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

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

Action Plan to Prevent 

Heart Disease and Stroke
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

Section 1. Heart Disease and Stroke Prevention: Time for Action . . . . . . . . . . . . . . . 13

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Introduction: Planning for the Prevention of Heart Disease and Stroke . . . . . . . . . . . . .14

Heart Disease and Stroke: Scope, Burden, Disparities, and a Forecast . . . . . . . . . . . . . . 14

Myths and Misconceptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

The Knowledge Base for Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Evolution of Prevention Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Healthy People 2010 Goals and Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

The Present Opportunity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Section 2. A Comprehensive Public Health Strategy and the Five Essential 

Components of the Plan: A Platform for Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Introduction: A Vision of Cardiovascular Health for America . . . . . . . . . . . . . . . . . . . . 34

A Framework for a Comprehensive Public Health Strategy . . . . . . . . . . . . . . . . . . . . . . 34

The Three Core Functions of Public Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Five Essential Components of the Action Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Section 3. Recommendations: A Call to Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Overarching Premises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Fundamental Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Recommendations for the Five Essential Components of the Plan . . . . . . . . . . . . . . . . 47

Taking Action: Putting Present Knowledge to Work . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Strengthening Capacity: Transforming the Organization and Structure of 

Public Health Agencies and Partnerships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Evaluating Impact: Monitoring the Burden, Measuring Progress, 

and Communicating Urgency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Advancing Policy: Defining the Issues and Finding the Needed Solutions . . . . . . . . . 51

Engaging in Regional and Global Partnerships: Multiplying Resources 

and Capitalizing on Shared Experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Section 4. Implementation: Mobilizing for Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Fundamental Action Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Action Steps for the Five Essential Components . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Taking Action: Putting Present Knowledge to Work . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Strengthening Capacity: Transforming the Organization and Structure 

of Public Health Agencies and Partnerships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Evaluating Impact: Monitoring the Burden, Measuring Progress, 

and Communicating Urgency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Advancing Policy: Defining the Issues and Finding the Needed Solutions . . . . . . . . . 67

Engaging in Regional and Global Partnerships: Multiplying Resources 

and Capitalizing on Shared Experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

Steps Toward Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

Review, Evaluation, and Adaptation to Future Conditions . . . . . . . . . . . . . . . . . . . . . . . 73

Appendix A: Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-1

Appendix B: National Goals and Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-1

Appendix C: Profiles of the Co-Lead Agencies for the Healthy People 2010

Heart Disease and Stroke Focus Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C-1

Appendix D: Development of A Public Health Action Plan to Prevent 

Heart Disease and Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-1

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 full report 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.

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., voluntary and faith-based associations, professional and business groups,

media, foundations), and broad community participation.
9

• 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

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

“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

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 full document 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

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

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

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
13

Heart Disease and Stroke Prevention

SECTION 1. 

HEART DISEASE AND STROKE

PREVENTION: TIME FOR ACTION

Summary

The continuing epidemic of cardiovascular diseases (CVD) in the United

States and globally calls for renewed and intensified public health action

to prevent heart disease and stroke. Public health agencies at national,

state, and local levels (including CDC in partnership with NIH) bear a

special responsibility to meet this call, along with tribal organizations

and all other interested partners. The widespread occurrence and silent

progression of atherosclerosis and high blood pressure (the dominant

conditions underlying heart disease and stroke) has created a CVD

burden that is massive in terms of its attendant death, disability, and

social and economic costs. This burden is projected to increase sharply

by 2020 because of the changing age structure of the U.S. population

and other factors, including the rising prevalence of obesity and diabetes.

Several popular myths and misconceptions have obscured this reality,

and these must be dispelled through effective communication with the

public at large and with policy makers.

More than a half-century of research and experience has provided a strong

scientific basis for preventing heart disease and stroke. Policy statements

and guidelines for prevention have been available for more than four

decades and have increased in breadth, depth, and number to guide both

public health action and clinical practice. National public health goals have

been updated to 2010 and include a specific call to prevent heart disease

and stroke. Achieving this goal would greatly accelerate progress toward

achieving the nation’s two overarching health goals—increasing quality

and years of healthy life and eliminating health disparities. CVD is a major

contributor to early death (measured as years of life lost) and to differences

in life expectancy among racial and ethnic groups. 

An unprecedented opportunity exists today to develop and implement an

effective public health strategy to prevent heart disease and stroke.

Three major factors have contributed to this opportunity:

• More cumulative knowledge and experience in CVD prevention exists

today than ever before.

• Major national partnerships have been established to support heart

disease and stroke prevention.

• Health professionals increasingly recognize the continuing CVD

epidemic, unfavorable recent trends, and forecasts of a mounting burden

of heart disease and stroke, nationally and worldwide. This recognition

has increased their awareness of the need for immediate action.

Despite this opportunity, the public health investment in preventing

heart disease and stroke remains far below what is needed for fully

effective intervention. Serious shortcomings also exist in the delivery of
14

Public Health Action Plan to Prevent Heart Disease and Stroke

established treatments for these conditions in clinical practice. These

facts demonstrate that the vast body of current knowledge and

experience in CVD prevention has yet to be adequately applied to realize

the full potential benefit to the public’s health. The most critical need

today is for public health action that is guided by the knowledge and

experience already at hand.

Introduction: Planning for the Prevention of Heart

Disease and Stroke

Heart disease and stroke together exact a greater toll on America’s health

than any other condition.1 Early death, disability, personal and family

disruption, loss of income (more than $142 billion for 2003), and medical

care expenditures (more than $209 billion) are some indicators of this toll.

Young and old, women and men, rich and poor, and all racial and ethnic

groups share this burden. Moreover, we can expect even greater numbers

of heart attacks and strokes, increasing dependency (especially among the

expanding population of older Americans), and mounting costs of care for

victims and their families unless we as a nation renew and greatly intensify

our public health effort to prevent these conditions.

Heart attacks and strokes can be prevented or delayed if the

knowledge we already have is put into action now. In fact, a broad

coalition of national organizations and federal health agencies have

already adopted a comprehensive goal for preventing heart disease and

stroke as part of the Healthy People 2010 national health goals.2 But

having goals is only a beginning. Attaining these goals requires a plan

with specific recommendations and action steps for implementing

them. Today, we can build such an action plan on a solid knowledge

base resulting from decades of research on the causes and prevention

of heart disease and stroke, especially because of the support of NIH

and the American Heart Association.

For CDC, developing an action plan for cardiovascular health (CVH) is

critical for two compelling reasons. First, CDC and NIH have been

assigned responsibility as co-lead agencies to head the nation’s effort to

attain the Healthy People 2010 goal for preventing heart disease and stroke.2

Second, Congress charged CDC in 1998 to develop and implement

state-based cardiovascular disease prevention programs in every state and

U.S. territory. These recent mandates create a need and responsibility to

formulate a long-range strategy to guide the public health community in

preventing heart disease and stroke. Accordingly, in December 2001,

CDC initiated a planning process that included an intensive series of

expert consultations as the basis for developing this Action Plan.

Heart Disease and Stroke: Scope, Burden,

Disparities, and a Forecast

The Scope of “Heart Disease and Stroke”

Disorders of the circulation that affect the heart, brain, and other organs

may be described in various terms, sometimes with specific technical
15

Heart Disease and Stroke Prevention

meaning.1,3 For clarity, the most important terms used in this plan are

defined either in the text or in the glossary (see Appendix A). Some of

the more common terms are defined in this section.

“Heart disease and stroke” refers to the two major classes of circulatory

conditions that are the main focus of the Action Plan. This usage, which

was chosen for the title of the plan, corresponds with the terminology of

Chapter 12, Heart Disease and Stroke of Healthy People 2010.2 “Heart

disease” most often refers to coronary heart disease (including heart

attack and other effects of restricted blood flow through the arteries that

supply the heart muscle) or to heart failure. Other times, this term refers

to several conditions or all diseases affecting the heart (e.g., “heart

disease deaths”). “Stroke” refers to a sudden impairment of brain

function, sometimes termed “brain attack,” that results from interruption

of circulation to one or another part of the brain following either

occlusion or hemorrhage of an artery supplying that area.

“Cardiovascular health” (CVH) refers broadly to a combination of 

favorable health habits and conditions that protects against the

development of cardiovascular diseases. “CVH promotion” is support

and dissemination of these favorable habits and conditions. “Cardiovascular

disease or diseases” (CVD), in turn, refers in principle to any or all of the

many disorders that can affect the circulatory system. Here, CVD most

often means coronary heart disease (CHD), heart failure, and stroke,

taken together, which are the circulatory system disorders of the greatest

public health concern in the United States today. However, CVD can

also mean cerebrovascular disease, or disease of brain circulation.

