 

For the Expert Panels, each of which was chaired by an extramural 

public health expert, 45 national and international experts contributed 

to formulation of the recommendations and proposed action steps. For

the Working Group, which also was chaired by an extramural public

health expert, 20 national and international experts served. For the

National Forum, which was presided over by the chair of the Working

Group, 81 individuals representing 66 national and international organizations and agencies other than CDC participated. With technical 

support from CDC, these groups developed the substance of the plan.

These activities occurred from December 2001 through September 2002.

The resulting plan belongs to all who wish to use it. For successful 

implementation, public health agencies and the overall public health 

community must join with new and existing partners representing 

every interested segment of society. CDC and other public health 

agencies will provide leadership for working with partners to assure 

that meaningful progress is made. Participation is welcomed from all 

who wish to contribute. Continuing collaboration with NIH as co-lead

agency will be important.

The Challenge

Despite the major progress in reducing death rates from heart disease

and stroke, their total impact has increased in the past 50 years according

to many health status indicators.1,6 In the United States, growing 

Every 29 seconds, someone 

will suffer a coronary event 

in the United States. 

Every 60 seconds, someone 

will die from such an event.

Every 45 seconds, someone will

suffer a new or recurrent stroke.

Every 3.1 minutes, someone will

die from a stroke.

Overview

Many people believe 

that cardiovascular disease 

only affects men and older 

people. But heart disease 

and stroke are among 

the leading causes of death 

for U.S. women and men 

in all racial and ethnic groups,

and sudden cardiac deaths have

increased dramatically among

people younger than age 35.

Causes of Death for all Americans

in the United States, 2000

Cardiovascular 

Disease and Stroke

39%

All Other Causes

38%

Cancer

23%
4

Public Health Action Plan to Prevent Heart Disease and Stroke

In 2002, CDC funded 

cardiovascular disease 

prevention programs in 29

states and the District of

Columbia. The Heart Disease

and Stroke Prevention Program

is designed to reduce disparities 

in treatment, risk factors, and

disease; delay the onset of 

disease; postpone death; and

reduce disabling conditions. 

The goal is a national program

with sufficient funding for 

every state.

CDC Funding 

for State Programs

Fiscal Year 2002

No CDC Funding

Funding for Capacity Building

Funding for Basic Implementation

numbers of people are dying from these conditions or surviving with 

disability, dependency, and high risk for recurrence. During the 1990s,

although the overall death rate for these conditions declined 17.0%, the

actual number of deaths increased 2.5%. This reflects, in part, growth in

the population over age 65, which has the highest rates and therefore

contributes most to the mounting numbers of deaths each year.7

As a result, heart disease remained the nation’s leading cause of death in

2000 for women and men and for nearly every racial and ethnic group.

Stroke is the third leading cause of death, and both conditions are major

causes of disability for people 65 and older, as well as for many younger

adults. Thus, the importance of these conditions is not restricted to the

older population, though the number of victims at older ages are especially great. Risk factors such as diabetes have increased sharply, even for

younger people.8 Growing health disparities place certain populations,

especially racial or ethnic minorities and people of low income or 

education, at excess risk relative to groups with the most favorable 

rates of heart disease and stroke.9–12 Aging of the baby boom generation

portends a sharp rise by 2020 in the number of people who die from

heart disease and stroke or survive with dependency.3,4

Clearly, heart disease and stroke contribute substantially to the nation’s

health care crisis, as addressed by Secretary of Health and Human

Services Tommy G. Thompson in his initiative, Steps to a HealthierUS.

This initiative places an important new emphasis on prevention of

chronic diseases and conditions.

The epidemic of heart disease and stroke can be expected to continue,

with an increasing burden and widening disparities, unless unprecedented public health efforts are mounted to arrest and reverse it. This challenge will test the ability of public health institutions at all levels to fulfill

their obligation to protect society against this rising epidemic. Three

factors affect the current challenge.

• Support for public health programs to prevent heart disease

and stroke is low. State public health agencies expend less than 3% of

their budgets on chronic disease programs, including heart disease and

stroke prevention.7

• The costs of failure are very high. The economic costs of heart 

disease and stroke rise each year. These costs include the numbers of

people requiring treatment for risk factors or early signs of disease;

emergency treatment for first or recurrent episodes of heart attack,

heart failure, or stroke; and efforts to reduce disability and prevent

recurrent episodes. In 2003, health care costs alone are projected to be

$209.3 billion. Although personal and societal costs are incalculable,

they include another $142.5 billion in lost productivity.1 These costs

will escalate further if this epidemic is not halted and reversed. As

noted by Secretary Thompson, chronic diseases and conditions,

including heart disease, consume more than 75% of our nation’s health

care dollars, yet they are largely preventable.

• An unprecedented opportunity to prevent heart disease and

stroke exists today in the United States. We know what causes
5

these conditions and how to prevent them, largely because of the

decades of research supported by NIH, the American Heart

Association, and others.6 Healthy People 2010 has outlined clear goals,

and the Healthy People 2010 Heart and Stroke Partnership* was

established to help in achieving them.5 Also, health professionals 

have become more aware of the need for immediate action as they

increasingly recognize the continuing cardiovascular epidemic, recent

unfavorable trends, and forecasts of a mounting disease burden.8

The Public Health Response

Substantial public health achievements have been made in preventing

heart disease and stroke, but they are insufficient to arrest or reverse the

epidemic. Public health serves society by guaranteeing conditions of life

in which people can be healthy and by addressing three core functions—

assessment, policy development, and assurance.13 Achievements in these

areas as they relate to heart disease and stroke6 include the following:

• Assessment. For several decades, public health agencies and

researchers have collected data on the epidemic and conducted

research on how to control it. Although important gaps persist, the

accumulated knowledge provides a solid evidence base for public

health decision making.

• Policy development. A wealth of policies has been developed on

the basis of this knowledge. Some policies have been implemented

effectively but await broader, more intensive application to achieve

their full impact. Others have yet to be acted upon. Evaluating these 

policies requires implementation on a sufficient scale and adequate

resources for evaluation.

• Assurance. Assurance, measured by how much society is protected

from epidemic heart disease and stroke, remains to be achieved

despite recent progress. Public health agencies can put current

knowledge to work through a targeted plan of action. Unfortunately,

most public health agencies are not yet well-equipped for this task.13

The U.S. Department of Health and Human Services (HHS) and its 

component agencies, including NIH and especially its National Heart,

Lung, and Blood Institute and National Institute of Neurological

Disorders and Stroke, represent a long history of research and program

development in the area of heart disease and stroke for both health 

professionals and the public. It is beyond the scope of this document to

inventory the contributions of even one agency, much less those of HHS

as a whole, but it is important to recognize that today’s knowledge base

about prevention of heart disease and stroke is, to a large degree, a

reflection of this work. Other organizations, especially the American

Heart Association, also have supported research that has led to the kinds

of policy developments—often in partnership with others, such as the

American College of Cardiology—that underlie the present opportunity

Overview

* Current partners include the American Heart Association/American Stroke Association,

CDC, Centers for Medicare & Medicaid Services, Indian Health Service, NIH, and

Office of Public Health and Science, U.S. Department of Health and Human Services.

The Steps to a HealthierUS

initiative envisions a healthy,

strong United States where 

diseases are prevented when

possible, controlled when 

necessary, and treated when

appropriate. This initiative is 

a bold shift in our approach 

to the health of our citizens,

moving us from a disease care

system to a health care system.

We can no longer sustain the

skyrocketing health care costs

created by an over reliance 

on treatment, nor should

Americans continue to suffer

from preventable diseases.
6

Public Health Action Plan to Prevent Heart Disease and Stroke

Note: Healthy People 2010 goals are explained in the text. HBP = high blood pressure, TC = total cholesterol, DM = diabetes mellitus, MI = myocardial infarction, CHF = congestive heart failure, 

CVD = cardiovascular disease.