Throughout this plan, which is intended to address heart disease and

stroke together, use of either CVH or CVD means both cardiovascular

and cerebrovascular disease. More often, if less conveniently, the phrase

“heart disease and stroke” means explicitly that both are included.

Heart disease and stroke are mainly consequences of atherosclerosis and

high blood pressure (hypertension).3 They are sometimes included in the

broader category of atherosclerotic and hypertensive diseases (see The

Knowledge Base for Intervention later in this section). Risk factors for

heart disease and stroke have been well established for many years.

Distinct from age, family history, and possible genetic determinants are

modifiable risk factors that cause heart attacks and strokes, including

high blood cholesterol, high blood pressure, smoking, and diabetes.

Behaviors that contribute to development of risk factors, partly by 

causing obesity, include adverse dietary patterns and physical inactivity.

Social and environmental conditions that may determine such behavioral

patterns, in turn, include education and income, cultural influences, 

family and personal habits, and opportunities to make favorable choices.

Policies—especially in the form of laws, regulations, standards, or

guidelines—contribute to setting these and other social and environmental

conditions. For example, dietary patterns result from the influences of

food production policies, marketing practices, product availability, cost,

convenience, knowledge, choices that affect health, and preferences that

are often based on early-life habits. Because many aspects of behavior are

clearly beyond the control of the individual, the scope of heart disease
16

Public Health Action Plan to Prevent Heart Disease and Stroke

and stroke prevention, from the public health perspective, extends far

beyond the individual or the patient. Thus, a comprehensive public

health strategy for prevention must address the broader determinants of

risk and disease burden as they affect both the population as a whole and

particular groups of special concern, including those determinants that

make healthier choices more likely. 

The Nation’s CVD Burden

The nation’s CVD burden can be described in many ways. Examples

include the number and rate of deaths by age, sex, race or ethnicity, or

place of residence; the number and percentage of the population with a

specific CVD condition or risk factor; and estimates of economic costs,

including direct health care expenditures and loss of income from early

death or disability. Several federal agencies contribute data on these

aspects of the burden, including CDC and its National Center for Health

Statistics and NIH’s National Heart, Lung, and Blood Institute and

National Institute of Neurological Disorders and Stroke. Table 1

illustrates several measures of the CVD burden in the U.S. population as

reported by the American Heart Association on the basis of these data

sources.1

The dominant change in CVD mortality in the United States in recent

decades was a major decline in the annual rates of death for the population

as a whole (i.e., age-adjusted death rates) for both CHD and stroke. These

declines resulted in a substantial reduction in the numbers of deaths from

these conditions that would have occurred for any particular age group

(e.g., 45–54 years) under the previously higher rates. Despite these

declines in rates, actual numbers of deaths from heart disease have

changed little in 30 years and have actually increased within the past

decade, especially for stroke.1 This is mainly because more people are

living longer, and rates are higher among successively older age groups.

As a consequence, heart disease remains the nation’s leading cause of

death.1 Stroke is the third leading cause of death, and both conditions

are major causes of adult disability. The decline in rates of coronary

heart disease mortality slowed from -3.3% a year in the 1980s to -2.7% 

a year in the 1990s, and the decline in overall rates of stroke mortality

slowed markedly in contrast to the 1970s and 1980s.4 Meanwhile, the

frequency of heart failure increased steadily during the last 25 years.3

Peripheral arterial disease continues to be a major predictor of CVD

death.1,3 In addition, the previous favorable trends were not uniform

among racial and ethnic groups. For example, heart disease rates

declined more slowly among blacks than whites.1 These shifting trends

are consistent with forecasts of the global burden of CVD over the next

two decades and support the prediction that heart disease and stroke will

persist as the leading causes of death and disability worldwide unless

effective public health action is taken to prevent them.5,6

Two other points should be emphasized. First, sudden deaths from 

coronary heart disease that occur without hospitalization or in the

absence of any previous medical history of coronary heart disease
17

Heart Disease and Stroke Prevention

(250,000 each year) make the strongest case for prevention.1 For some

victims, no opportunity exists for treatment because their death is the

first sign of CVD. Second, the annual cost of CVD to the nation is

projected to exceed $351 billion in 2003.1 This total includes direct

health care costs (for hospital and nursing home care, physicians and

other professionals, drugs and other medical durables, and home health

care) and indirect costs (due to lost productivity from disability and

death). This cost substantially exceeds comparable costs for all cancers

($202 billion) and for human immunodeficiency virus (HIV) infections

($28.9 billion) reported for 2002.1

Such data confirm that the CVD epidemic is continuing in the United

States and that it is a major component of our health care costs. Yet they

do not convey the full impact of CVD. For example, cognitive impairment

and dementia caused by underlying vascular disease of the brain (vascular

cognitive impairment [VCI]) may occur in as many as 30% of stroke

survivors, as well as in people without a clear history of stroke.7 These

observations also apply to people with or without Alzheimer’s disease.

Such findings suggest that VCI is part of the CVD spectrum and should

be included in estimates of both the CVD burden and the potential

health and economic impact of prevention. These factors reinforce

concerns that the aging of the U.S. population will make CVD an even

greater burden than previously estimated in the next two decades.

Table 1. Selected indicators of the cardiovascular disease (CVD) burden,

United States

Number of Deaths in 2000

2,600 CVD deaths occur every day—that’s one every 33 seconds.

150,000 CVD deaths occur each year among people younger than age 65.

250,000 coronary heart disease (CHD) deaths occur each year without hospitalization.

50% of men and 63% of women who suffered a sudden CHD death lacked any previous CHD history.

40,429 deaths occurred in 2000 from peripheral vascular disease, aortic aneurysm, and other diseases of the arteries.

During 1990–2000, the number of CVD deaths increased 2.5%, although the death rate decreased 17.0%.

Survivors in 2000

450,000 people had survived a first heart attack for more than 1 year.

450,000 people had survived with heart failure for more than 1 year.

375,000 people had survived a first stroke for more than 1 year.

Prevalence in 2000

12.9 million people were living with coronary heart disease.

4.9 million people were living with heart failure.

4.7 million people were living with stroke.

Risk Factors in 2000

105 million people had high total cholesterol (≥200 mg/dl).

50 million people had high blood pressure (systolic ≥140 mm Hg, diastolic ≥90 mm Hg) or were taking 

antihypertensive medication.

Nearly 48.7 million people age ≥18 were current smokers.

More than 44 million people were obese (body mass index ≥30.0 kg/m2

).

10.9 million people had physician-diagnosed diabetes.

Projected Costs in 2003

$209.3 billion in direct costs and $142.5 billion in indirect costs, for a total of $351.8 billion.

Note: Death rates and prevalence per 100,000 were age-adjusted to the 2000 U.S. standard population.

Source: Based on data compiled and reported by the American Heart Association. Heart and Stroke Statistics—2003 Update.
18

Public Health Action Plan to Prevent Heart Disease and Stroke

* In Tables 2 and 3, data for Hispanics are presented twice—once under the category 

of “Hispanic,” which includes Hispanics of all racial identities (e.g., Hispanic blacks,

Hispanic whites), and again under any of the four racial categories according to a 

person’s racial identity. Consequently, data for the five groups are not mutually 

exclusive because “Hispanic” is considered a designation of ethnicity, not race.

The CVD burden can also be expressed in the personal stories of how 

it affects people and their families. Just one example is the sudden death

from heart attack in June 2002 of the St. Louis Cardinals’ star pitcher,

Darryl Kile. Kile was 33 years old and is survived by his widow and three

young children.8 This is a striking example of the increased number of

victims of sudden cardiac death younger than age 35 in the past decade.1

With an estimated 12.9 million Americans living with heart disease and

4.7 million living with stroke, many people can recount the impact on

their lives of becoming a victim of CVD. For millions of others who did

not survive their first encounter with heart disease or stroke, only the

family members or friends left behind can tell their stories.

Disparities

Health disparities have long been a special concern in setting national

objectives, and Healthy People 2010 calls for the elimination of such

disparities as one of its two overarching goals.2 Disparities can exist

among certain populations defined by sex, race or ethnicity, education or

income, disability, place of residence, or sexual orientation. Sex-specific

data are commonly available for CVD. In contrast to previous beliefs,

CVD is clearly not an affliction primarily of men. In fact, it causes more

deaths among women. In 2000, CVD was responsible for 505,661 deaths

among U.S. women and 440,175 deaths among U.S. men. The higher

numbers among women are partially due to the greater numbers of

women in the oldest age groups, where CVD mortality is highest.1

Major disparities in the burden of heart disease and stroke and their risk

factors among different racial and ethnic groups are widely recognized.

However, relevant data for some groups are scant or nonexistent because

data have not been collected to address this concern adequately. To

improve data collection, the federal government has promulgated

standards for classifying race and ethnicity in federal data systems.9

Researchers have also explored and published data on the geographic

variations in the burden of heart disease death—by state and by county—

for both women and men in the five major racial and ethnic categories.10,11

These publications include information on local economic resources and

medical care resources in the different areas examined. Data on the

geographic variations in stroke deaths were published in 2003.12

Table 2 summarizes heart disease mortality differences by race and

ethnicity in the United States. Table 3 presents similar data for stroke

deaths for the most recent years available, 1999–2000.*12 Both tables

illustrate striking disparities in the excess mortality among blacks (for

both women and men) compared with all other groups.
19

Heart Disease and Stroke Prevention

Table 2. Heart disease death rates for people aged ≥35 years, United States, 1991–1995*

* Rates per 100,000 are age-adjusted using the 1970 U.S. standard population. 

Source: CDC. References 10 and 11.

Women 259 221 553 265 388

Men 465 372 841 432 666

Sex

American Indian or

Alaskan Native

Asian or 

Pacific Islander Black Hispanic White

Race or Ethnicity

Disparities in other areas have been published in Health, United States,

2002, an annual report on national trends in health statistics.13 This

report also examines differences in health outcomes and risk factors for

major racial and ethnic groups in the United States. Table 4 (page 20)

presents examples of these disparities, some of which relate specifically to

heart disease and stroke, whereas others relate to overall health. Several

key points about health disparities among different groups are evident in

this table. First, the extent to which data are lacking for major population

groups is evident. Second, for populations with adequate data, disparities

are striking—particularly among African Americans—in terms of years

of life lost to death from heart disease and cerebrovascular disease,

prevalence of hypertension and obesity (women only), and poverty.

Other noteworthy points are the low values of several indicators for

Asians (including Native Hawaiians and Other Pacific Islanders); the

excess years of life lost because of deaths from cerebrovascular disease

and diabetes among American Indians or Alaska Natives; and the high

prevalence in the Hispanic or Latino population of poverty, lack of

health coverage, and obesity. The table also indicates that a substantial

proportion of these three minority groups live in poverty or without

health care coverage.

Although other data sources are available for some of these populations,

they suffer several limitations. Some of these were outlined in a 1999

report that illustrated the insufficiencies of data on Asian American and

Pacific Islander populations.14 These include a lack of data for subgroups

with heterogeneous health characteristics, relatively small sample sizes, a

lack of systematic data collection, a lack of longitudinal studies, a lack of

population-based CVD data, and self-selection bias in sampling methods.

Eliminating disparities requires adequate CVD data to establish the

nature and extent of the disparities and to monitor changes. Clearly, data

Table 3. Stroke death rates for people aged ≥35 years, United States,

1991–1998*

* Rates per 100,000 are age-adjusted using the 2000 U.S. standard population.

Source: CDC. Reference 12.

Women 77 96 153 72 113

Men 80 118 182 88 121

Sex

American Indian

or Alaskan Native

Asian or

Pacific Islander Black Hispanic White

Race or Ethnicity
20

Public Health Action Plan to Prevent Heart Disease and Stroke

systems must be strengthened if disparities are to be addressed effectively.

What we do know about existing disparities indicates that interventions

must affect disadvantaged groups more than they do the population as a

whole. The population-based health objectives for heart disease and

stroke presented in Healthy People 2010 that could be improved in the

short term have targets that are predominantly based on the criterion

“better than the best”—that is, all groups are expected to achieve a better

1238.9 617.5 2398.9 —§ 1222.9 869.8

243.3 214.4 508.2 — 180.8 207.5

41.4 84.6 402.5 — 155.6 214.2

42.3% 16.5% 23.3% — 25.9% 20.7%

— — 36.4% — 25.5% 25.9%

— — 35.9% — 19.7% 22.3%

— — 16.4% — 19.1% 18.7%

— — 19.5% — 20.7% 17.7%

— — 21.1% — 20.7% 24.4%

— — 39.0% — 23.3% 36.1%

38.2% 17.3% 20.0% — 15.2% 35.4%

— 10.7% 22.0% — 7.5% 21.2%

— 32.3% 49.4% — 27.9% 48.3%

Heath Indicators

Years of potential life lost before age 75† from

heart disease‡ (1999 data)

Years of potential life lost before age 75† from

CVDII (1999 data)

Years of potential life lost before age 75† from

diabetes mellitus¶ (1999 data)

Tobacco use (cigarettes) during the past month

among persons aged >12 (2000 data)

Hypertension** among men aged 20–74

(1988–1994 data)

Hypertension among women aged 20–74††

(1988–1994 data)

Total cholesterol ≥240 mg/dl among men

(1988–1994 data)

Total cholesterol ≥240 mg/dl among women

(1988–1994 data)

Body mass index ≥30 kg/m2 among men 

aged ≥20 (1988–1994 data)

Body mass index ≥30 kg/m2 among women††

aged ≥20 (1988–1994 data)

No health care coverage among persons 

aged <65 (2000 data) ‡‡

Poverty, all§§ (2000 data)

Poverty, aged <18, female head, no spouseII II

(2000 data)

Table 4. Disparities in selected health indicators by race/ethnicity, United States

American Indian

or Alaska Native Asian* 

Black or

African American

White, 

Non-Hispanic

Native Hawaiian or

Other Pacific Islander Hispanic

or Latino

* Includes data for Native Hawaiians or other Pacific Islanders except for tobacco use.

† Rates per 100,000 are age-adjusted using the 2000 U.S. standard population.

‡ Includes all heart disease deaths coded according to the International Statistical Classification of Diseases and Related Health Problems (ICD-10) 

(Geneva, Switzerland: World Health Organization; 1992).

§ Data do not meet the criteria for statistical reliability, data quality, or confidentiality. II Includes all cerebrovascular disease deaths coded according to the ICD-10. ¶ Includes all diabetes deaths coded according to the ICD-10.

** Defined as a person having blood pressure ≥140/90 mm Hg or reporting current antihypertensive therapy.

†† Excludes pregnant women.

‡‡ Percentages are age-adjusted using the 2000 U.S. standard population.

§§ Defined as all persons living in a household with income below the poverty level. IIII Defined as all related children aged <18 years living in a household with income below the poverty level and headed by a female with no spouse present.

Note: Data on hypertension, total cholesteral, and body mass index (BMI) that are labeled “Hispanic or Latino” are for the Mexican population. Data labeled as “Black or African American” are for

non-Hispanic blacks. Percentages are age-adjusted using the 2000 U.S. standard population.

Sources: CDC, NCHS, National Vital Statistics System: estimates of years of potential life lost. Substance Abuse and Mental Health Services Administration, National Household Survey on Drug Abuse:

estimates of tobacco use. CDC, NCHS, National Health and Nutrition Examination Survey: estimates of hypertension, total cholesteral, and body mass index. CDC, NCHS, National Health Interview

Survey: estimates of no health care coverage. U.S. Bureau of the Census, Current Population Survey: poverty.
21

Heart Disease and Stroke Prevention

measure of health status by 2010 than that of the most favorable group at

the baseline.2 This implies that we should attain health improvements

for all groups within the population, but that groups with poorer baseline

status need to experience accelerated improvement, so that all groups

will reach the same measures of better health by 2010. Attaining the

targets for these objectives will require that the most effective programs,

including those aimed at reducing the prevalence of CVD risk factors,

reach the groups with the greatest CVD burden.

A Forecast

Over the next two decades, the number of Americans older than age 

65 will increase dramatically, from approximately 34.7 million in 2000 

to more than 53.2 million in 2020.15 By 2020, a total of 16.5% of

Americans will be aged 65 or older, compared with 12.6% in 2000—an

increase of nearly one-third. Proportions of minorities in the overall

population are expected to increase from 12.9% to 14.0% for blacks,

4.1% to 6.1% for Asians, 0.9% to 1.0% for American Indians, and

11.4% to 16.3% for Hispanics. Heart disease deaths are projected to

increase sharply between 2010 and 2030, and the population of heart

disease survivors is expected to grow at a much faster rate than the U.S.

population as a whole. Marked increases in numbers of stroke deaths are

also predicted.16 These changes together will constitute a major increase

in the nation’s CVD burden, accompanied by increasing demands for

related health care services, as well as increases in health care

expenditures; lost income and productivity; and prevalence of disease,

disability, and dependency. This forecast suggests that instead of

increasing quality and years of healthy life, we may lose ground.

Moreover, if recent trends continue, disparities may widen rather than 

be eliminated.4 The need for prevention has never been as great as it 

is today.