A Vision of the Future

Social and

Environmental

Conditions

Favorable to Health

Behavioral

Patterns That

Promote Health

Low

Population

Risk

Few Events/

Only Rare 

Deaths

Full Functional

Capacity/Low Risk of

Recurrence

Good Quality of Life

Until Death

The Present Reality

Unfavorable Social

and Environmental

Conditions

Adverse 

Behavioral 

Patterns

Major Risk 

Factors

First Event/

Sudden Death

Disability/Risk 

of Recurrence

Fatal CVD

Complications/

Decompensation

Target Population

Total Population

281,000,000

Total Population

281,000,000

Smoking

HBP

TC 

DM 

Stroke 500,000

MI 650,000

CHF 550,000

Stroke 375,000

MI 450,000

CHF 450,000

CVD 525,000

The Healthy People 2010 Partnership Goals

Rehabilitation/

Long-term Case

Management End-of-Life Care

Risk Factor

Detection 

and Control

Behavioral

Change

Policy and

Environmental

Change Emergency Care/

Acute Case

Management

Goal 1 Goal 2 Goal 3 Goal 4

Increase Quality and Years of Healthy Life

Eliminate Disparities

Intervention Approaches

Figure 1. Action Framework for a Comprehensive Public Health Strategy to Prevent Heart Disease 

and Stroke (see the inside back cover for a color version of this figure)

for heart disease and stroke prevention. CDC has contributed in this

area for many years through its laboratory standardization, surveillance,

and vital statistics activities, as well as through more recent public health

program implementation.

In the context of this HHS tradition, Secretary Thompson’s Steps to a

HealthierUS initiative is a significant new development. It calls for 

marshalling all available resources within HHS and for action by other

federal agencies, such as transportation, agriculture, and education, and

private-sector interests, such as the food industry and many others. All are

urged to take steps to improve the nation’s health. Further, this initiative

calls on policy makers to embrace prevention as the first step toward solving our nation’s health care crisis. Clearly, it is understood that business as

usual will not be sufficient to meet today’s challenges in addressing chronic diseases and conditions, including heart disease and stroke.

48,700,000

50,000,000

105,000,000

10,910,000
7

The Action Plan

The Action Plan embraces the two overarching goals of Healthy People

2010, which are to increase quality and years of healthy life and to eliminate health disparities.5 It also addresses four goals specific to heart disease and stroke, as distinguished by the Healthy People 2010 Heart and

Stroke Partnership according to the different intervention approaches

that apply. These goals (which are based on the one Healthy People 2010

goal) are prevention of risk factors, detection and treatment of risk factors, early identification and treatment of heart attacks and strokes, and

prevention of recurrent cardiovascular events. An action framework that

outlines the comprehensive public health strategy of the Action Plan (see

Figure 1) highlights these goals. The main features of the action framework can be described briefly as follows (see the complete Action Plan for

further discussion):

• The Present Reality, which summarizes current knowledge of the

progressive development of heart disease and stroke.

• A Vision of the Future, which summarizes the favorable circumstances that must be achieved if the epidemic of heart disease and

stroke is to be arrested and reversed.

• Intervention Approaches, which include the six broad approaches

that, when fully and effectively implemented, can help bring about

the transition to the vision of the future.

• Healthy People 2010 Partnership Goals for reducing heart disease

and stroke and how the six intervention approaches can address 

successive stages of disease and help attain these goals.

• Target Population, which indicates how many people could be

reached by each successive intervention approach.

This public health strategy is based on the concept of pursuing the

Healthy People 2010 goal for preventing heart disease and stroke by

applying the full array of intervention approaches. For this Action Plan,

participants proposed specific recommendations after identifying public

health areas critical to preventing heart disease and stroke. Five such

areas were established as essential components of the plan (see Figure 2,

next page). For each component, CDC convened an Expert Panel to

consider the relevant issues and recommend action steps through which

to address them. Detailed implementation plans will be developed in

each area subsequently, guided by the overall plan. 