Myths and Misconceptions

Although data show us the hard facts, the disease burden also can be

expressed in more visual ways to dramatize its magnitude. For example,

the number of annual deaths from heart attacks alone exceeds the

number of deaths that would occur if two fully occupied 747 aircraft

crashed every day of the year with no survivors. Yet, CVD has not

aroused a level of public concern commensurate with its relative

importance.1 Why?

Among the reasons are several myths or misconceptions about heart

disease and stroke that must be addressed as this plan gains the needed

support of the public and policy makers. These include the beliefs that

heart attacks only affect the elderly, that heart attack death is quick and

easy (“the best way to go”), that a heart attack can be “fixed” with

modern medical and surgical technology, and that heart attacks and

strokes occur when “your time has come.”

The truth is very different. Of the 945,836 people who died of CVD in

2000, 32% were younger than age 75.1 Currently, the average expected

age at death in the United States is 76.9 years.17 As noted previously,
22

Public Health Action Plan to Prevent Heart Disease and Stroke

250,000 coronary heart disease deaths occur each year without the victim

reaching a hospital. For one-half to two-thirds of those who die suddenly

of CHD, there was no previous recognition of the disease.1 Many people

who died under these conditions had no opportunity for treatment and

could only have been saved by preventive measures that reach the

population as a whole. The more common outcome, however, is to

survive for days, weeks, months, or years. Those who survive may

experience disability, job loss, or dependency, often with long-term

consequences. Survivors also have a greatly increased risk of having

another heart attack or stroke. Modern medicine and surgery can offer

great benefit to those who survive long enough to receive treatment, but

are no help to those who die suddenly following their first CVD event.

There is no complete “cure” once a heart attack or stroke has occurred,

as survivors continue to be at increased risk for another attack.1 Finally,

“your time” has not yet come if readily available preventive measures can

still increase quality and years of healthy life.

These and other myths about heart disease and stroke must be dispelled

through effective communication and education. They are significant

barriers to understanding the urgency of the CVD epidemic and the

potential for preventing these conditions.

The Knowledge Base for Intervention

The CVD epidemic in the United States and other Western industrialized

countries was first recognized around the middle of the twentieth century.3

In response, extensive research programs involving laboratory, clinical,

and population-based investigations were undertaken to identify the

causes and the means of preventing coronary heart disease and stroke.

The result of this research has been a major growth in knowledge and

understanding of the causes of CVD, especially because of the work of

NIH and the American Heart Association.

Statistical research has shown that death rates from heart disease and

stroke vary among populations and over only a few years’ time in ways

that cannot be explained by differences or changes in genetic factors.

Such findings demonstrate clearly that environmental factors, in the

broadest sense, play a major role in the occurrence of heart disease and

stroke and can do so over a relatively short term. Thus, controlling 

these factors offers opportunities for prevention. Major epidemiologic

studies revealed that incidence rates (measures of the occurrence of 

new cases of CVD, whether fatal or not) could be predicted by blood

cholesterol level, blood pressure level, smoking, diabetes, and certain

other potentially modifiable characteristics. These characteristics,

recognized as “risk factors” since the 1960s, were ultimately established

as the major causes of CVD.

How do these factors cause CVD? The principal pathway to a heart

attack or stroke is through the gradual, years-long development of

atherosclerosis and high blood pressure. Atherosclerosis is a disease of

the medium-sized and larger arteries, such as those that supply the heart 

(the coronary arteries), the brain (the carotid and cerebral arteries), and
23

Heart Disease and Stroke Prevention

the lower extremities (the peripheral arteries), as well as the aorta.

Atherosclerosis consists of concentrated areas of mushy material

(atheromas) within the arterial wall that are often encrusted or hardened

(sclerosed) by deposited calcium. The resulting abnormality is a plaque

that weakens the arterial wall and may intrude into the lumen or channel

of the artery to limit blood flow or obstruct it completely. A plaque may

suddenly rupture, leading to blockage of the artery and precipitating a

heart attack or stroke.

High blood pressure (or hypertension) also can cause heart disease or

stroke by exacerbating the effects of other risk factors in accelerating 

progression of atherosclerosis by placing a continuous, excess workload

on the heart (hypertensive heart disease). It can also cause a cerebral

artery to rupture (cerebral hemorrhage).

Atherosclerosis begins to develop in childhood and progresses into the

adult years, under strong influence of the risk factors noted previously.

Autopsy studies of young American men who died in the Korean War

and in Vietnam confirmed that people in their 20s can have moderate

and sometimes severe atherosclerosis despite a lack of any medical 

history to suggest it.18,19 More recent studies of children, adolescents,

and young adults (younger than 35) have demonstrated the close link 

of blood cholesterol level, blood pressure level, smoking, and obesity

with the extent and severity of atherosclerosis among people well

below age 20.20,21 High blood pressure also develops progressively

throughout life, undergoing major increases in adolescence and late

adulthood. These findings underscore the opportunities for preventing

CVD during childhood and adolescence, as well as the lifelong

importance of prevention.

Establishing a way to prevent risk factors requires knowledge about the

risk factors themselves. That is, can they be changed? Can heart attacks

and strokes be prevented as a result? How prevalent are these risk factors?

If their frequency is reduced in the population as a whole, what will the

impact be on rates of heart disease and stroke nationwide? An impressive

body of evidence amassed over the last 30 years has established that blood

cholesterol levels, blood pressure levels, and smoking habits can be

modified and that diabetes can be prevented and controlled by behavioral

change as well as by medication, all with favorable impact on CVD risk.

Population studies have monitored the continuing high prevalence of

these risk factors in the United States since the early 1960s.

In the mid-1980s, researchers projected how the CVD burden would 

be affected if the major risk factors were reduced.22 These projections

suggested that CVD death rates could be reduced by 70% by reducing

the population’s mean level of blood cholesterol to 190 mg/dl and the

mean level of diastolic blood pressure to 80 mm Hg. Because this 

estimate did not consider the added impact of reducing the prevalence 

of smoking, it probably underestimated how much CVD death rates

could be reduced. Current estimates indicate that these major risk factors

account for 75% of the difference in risk for CHD within populations.23

If these projections were systematically updated, we could estimate how
24

Public Health Action Plan to Prevent Heart Disease and Stroke

much the CVD burden might be reduced over the next two decades.

This estimate might be substantially greater than the Healthy People 2010

target of reducing heart disease and stroke deaths by 20%. As indicated

previously, a greater reduction is needed if the projected increase in

CVD burden is to be offset.

Finland’s experiences during 1970–1990 are a good example of the

healthy changes that can be achieved by reducing major risk factors for

heart disease.24 Improvements in blood cholesterol levels, blood pressure

levels, and smoking rates for both women and men closely predicted the

actual declines in heart disease deaths that were observed over 20 years.

Deaths declined more than 60% for women and more than 50% for

men. Although community intervention studies in the United States also

have demonstrated positive changes, these interventions have generally

lacked the intensity and duration (i.e., the “preventive dose”) needed to

demonstrate that they actually reduced CVD deaths beyond the

influence of favorable changes taking place in society at large.25

What knowledge constitutes a sufficient basis for public health action?

Both formal research and relevant practical experience are important.

Like evidence-based medicine, evidence-based public health needs

established criteria for systematically evaluating available evidence.

Continuous evaluation can guide current and future programs and

advance policies as new knowledge is acquired.

In contrast to evidence-based medicine, evidence-based public health

depends on different types of evidence. For example, randomized

controlled trials are considered essential to evidence-based medicine 

but are often lacking in the public health arena. On the other hand,

population-based observations that are often unavailable in clinical

decision making are included in the evidence base for public health

decisions. The context of public health practice is the world at large,

where many influences on health are continually at play. Therefore, the

central question for evidence-based public health is not whether to take 

a particular action or no action, but whether the status quo, with its

prevailing influences on the population’s health, is best. By asking what

evidence supports the status quo, as well as what supports a proposed

alternative policy or program, evidence-based public health can help

establish the relative merits of proposed interventions.

Clearly, the CVD burden of this nation will not improve under the status

quo. We have the knowledge needed to launch a comprehensive public

health strategy to change this situation. In fact, only by putting current

knowledge into action now can we strengthen the body of knowledge

substantially, as new and expanded programs and policy frameworks are

implemented and rigorously evaluated.

Evolution of Prevention Policy

As our knowledge about CVD has grown during the past half-century,

our policies for preventing heart disease and stroke have also advanced.3

The first recommendations appeared in 1959 in A Statement on
25

Heart Disease and Stroke Prevention

Arteriosclerosis: Main Cause of “Heart Attacks” and “Strokes,” which was

signed by five past presidents of the American Heart Association.26

Citing studies published in the 1950s, this report identified most of the

same risk factors discussed here as the focus for preventive measures to

be taken by patients and their physicians. 