The five components and their respective panels are summarized as 

follows:

• Taking action. Translating current knowledge into effective public

health action (Expert Panel A).

• Strengthening capacity. Transforming public health agencies 

with new competencies and resources and expanding partnerships 

to mount and sustain such action (Expert Panel B).

• Evaluating impact. Systematically monitoring and evaluating the

health impact of interventions to identify and rapidly disseminate

those most effective (Expert Panel C).

Overview

“We have the scientific 

knowledge to create a world 

in which most cardiovascular

disease could be eliminated.”

From The 2000 Victoria Declaration

on Women, Heart Diseases and

Stroke

The Utah Cardiovascular Health

Program partnered with 140

organizations representing 

government, private businesses,

health care organizations, 

and nonprofit agencies 

to form the Alliance for

Cardiovascular Health. This

group has developed a 3-year

plan to identify key strategies

for improving cardiovascular

health, including policy and

environmental change.
8

Public Health Action Plan to Prevent Heart Disease and Stroke

African Americans are more

adversely affected by heart 

disease and stroke than any

other racial group in the United

States. To combat this disparity,

the Association of Black

Cardiologists is conducting a

public education campaign

called Children Should Know

Their Grandparents: A Guide to

a Healthy Heart. This program

encourages healthy lifestyle

choices to prevent heart disease

and stroke and stresses the

importance of sharing family

medical histories.

Figure 2. An Integrated Action Plan to Prevent Heart Disease and Stroke

Taking

action

Evaluating

Impact

Advancing

Policy

Engaging in regional and 

global partnerships

Strengthening

capacity

• Advancing policy. Defining the most critical policy issues and 

pursuing the needed prevention research to resolve them and 

expedite policy development (Expert Panel D).

• Engaging in regional and global partnerships. Multiplying

resources and capitalizing on shared experience with others 

throughout the global community who are addressing similar 

challenges (Expert Panel E).

The Expert Panels proposed specific recommendations and action steps

for implementing the plan over the next two decades and beyond. For

this Overview, the full list of recommendations was synthesized into two

fundamental requirements and 10 summary recommendations. All 

recommendations and action steps are available at www.cdc.gov/cvh 

in the complete Action Plan.

Fundamental Requirements

• We must communicate to the public at large and to policy 

makers the urgent need and unprecedented opportunity to 

prevent heart disease and stroke in order to establish widespread awareness and concern about these conditions, as well 

as confidence in the ability to prevent and control them.

An effective, comprehensive public health strategy to prevent heart 

disease and stroke depends on widespread understanding of three

basic messages. Heart disease and stroke threaten the health and

well-being of all Americans, especially during the middle and older

adult years. Prevention is possible by reversing community-acquired

behaviors, risks, and health disparities. Failure to intensify preventive

efforts now will sharply escalate the future burden and cost of these

conditions. To effectively implement this plan, we must communicate these and other clear messages through appropriate channels,

with support from appropriate partners. A communications infrastructure is needed that includes public health agencies at all levels,

tribal and other governmental agencies, the private sector (e.g., 
9

voluntary and faith-based associations, professional and business

groups, media, foundations), and broad community participation.

• We must transform the nation’s public health infrastructure to

provide leadership and to develop and maintain effective partnerships and collaborations for the action needed.

Such changes, which will be elaborated in a detailed implementation

plan, will enable public health leaders to bring together the array of

partners needed to prevent heart disease and stroke. These changes

will also lead public health agencies to recognize and aggressively

emphasize the policy and environmental changes and populationwide information and education needed for health behavior change.

Summary Recommendations

1. Develop policies for preventing heart disease and stroke at

national, state, and local levels to assure effective public health

action, including new knowledge on the efficacy and safety of

therapies to reduce risk factors. Implement intervention programs in a timely manner and on a sufficient scale to permit

rigorous evaluation and the rapid replication and dissemination

of those most effective.

Active intervention is needed continually to develop and support

policies (both in and beyond the health sector) that are favorable 

to health, change those that are unfavorable, and foster policy 

innovations when gaps are identified. Policies that adversely affect

health should be identified because they can be major barriers to 

the social, environmental, and behavioral changes needed to 

improve population-wide health. 

2. Promote cardiovascular health and prevent heart disease and

stroke through interventions in multiple settings, for all age

groups, and for the whole population, especially high-risk

groups.

This recommendation defines the scope of a comprehensive public

health strategy to prevent heart disease and stroke. Such a strategy

must 1) emphasize promotion of desirable social and environmental

conditions and favorable population-wide and individual behavioral

patterns to prevent major risk factors and 2) assure full accessibility 

and timely use of quality health services among people with risk 

factors or disease.

3. Strengthen public health agencies to assure that they develop

and maintain sufficient capacities and competencies, including

their laboratories.

Public health agencies at state and local levels should establish specific

programs designed to promote cardiovascular health and prevent

“At no time in the history of 

this nation has the mission of

promoting and protecting the

public’s health resonated 

more clearly with the public

and the government than 

now. To improve health in 

our communities, we need 

high-quality and well-educated 

public health professionals.”

From Who Will Keep the Public

Healthy? Educating Public Health

Professionals for the 21st Century,

Institute of Medicine, 2002

Overview

“To reach minority populations,

the American Heart Association

created Search Your Heart. 

This faith-based program is

established primarily in the

inner cities for the medically

underserved, high-risk segment

of our population. Important

cardiovascular health messages

are delivered through the 5,000

places of worship enrolled in 

this program nationwide.”

Robert O. Bonow, MD, President,

American Heart Association
10

Public Health Action Plan to Prevent Heart Disease and Stroke

heart disease and stroke. Skills are required in the new priority areas

of policy and environmental change, population-wide health promotion through behavioral change, and risk factor prevention. Public

health agencies must also be able to manage and use health data systems to effectively monitor and evaluate interventions and prevention

programs. Laboratory capacity and standardization must be maintained to address new and continuing demands and opportunities.

4. Create opportunities for training, offer model standards for

preventing chronic diseases, and make consultation and technical support continuously available to public health agencies,

including their laboratories.

This plan demands new skills and competencies that can only be met

through new training opportunities (see the complete Action Plan for

details). Public health agencies can fulfill their responsibilities and

function effectively in the new era of diverse partnerships by taking

advantage of these opportunities.

5. Define criteria and standards for population-wide health data

sources. Expand these sources as needed to assure adequate

long-term monitoring of population measures related to heart

disease and stroke.

Such measures include mortality, incidence, and prevalence rates;

selected biomarkers of CVD risk; risk factors and behaviors; economic conditions; community and environmental characteristics;

sociodemographic factors (e.g., age, race/ethnicity, sex, place of residence); and leading health indicators. Appropriate criteria and standards can be defined through a national meeting of key stakeholders.

In addition, they must conform to the National Health Information

Infrastructure (www.health.gov/ncvhs-nhii) and the Standards for

Privacy of Individually Identifiable Health Information, also called

the Privacy Rule (www.hhs.gov/ocr/hipaa).

6. Upgrade and expand health data sources to allow systematic

monitoring and evaluation of policy and program interventions.

To learn what works best, all programs funded by public health agencies should allocate resources for evaluation upfront, and staff must

be trained to develop and apply evaluation methods. The resulting

data must be communicated effectively to other agencies and to policy

makers.

7. Emphasize the critical roles of atherosclerosis and high blood

pressure, which are the dominant conditions underlying heart

disease and stroke, within a broad prevention research agenda.

Prevention research on policy, environmental, and sociocultural

determinants of risk factors, as well as potentially useful genetic and

other biomarkers of risk, is critical, as is rapid translation of this

The state-based Behavioral 

Risk Factor Surveillance System

(BRFSS) is the largest telephone

survey tool in the world. Data

have been collected on the

public’s knowledge of the signs 

and symptoms of heart attack

and stroke, their access to and

participation in health care, and

other issues related to quality 

of life. BRFSS data help health

care professionals and policy

makers effectively address the

needs of specific populations

and geographic areas.