A wealth of recommendations has appeared subsequently. For example,

the 1972 report from the Inter-Society Commission for Heart Disease

Resources, Primary Prevention of the Atherosclerotic Diseases, recommended

“a strategy of primary prevention of premature atherosclerotic diseases be

adopted as long-term national policy for the United States and to

implement this strategy that adequate resources of money and manpower

be committed to accomplish: changes in diet to prevent or control

hyperlipidemia, obesity, hypertension and diabetes; elimination of cigarette

smoking; [and] pharmacologic control of elevated blood pressure.”27

The Cardiovascular Disease Unit of the World Health Organization 

and the International Heart Health Conferences also have issued

recommendations, usually addressing international and global

concerns.3,28 Recommendations have been published by the American

Heart Association/American Stroke Association, the American College

of Cardiology, and the National Heart, Lung, and Blood Institute,

including clinical practice guidelines for detecting and treating risk

factors and preventing heart disease and stroke.3

In 1994, an important predecessor to the present plan was published by

the CVD Plan Steering Committee,* Preventing Death and Disability from

Cardiovascular Diseases: A State-Based Plan for Action.29 This document 

was a call to the states to expand their capacity and obtain additional

resources so they could develop the infrastructure needed to achieve the

year 2000 objectives for CVD prevention and control. By outlining basic

functions for CVD programs and strategies for building capacity, this

report contributed directly to implementation of CDC’s state heart

disease and stroke prevention program in 1998. It also indicated the value

of partnership and collaborative in producing a policy document with

broad support, based on the contributions of participating members.

In this extensive body of policy documents, what is advised for

preventing heart disease and stroke? Two main approaches have been

recommended—interventions addressing individuals and interventions

addressing whole populations.30 The individual or “high-risk” approach

centers either on people with CVD risk factors but no evident disease or

on those with CVD, including survivors of CVD events. For people with

risk factors but no recognized disease, “primary prevention” is intended

to prevent a first heart attack or stroke by detecting and treating risk

factors. For people with known CVD, “secondary prevention” is

* Members represented the American Heart Association/American Stroke Association,

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

Health Education, the Association of State and Territorial Public Health Nutrition

Directors, CDC, the Chronic Disease Directors, and the National Heart, Lung, and

Blood Institute.
26

Public Health Action Plan to Prevent Heart Disease and Stroke

intended to reduce the risk for subsequent heart attacks or strokes by

treating CVD and the risk factors. Both aspects focus on individual risk.

The “population-wide” approach, which focuses on a whole population

or community, recognizes that the excess risk for heart disease and 

stroke is widely distributed in the population, with most victims having

moderate, rather than extreme, risk. Therefore, even modest change in

average risk in the whole population, achievable through means such as

public education, can markedly reduce the risk for CVD events.

A third approach aims to prevent CVD risk factors in the first place.

Sometimes called “primordial prevention,” this plan uses the term

“CVH promotion.”31 This approach is most widely applicable in

populations where social and economic development has yet to progress

to the point of fostering epidemic occurrence of the major risk factors.

CVH promotion also encompasses interventions aimed at individuals at

any age who have not yet developed treatable levels of CVD risk factors

because the interventions occur before the risk factors begin to cause or

accelerate atherosclerosis. Such intervention should occur in childhood

or even, as recent research suggests, during gestation (to improve the

fetal environment).32 These interventions should continue throughout

adulthood to prevent risk factors from ever developing.

Despite the many policy recommendations made since the 1950s, practice

has lagged far behind. Assessments in recent years have consistently shown

that doctors and patients have not adhered well to treatment guidelines for

secondary prevention.33 Although well-supported and detailed policies for

preventing heart disease and stroke have long been available, the actions

recommended in these policies have, to a large degree, not been followed.

Action is needed to support their effective implementation.

Healthy People 2010 Goals and Objectives

Published in January 2000, Healthy People 2010 is the latest in a series 

of documents initiated in 1979 to present national health objectives.2

This new volume makes an important advance over Healthy People 2000

in presenting a goal and related objectives for preventing heart disease

and stroke. The Healthy People 2010 Heart and Stroke Partnership*

divided this goal into four separate goals based on the different

intervention approaches that would be needed to achieve them. These

four goals 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. Objectives outline

specific measures of progress that should be attained by the year 2010. 

A total of 16 objectives specifically address coronary heart disease, heart

* Current partners include the American Heart Association/American Stroke

Association; National Center for Chronic Disease Prevention and Health Promotion

(NCCDPHP), CDC; Centers for Medicare & Medicaid Services; Indian Health

Service; National Heart, Lung, and Blood Institute and National Institute of

Neurological Disorders and Stroke, NIH; and Office of Disease Prevention and

Health Promotion, Office of Public Health and Science, U.S. Department of Health

and Human Services.
27

Heart Disease and Stroke Prevention

failure, stroke, blood pressure, and total blood cholesterol levels. In

addition, 48 related objectives address chronic kidney disease, diabetes,

nutrition and overweight, physical activity and fitness, tobacco use, access

to quality health services, and public health infrastructure. Several other

objectives relate indirectly to CVH. All of the related objectives are

tabulated in Appendix B.

When the 2010 goal and its objectives were adopted, CDC was

designated to join NIH as the co-lead federal health agency responsible

for heart disease and stroke prevention. CDC and NIH share

responsibility “for undertaking activities to move the nation toward

achieving the year 2010 goals and for reporting progress . . . over the

course of the decade.”2 The activities of these two co-lead agencies in

heart disease and stroke prevention are highlighted in Appendix C. 

Publishing these goals and objectives alone will not assure that they 

are attained. When progress toward meeting the Healthy People 2000

objectives was reviewed, three of the 17 objectives were met, some

progress had been made for another 12 objectives, and health status had

worsened for the remaining two.34 Among the 9 objectives for which

positive percentage changes could be calculated, only 5 reached more

than 50% of the target. 

Unless we make substantial progress toward meeting the 2010 goal for

preventing heart disease and stroke, we will see increasing numbers of

people with CVD risk factors, increasing numbers of first and recurrent

heart attack and stroke victims, and increasing numbers of people who die

of CVD. Further, costs will increase because of the larger numbers of

people needing CVD treatment and the higher cost for each CVD event

(if the trend of increasing costs for health services continues as expected).

In contrast, success in meeting this goal can reverse the unfavorable trends

of the past decade. We must build on the promise of knowledge and

experience that awaits widespread translation into public health practice.

The Present Opportunity

To be effective, public health action must have a solid knowledge base

that is built on science and practical experience and sound policies that

are founded on this knowledge. Over the past 30 years, such support for

heart disease and stroke prevention has been greatly strengthened. But

this support has not been sufficient to establish and sustain the needed

public health effort. Until the early 1970s, the Bureau of State Services

in the former U.S. Department of Health, Education, and Welfare

supported state health departments through its Heart Disease and Stroke

Control Program, but that program was discontinued. And although the

Inter-Society Commission on Heart Disease Resources called for a

national commitment to prevent atherosclerosis in the early 1970s,

public health efforts to address these problems have remained too

limited to offer the full potential benefit of existing knowledge.27

What is different now from those early transient efforts? What new 

and unprecedented opportunities exist for heart disease and stroke
28

Public Health Action Plan to Prevent Heart Disease and Stroke

prevention? This Action Plan describes the current opportunities for

action and the potential for success in the immediate future. Recent

trends in the CVD burden in the United States and projections of the

continuing predominance of heart disease and stroke as causes of death

and disability worldwide have motivated concerned health professionals

to consider a new level of concerted action to prevent CVD.4,5 Clearly,

treating victims of heart disease and stroke cannot alone solve the

problem. Prevention is preferable in principle and necessary as a matter

of national policy if we are to attain our goals of increasing quality and

years of healthy life and eliminating health disparities. This perspective

has recently been strongly reinforced by Steps to a HealthierUS, a bold

new initiative by Secretary of Health and Human Services Tommy G.

Thompson. The Steps initiative is designed to address this nation’s health

care crisis and the need to prevent the chronic diseases and conditions,

including heart disease and stroke, that represent 75% of our health care

expenditures. The Secretary’s initiative is a response to President George

W. Bush’s HealthierUS initiative, which directs key departments of the

federal government to develop plans to better promote fitness and health

for all Americans.

To implement Steps to a HealthierUS, the U.S. Department of Health 

and Human Services (HHS) is marshalling all available resources within

the department and calling on other federal agencies and the private

sector (e.g., the fast food and soft drink industries) to take steps to

improve our nation’s health. At the personal level, all Americans are

challenged to take the first step by walking 30 minutes a day. At the

societal level, policy makers are asked to take their first step by

embracing prevention as the long-term solution for our health care

crisis. The Steps initiative thus constitutes a significant impetus toward

prevention, which is strongly supported by this Action Plan.