The Oklahoma Cardiovascular

Health Program has developed

rules to help emergency and

hospital workers better serve

stroke patients, based on

American Heart Association 

and National Stroke Association

guidelines.
11

information into health care practice. Policy makers must understand

the value of such research. Such research should focus especially on

children and adolescents because atherosclerosis and high blood

pressure can begin early in life. The prevention research agenda

should be developed and updated collaboratively among interested

parties, taking current and planned research programs into account.

8. Develop innovative ways to monitor and evaluate policies and

programs, especially for policy and environmental change and

population-wide health promotion.

Public health agencies and their partners should conduct and promote research to improve surveillance methods in multiple areas, 

settings, and populations. Marketing research can be used to evaluate

public knowledge and awareness of key health messages and to

update these messages over time. Methodological research can 

help assess the impact of new technologies and regulations on 

surveillance systems.

9. Reap the full benefit of shared knowledge and experience from

regional and global partners through information exchange in

the area of heart disease and stroke prevention.

Such communication will promote productive interactions among

public health agencies in the United States and their counterparts

elsewhere in the world addressing similar challenges. As a result, this

nation will benefit from the investment of others by gaining valuable

knowledge and experience in public health approaches to heart disease

and stroke prevention.

10. Work with regional and global partners to develop prevention

policies, formulate strategies for use of global media for health

communications, and assess the impact of globalization on 

cardiovascular health.

With these partners, the U.S. public health community can explore

new ways to enhance the skills and resources of global health agencies,

apply new methods for monitoring and evaluating interventions, 

and further research by fostering replication of studies in diverse 

settings.

Implementation

Immediate action is needed to prevent heart disease and stroke. To 

initiate and sustain this action, commitment is needed from national,

state, and local public health agencies; tribal organizations; and others

within and beyond the health sector. Implementation of the Action Plan

should complement other activities in pursuit of the Healthy People 2010

goal for preventing heart disease and stroke and be appropriately coordinated with the existing Healthy People 2010 Heart and Stroke Partnership. The complete Action Plan can be reviewed at www.cdc.gov/cvh.

Overview
References

1. American Heart Association. Heart and Stroke Statistics—2003 Update. Dallas,

TX: American Heart Association; 2003.

2. Murray CJL, Lopez A. Alternative Projections of Mortality and Disability by

Cause 1990–2020: Global Burden of Disease Study. Lancet 1997;349:1498–1504.

3. Foot DK, Lewis RP, Pearson TA, Beller GA. Demographics and Cardiology,

1950–2050. Journal of the American College of Cardiology 2000;35(No. 5, Suppl

B):66B–80B.

4. Howard G, Howard VJ. Stroke Incidence, Mortality, and Prevalence. In:

Gorelick PB, Alter M, editors. The Prevention of Stroke. New York, NY: The

Parthenon Publishing Group; 2002:1–10.

5. US Department of Health and Human Services. Healthy People 2010:

Understanding and Improving Health and Objectives for Improving Health. 2nd ed.

Vol 1. Washington, DC: US Government Printing Office; November 2000.

6. Labarthe DR. Epidemiology and Prevention of Cardiovascular Diseases: A Global

Challenge. Gaithersburg, MD: Aspen Publishers; 1998.

7. Centers for Disease Control and Prevention. Unrealized Prevention Opportunities:

Reducing the Health and Economic Burden of Chronic Disease. Atlanta, GA: US

Department of Health and Human Services, Centers for Disease Control and

Prevention; 2000.

8. Cooper R, Cutler J, Desvigne-Nickens P, et al. Trends and Disparities in

Coronary Heart Disease, Stroke, and Other Cardiovascular Diseases in the

United States. Findings of the National Conference on Cardiovascular Disease

Prevention. Circulation 2000;102:3137–47.