The breadth of the 2010 goal for preventing heart disease and stroke

calls attention to the wide range of opportunities for intervention—

both to prevent CVD through primary and secondary prevention and to

promote CVH. This goal also underscores the increased role for public

health agencies, including CDC. As population-wide approaches become

more common, the skills and resources of public health agencies at all

levels of government will be increasingly called upon.

In recent years, it has also been realized that effective, concerted action

requires partnerships with familiar organizations and agencies, as well as

with nontraditional partners with distinct perspectives and contributions.

As a result, new alliances are being formed, and new ideas, expertise, and

resources are being shared. The Healthy People 2010 Heart and Stroke

Partnership is a good example of this type of partnership, which can

potentially include partners within and beyond the health sector.

Already, channels of communication have been opened that will help

identify common areas of interest and opportunities for synergy among

these national organizations and agencies. Additional agreements

between federal agencies and other organizations further illustrate the

development of key partnerships in CVH.
29

Heart Disease and Stroke Prevention

Recent advances in knowledge heighten confidence that public health

intervention can improve on our CVD forecast for the next two decades.

For example, researchers demonstrated that high blood pressure can be

prevented with dietary interventions.35 We now know that diabetes can

be prevented or delayed with dietary and physical activity interventions.36

And recent findings strongly suggest that by preventing CVD risk

factors from emerging in adolescence and early adulthood, we can expect

to prevent atherosclerosis later in life.20Evidence that blood cholesterol

and blood pressure levels are improving in the population reinforce the

belief that positive changes are occurring and can be accelerated, even

while adverse changes (e.g., the obesity and diabetes epidemics) call for

more innovative approaches to reverse these alarming trends.37,38

The health of this nation is the central focus of the Action Plan, but 

not to the exclusion of concern for the global dimensions of the burden

of heart disease and stroke and recognition of the potential value of

international collaboration in their prevention. The Global Burden of

Disease Study, cited earlier, stated that heart disease and stroke were the

foremost causes of death throughout the world in 1990 and projected

that they will remain so in 2020.5 In its 1999 report, Impending Global

Pandemic of Cardiovascular Diseases, the World Heart Federation provides

extensive documentation of this epidemic, as well as resources and

strategies by which to address it.39

In the same year, the Director-General of the World Health

Organization presented a report titled, Global Strategy for the Prevention

and Control of Noncommunicable Diseases, which noted that, “Four of the

most prominent noncommunicable diseases—cardiovascular disease,

cancer, chronic obstructive pulmonary diseases and diabetes—are linked

by common preventable risk factors related to lifestyle. These factors are

tobacco use, unhealthy diet and physical inactivity . . . Intervention at the

level of the family and community is essential for prevention because the

causal risk factors are deeply entrenched in the social and cultural

framework of the society. Addressing the major risk factors should be

given the highest priority in the global strategy for the prevention and

control of noncommunicable diseases.”40

A major contribution toward this end is The World Health Report 2002:

Reducing Risks, Promoting Healthy Life.6 This report presents an extensive

analysis of the major risk factors and the potential impact of their

prevention and control on the burden of cardiovascular and other

chronic diseases throughout the world. The report notes, “In order to

protect people—and help them protect themselves—governments need

to be able to assess risks and choose the most cost-effective and

affordable interventions to prevent risks from occurring.”6 Significant

advances in approaches and methods for such an assessment are offered

by that report. 

Does this nation have a role in the global arena of heart disease and

stroke prevention? Addressing this question, the Institute of Medicine’s

1997 report, America’s Vital Interest in Global Health, concluded that 

“. . . the United States should build on its strengths and seize the
30

Public Health Action Plan to Prevent Heart Disease and Stroke

unprecedented opportunities to work with its international partners to

improve health worldwide.”41 Proposed action areas included biomedical

research and development, education and training in the health sciences,

and effective international cooperation. An underlying premise of the

report was that “global health problems affect all peoples in all countries

and transcend national boundaries, levels of development, and political

systems.”41 A sequel to this report, Control of Cardiovascular Diseases in

Developing Countries: Research, Development, and Institutional

Strengthening, appeared in 1998 and recommended specific steps to be

taken to assess the burden, develop intervention plans, and take effective

action country by country.42 At the same time, it was noted that, “Many

organizations and programs are engaged in activities relevant to CVD

prevention and control. The impact of their work can be enhanced, and

duplication avoided, by effective exchange of information on CVD

activities.”42

These recent reports, which have documented the global problem of CVD

and the growing recognition of its worldwide importance, strongly suggest

that this nation does have a role in the global arena of heart disease and

stroke prevention. This role includes providing information from our own

experiences to support the work of others and gaining from their growing

knowledge and experience in return. Another basis for this view stems

from the position of HHS, which is conducting and supporting programs

to advance global health issues, including policy development, public

health infrastructure strengthening, scientific research and research

training, and tobacco control (see www.hhs.gov/news/press/2002pres/global.html).

The recommendations of this Action Plan for engaging in regional and

global partnerships for heart disease and stroke prevention are in full

accord with this view.

The challenging circumstances we face today, in combination with

significant advances in research, provide strong justification for

developing a public health action plan to prevent heart disease and

stroke. In response, this Action Plan has been developed. If effectively

implemented, this plan can arrest or reverse the epidemic of heart

disease and stroke in the United States and contribute substantially to

preventing these conditions throughout the world.

References

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

Dallas, TX: American Heart Association; 2003.

2. 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.

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

Challenge. Gaithersburg, MD: Aspen Publishers; 1998.

4. 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.
5. Murray CJL, Lopez A. Alternative Projections of Mortality and Disability by

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

1498–1504.

6. World Health Organization. The World Health Report 2002: Reducing Risks,

Promoting Healthy Life. Geneva: World Health Organization; 2002.

7. Gorelick PB. Prevention. In: Erkinjuntti T, Gauthier S, editors. Vascular

Cognitive Impairment. London: Martin Dunitz LTD; 2002:571–86.

8. The Associated Press. Playing Through the Pain. Atlanta Journal Constitution

2002 June 24;Sect. D:1.

9. Office of Management and Budget. Standards for the Classification of Federal

Data on Race and Ethnicity. Washington, DC: Executive Office of the

President, Office of Management and Budget; 1994. Available at

www.whitehouse.gov/omb/fedreg/notice_15.html.

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. 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.

14. Asian & Pacific Islander American Health Forum. A Public Health Action Plan.

Eliminating Racial and Ethnic Disparities in Cardiovascular Health: Improving the

Cardiovascular Health of Asian American and Pacific Islander Populations in the

United States. San Francisco, CA: Asian & Pacific Islander American Health

Forum; 1999.

15. 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.

16. 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.

17. Minino AM, Arias E, Kochanek KD, Murphy SL, Smith BL. Deaths: Final

Data for 2000. Hyattsville, MD: US Department of Health and Human

Services, Centers for Disease Control and Prevention; 2002. (National Vital

Statistics Reports, vol 50, no. 15).

18. Enos WF, Holmes RH, Beyer J. Coronary Disease Among United States

Soldiers Killed in Action in Korea. JAMA 1953;152:1090–3.

19. McNamara JJ, Molot MA, Stremple JF, Cutting RT. Coronary Artery Disease

in Combat Casualties in Vietnam. JAMA 1971;216:1185–7.

20. Berenson GS, Wattigney WA, Tracy RE, et al. Atherosclerosis of the Aorta

and Coronary Arteries and Cardiovascular Risk Factors in Persons Ages 6 to

30 Years and Studied at Necropsy (the Bogalusa Heart Study). American

Journal of Cardiology 1992;70:851–8.

21. Pathobiological Determinants of Atherosclerosis in Youth (PDAY) Research

Group. Relationship of Atherosclerosis in Young Men to Serum Lipoprotein

Cholesterol Concentrations and Smoking. JAMA 1990;264:3018–24.

22. Kottke TE, Puska P, Salonen JT, Tuomilehto J, Nissinen A. Projected Effects

of High-Risk Versus Population-Based Prevention Strategies in Coronary

Heart Disease. American Journal of Epidemiology 1984;121:697–704.

23. Magnus P, Beaglehole R. The Real Contribution of the Major Risk Factors to

the Coronary Epidemics: Time to End the “Only 50%” Myth. Archives of

Internal Medicine 2001;161:2657–60.

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24. Puska P, Tuomilehto J, Nissinen A, Vartiainen E, editors. The North Karelia

Project: 20 Year Results and Experiences. Finland: National Public Health

Institute (KTL); 1995.

25. O’Connor B, Cameron R, Farquharson J, et al. Marketing the Heart Health

Vision: Delivering the “Preventive Dose.” Ottawa, Canada: WHO

Collaborating Centre for Policy Development in the Prevention of

Noncommunicable Disease; 2000.

26. White PD, Wright IS, Sprague HB, et al. A Statement on Arteriosclerosis: Main

Cause of “Heart Attacks” and “Strokes.” New York, NY: National Health

Education Committee, Inc.; 1959.

27. Atherosclerosis Study Group (Stamler J, chair), Epidemiology Study Group

(Lilienfeld A, chair). Primary Prevention of the Atherosclerotic Diseases. In:

Wright IS, Frederickson DT. Cardiovascular Diseases. Guidelines for Prevention

and Care. Reports of the Inter-Society Commission for Heart Disease

Resources. New York, NY: Inter-Society Commission for Heart Disease

Resources; 1972:44.

28. Wilson E, Farquhar JW, O’Connor B, Harriman ME, McLean D, Pearson

TA. International Action On Cardiovascular Disease: A Platform For Success (in

press).

29. CVD Plan Steering Committee. Preventing Death and Disability from

Cardiovascular Diseases: A State-Based Plan for Action. Washington, DC:

Association of State and Territorial Health Officers; 1994.

30. Rose G. Strategy of Prevention: Lessons from Cardiovascular Disease. BMJ

1981;282:1847–51.

31. Strasser T. Reflections on Cardiovascular Diseases. Interdisciplinary Science

Reviews 1978;3:225–30.

32. Barker DSP, editor. Fetal and Infant Origins of Adult Disease. London: British

Medical Journal; 1992.

33. Pearson TA, McBride PE, Miller NH, Smith SC Jr. Task Force 8:

Organization of Preventive Cardiology Service. Journal of the American College

of Cardiology 1996;27:1039–47.

34. US Department of Health and Human Services. Healthy People 2000 Final

Review. Washington, DC: US Department of Health and Human Services;

2001. DHHS publication no. 01-0256.

35. Sacks FM, Svetkey LP, Vollmer WM, et al. Effects on Blood Pressure of

Reduced Dietary Sodium and the Dietary Approaches to Stop Hypertension

(DASH) Diet. DASH-Sodium Collaborative Research Group. New England

Journal of Medicine 2001;344:3–10.

36. Knowler WC, Barrett-Connor E, Fowler SE, et al and the Diabetes

Prevention Program Research Group. Reduction in the Incidence of Type 2

Diabetes with Lifestyle Intervention or Metformin. New England Journal of

Medicine 2002;346:393–403.

37. Goff DC Jr, Howard G, Russell GB, Labarthe DR. Birth Cohort Evidence of

Primary Prevention of High Blood Pressure in the United States, 1887–1994.

Annals of Epidemiology 2000;11:271–9.

38. Goff DC Jr, Labarthe DR, Howard G and Russell GB. Primary prevention of

high blood cholesterol concentrations in the United States. Archives of Internal

Medicine 2002;162:913–9.

39. Chockalingam A, Balaguer-Vintró I, editors. Impending Global Pandemic of

Cardiovascular Diseases. Barcelona: Prous Science; 1999.

40. Brundtland GH. Global Strategy for the Prevention and Control of

Noncommunicable Diseases. Geneva: World Health Organization; 1999:1.

41. Institute of Medicine. America’s Vital Interest in Global Health. Washington,

DC: National Academy Press; 1997:44, 46.

42. Institute of Medicine. Control of Cardiovascular Diseases in Developing Countries:

Research, Development, and Institutional Strengthening. Washington, DC:

National Academy Press; 1998:60.

32

Public Health Action Plan to Prevent Heart Disease and Stroke
33

A Comprehensive Public Health Strategy 

SECTION 2. 

A COMPREHENSIVE PUBLIC HEALTH

STRATEGY AND THE FIVE ESSENTIAL

COMPONENTS OF THE PLAN: 

A PLATFORM FOR ACTION

Summary

Section 2 presents a vision of cardiovascular health (CVH) that is

achievable through a comprehensive public health strategy. Such a 

strategy will guide the needed action, from preventing heart disease and

stroke among healthy people to treating and managing these conditions

when prevention has failed. To develop the strategy, an action framework

was developed that outlines the present reality, a vision of the future, and

six broad intervention approaches that can help achieve this vision. These

six approaches address the two overarching goals of Healthy People 2010,

which are to increase quality and years of healthy life and eliminate health

disparities, as well as the specific goal for preventing heart disease and stroke.

The action framework helps to distinguish two widely recognized 

aspects of intervention—health promotion and disease prevention—as

they apply to heart disease and stroke. It also describes the nature and

magnitude of the target population for each intervention approach.

These descriptions illustrate a striking imbalance between the lack of

investment in prevention—when risk is still low—and the massive 

expenditures for health care once recognized cardiovascular disease

(CVD) has developed. A comprehensive public health strategy must

address this imbalance.

The meaning of “public health” is central to the concept of a comprehensive public health strategy and is clearly stated in the 1988

Institute of Medicine report, The Future of Public Health. That report

defined public health and its core functions and emphasized that 

state public health agencies have the primary responsibility for these

functions. The report also described the potential roles of other parties,

including health agencies at federal, state, and local (i.e., county/city)

levels; health care providers; other partners in and outside the health

sector; the public at large; and representatives of specific population

groups or particular target settings.

To proceed from a comprehensive public health strategy to a practical

plan of action requires that specific recommendations be developed and

concrete action steps be proposed. Accordingly, recommendations and

related action steps are presented in five essential areas that constitute

the core of this plan.
34

Public Health Action Plan to Prevent Heart Disease and Stroke

Introduction: A Vision of Cardiovascular Health

for America

A challenging vision of cardiovascular health for the United States is a

nation whose residents are heart-healthy and stroke-free. Can we reach

this vision from the present reality? What will the CVD burden be like in

such a future? By what means can so radical a change be achieved? What

roles will public health agencies and others need to play? What action

areas must be addressed in developing appropriate recommendations?

To effectively address these questions, we must develop a framework for

addressing the questions, understand the role and responsibilities of

public health agencies, and define the major action areas so that the most

pertinent issues can be identified and corresponding recommendations

formulated.

A Framework for a Comprehensive Public 

Health Strategy

Developing a comprehensive public health strategy requires considering

the full scope of a public health problem and the array of potential

approaches to controlling it. It also requires recognizing the present

reality and having a vision of the future that includes the most favorable

conditions that can result from effective public health action. Bringing

these four elements together in one action framework provides guidance

and helps ensure that all relevant aspects are addressed. The framework

developed for the Action Plan provides a useful point of reference for

considering the recommendations and proposed action steps (see figure

on inside back cover).

This framework is intended to represent the full scope of CVH in all 

its aspects, including the progressive development of CVD and the

corresponding opportunities for CVH promotion and CVD prevention.

It reflects the extensive research and practical experience of the past 50

years and more, which have provided a solid understanding of the causes

of CVD and identified a wide range of opportunities for intervention.

The framework also indicates where intervention approaches can be

applied, through greatly expanded public health efforts, to advance from

the present reality toward the vision of the future.

The Present Reality

The present reality of the burden of heart disease and stroke, especially

in the United States, was documented in Section 1.1,2 Underlying this

burden are the long-term development of atherosclerosis and high blood

pressure, conditions that are widely prevalent throughout our society.

The causes begin with unfavorable social and environmental conditions

that foster adverse behavioral patterns and result in a high prevalence of

major risk factors. Inadequate measures for preventing, detecting, and 
controlling risk factors lead to first CVD events (e.g., heart attack, heart

failure, stroke) from which many victims die suddenly, while others

survive with a high risk for recurrence and often with disability. Many

victims ultimately suffer fatal complications or cardiovascular

decompensation months or years after the initial event.

A Vision of the Future

We envision a future when the epidemic of heart disease and stroke has

been arrested and reversed. This future includes social and environmental

conditions that are favorable to health, a predominance of healthpromoting behaviors, a low prevalence of risk factors, fewer and less

frequently fatal CVD events, rapid recovery of full functional capacity for

victims who survive, and good quality of life thereafter until death from

whatever cause. The critical question is, how do we move from the

present reality to this vision of the future?