9. Centers for Disease Control and Prevention. Health, United States, 2002. With

Chartbook on Trends in the Health of Americans. Hyattsville, MD: US Department

of Health and Human Services, Centers for Disease Control and Prevention;

2002. DHHS publication no. 1232.

10. Casper ML, Barnett E, Halverson JA, et al. Women and Heart Disease: An Atlas of

Racial and Ethnic Disparities in Mortality. Second Edition. Morgantown, WV:

Office for Social Environment and Health Research; 2000.

11. Barnett E, Casper ML, Halverson JA, et al. Men and Heart Disease: An Atlas of

Racial and Ethnic Disparities in Mortality. First Edition. Morgantown, WV: Office

for Social Environment and Health Research; 2001.

12. Casper ML, Barnett E, Williams GI Jr, et al. Atlas of Stroke Mortality: Racial,

Ethnic, and Geographic Disparities in the United States. Atlanta, GA: US

Department of Health and Human Services, Centers for Disease Control 

and Prevention; January 2003.

13. Committee for the Study of the Future of Public Health, Division of Health

Care Services, Institute of Medicine. The Future of Public Health. Washington,

DC: National Academy Press; 1988.

12

Public Health Action Plan to Prevent Heart Disease and Stroke
Note: Healthy People 2010 goals are explained in the text. HBP = high blood pressure, TC = total cholesterol, DM = diabetes mellitus, MI = myocardial infarction,

CHF = congestive heart failure, CVD = cardiovascular disease.

(Figure 1 from p. 6)

Action Framework for a Comprehensive Public Health

Strategy to Prevent Heart Disease and Stroke 

A Vision of the Future

Social and

Environmental

Conditions

Favorable to Health

Behavioral

Patterns That

Promote Health

Low

Population

Risk

Few Events/

Only Rare 

Deaths

Full Functional

Capacity/Low Risk of

Recurrence

Good Quality of Life

Until Death

The Present Reality

Unfavorable Social

and Environmental

Conditions

Adverse 

Behavioral 

Patterns

Major Risk 

Factors

First Event/

Sudden Death Disability/Risk of Recurrence

Fatal CVD

Complications/

Decompensation

Target Population

Total Population

281,000,000

Total Population

281,000,000

Smoking

HBP

TC 

DM 

Stroke 500,000

MI 650,000

CHF 550,000

Stroke 375,000

MI 450,000

CHF 450,000

CVD 525,000

The Healthy People 2010 Partnership Goals

Rehabilitation/

Long-term Case

Management End-of-Life Care

Risk Factor

Detection 

and Control

Behavioral

Change

Policy and

Environmental

Change Emergency Care/

Acute Case

Management

Goal 1 Goal 2 Goal 3 Goal 4

Increase Quality and Years of Healthy Life

Eliminate Disparities

Intervention Approaches

48,700,000

50,000,000

105,000,000

10,910,000
U.S. Department of Health and Human Services

Centers for Disease Control and Prevention

The special contributions of the following partners to development of A Public 

Health Action Plan to Prevent Heart Disease and Stroke, through representation in

the Working Group or Expert Panels, are gratefully acknowledged:

American Heart Association/American Stroke Association

Association of State and Territorial Health Officials (ASTHO)

Association of State and Territorial Directors of Health Promotion and Public Health 

Education (ASTDHPPHE), ASTHO

Cardiovascular Health Council, Chronic Disease Directors, ASTHO

Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS)

Chronic Disease Directors (CDD), ASTHO

Health Canada

Heart and Stroke Foundation of Canada

International Stroke Society

National Association of County and City Health Officials

National Heart, Lung, and Blood Institute, National Institutes of Health (NIH), HHS

National Institute of Neurological Disorders and Stroke, NIH, HHS

National Stroke Association

Office of Disease Prevention and Health Promotion, Office of Public Health and Science, HHS

Prevention Research Centers Program, CDC, HHS

World Health Organization