Intervention Approaches

The answer can be found in the six-fold array of intervention approaches

available today. First, policy and environmental change addresses

fundamental social and environmental conditions that operate early in

CVD development; this approach can also influence later phases of the

disease process (e.g., by improving accessibility, use, and quality of health

care).3 Second, behavioral change, especially population-wide, can reduce

the effects of adverse social and environmental conditions. It can also

reinforce the approaches that follow (e.g., by fostering community

awareness and support for heart disease and stroke prevention). The third

approach—detecting and controlling risk factors—has been a mainstay of

CVD prevention and is needed continually once risk factors are present,

to prevent both first and recurrent CVD events. (This approach comes

too late in the process to prevent the risk factors themselves.) The fourth

approach is emergency care and acute case management for those victims

of first events who survive long enough to receive intervention. This

approach continues to apply when survivors of previous acute CVD

events experience recurrent ones. The fifth approach is rehabilitation,

which should be applied following most acute events, and long-term

management, which continues throughout the remainder of a victim’s 

life until the sixth approach, end-of-life care, may be required.

Healthy People 2010 Goals

The action framework establishes a clear link between the proposed

comprehensive public health strategy and Healthy People 2010 goals.4

Together, the six intervention approaches will help achieve the two 

overarching goals of Healthy People 2010, as well as the specific goal for

preventing heart disease and stroke. The Healthy People 2010 Heart and

Stroke Partnership divided this goal into four separate goals based on the

different intervention approaches that would be needed to achieve them.

35

A Comprehensive Public Health Strategy 
36

Public Health Action Plan to Prevent Heart Disease and Stroke

Target Population

Each intervention approach has the potential to affect millions of people

in the United States.1 The total U.S. population of 281 million people

stands to benefit from policy and environmental change and populationwide behavioral change. The more than 100 million people with risk

factors (e.g., high cholesterol, high blood pressure, smoking, obesity,

diabetes) could benefit from effective risk factor detection and control. 

In addition, the hundreds of thousands of victims of first major CVD

events each year can gain from acute or long-term case management and,

potentially, from end-of-life care.

Interventions with the greatest impact on the population as a whole 

are those applied in the earliest phases of CVD development. To treat

victims of heart disease, stroke, or other cardiovascular conditions is

clearly to intervene late in the disease process. For those who die

suddenly without warning, it is too late to have any benefit. Today, only 

a few cents per person per year are invested in the most far-reaching

intervention approaches, whereas thousands of dollars per person per

year are spent in efforts to treat established risk factors, rescue the

victims of acute events, restore function and reduce risk for recurrent

events among survivors, and provide end-of-life care. There is a need

and opportunity to support a continuum of care, from the whole

population to the individual victims of CVD, but we as a nation are not

doing so. To attain our vision of the future and achieve the applicable

goals of Healthy People 2010, a change in the balance of investment

between early and late intervention is needed. A comprehensive public

health strategy to prevent heart disease and stroke must aim for greatly

increased application of the earliest intervention approaches, while

working toward assurance that appropriate services of high quality will

be accessible and used by all those who continue to need them. In the

vision of the future, that need will be substantially reduced.

Finally, the action framework offers a clearer understanding of CVH

promotion and CVD prevention, as these terms are defined and used 

in the Action Plan (see Section 1 and Appendix A). CVH promotion is

intended to prevent risk factors (goal 1) and includes policy and

environmental change and behavioral change, especially at the

population level. CVD prevention applies to subsequent phases of CVD

development and includes primary and secondary prevention. Primary

prevention is intended to prevent first clinical events by detecting and

treating risk factors (goal 2), whereas secondary prevention follows the

first event and, for victims who survive, seeks to restore full functional

capacity and reduce the risk of recurrence (goal 4). Goal 3, early

detection and treatment of heart attacks and strokes, is part of CVD

prevention and falls between primary and secondary prevention.

The Three Core Functions of Public Health

For many people, addressing the meaning of “public health” and clarifying

its essential role in protecting society from such chronic diseases as heart

disease and stroke may be helpful. The 1988 IOM report, The Future of
37

Public Health, was a critical assessment of the nation’s public health system

by the Committee for the Study of the Future of Public Health.5 The

findings of that report provide an important perspective on what will be

needed for a successful public health strategy to prevent heart disease and

stroke. The following excerpts illustrate this point.

• A definition of public health: Public health is what we, as a society, do

collectively to assure the conditions in which people can be healthy.

• A key barrier to public health action: Health officials have difficulty

communicating a sense of urgency about the need to maintain current

preventive efforts and to sustain the capability to meet future threats to the

public’s health.

• The report’s overall appraisal: . . . this nation has lost sight of its

public health goals and has allowed the system of public health activities 

to fall into disarray.

• The needed response: This report conveys an urgent message to the

American people. Public health is a vital function that is in trouble.

Immediate public concern and support are called for in order to fulfill society’s

interest in assuring the conditions in which people can be healthy.

Especially relevant to the development of the Action Plan is the IOM

report’s formulation of the three core functions of public health: 

“. . . the core functions of public health agencies at all levels of

government are assessment, policy development, and assurance.”

Assessment refers to the obligation of every public health agency to

monitor the health status and needs of its community regularly and

systematically. Policy development refers to the responsibility of every

public health agency to develop comprehensive policies that are based

on available knowledge and responsive to communities’ health needs.

Assurance is the guarantee of governments that agreed-upon, highpriority personal and community health services will be provided to

every member of the community by qualified organizations.

Each of the recommendations in this plan is readily identifiable with one

of these three core functions or addresses requirements for public health

agencies to fulfill them. The recommendations also reflect many of the

perceptions about the roles and relationships of public health agencies

and other entities in the IOM report. Two points are especially relevant.

First is the scope of participation needed to achieve public health goals.

Private and voluntary organizations and individuals must join with

government entities in actively contributing to the functions of public

health. Second, state public health agencies have primary constitutional

responsibility for public health functions. This premise is reflected in

this plan’s development and the expectation that these agencies must

have a central role in implementing its recommendations.

In this respect, as in many others, the views of the five Expert Panels 

that helped develop the Action Plan closely matched those expressed in

the 1988 report. They also reflected agreement with the conceptual

framework described here. Subsequent to the work of the Expert Panels,

two new IOM reports on the present and future of public health in the

United States have been released, and both of them strongly reinforce

A Comprehensive Public Health Strategy 
38

Public Health Action Plan to Prevent Heart Disease and Stroke

the recommendations presented here.6,7 The first, Who Will Keep the

Public Healthy?, focuses on new requirements for educating health

professionals for the 21st century. It presents an ecological model (i.e., “a

model of health that emphasizes the linkages and relationships among

multiple determinants affecting health”) as the essential backdrop, both

in concept and in practice, for addressing future health challenges. The

framework guiding development of the Action Plan is such a model.

Further, the newly formulated goals and objectives for educating health

professionals closely mirror the recommendations for strengthening

capacity of the public health workforce.

The second report, The Future of the Public’s Health in the 21st Century,

builds on the 1988 report. It emphasizes a broad view of the “public health

system” that encompasses the governmental public health infrastructure as

well as other potential partners, specifically the community, health care

delivery system, employers and businesses, media, and academia. This

report also explicitly embraces the vision of the nation’s health expressed

by Healthy People 2010: “healthy people in healthy communities.” Topics

addressed in the report include “adopting a focus on population health

that includes multiple determinants of health; strengthening the public

health infrastructure; building partnerships; developing systems of

accountability; emphasizing evidence; and improving communication.”

The congruence between recommendations of the Action Plan and the

IOM’s recent reassessment of what is needed to strengthen the nation’s

public health system is striking. 

Potential Roles of Partners

The Action Plan recognizes the necessary scope of participation in public

health activities expressed in the 1988 IOM report and highlights the

need for partnership, collaboration, and shared responsibility. Although

state health agencies are primarily responsible for fulfilling the core

functions of public health, the potential roles of private and voluntary

organizations and individuals in public health activities are also important.5

In anticipation of the involvement of various types of organizations and

agencies, general descriptions of these roles are as follows:

• Public health agencies are responsible for leadership in convening 

all participating organizations and agencies to define and delineate

tasks and to support the long-term implementation of this plan at

national, state, and local levels. Agencies will participate in accordance

with their particular missions, interests, and resources. Some are

already involved through the Healthy People 2010 Heart and Stroke

Partnership. State and local (i.e., county/city) health agencies and

tribal organizations will help guide national implementation and take

direct responsibility for action at their own levels.

• Health care providers are central to the provision of preventive

services throughout the clinical phases of CVD. Addressing goals 

2–4 of the Healthy People 2010 Heart and Stroke Partnership

requires active collaboration with providers, third-party payers, and
39

other relevant partners to assure access to and appropriate use of

quality health services by those who need them.

• Other health-sector partners will help implement the plan at

national, state, or local levels, as appropriate. Their roles include

contributing to detailed implementation plans, raising public

awareness, and supporting legislative and regulatory action to fulfill

the plan’s policy goals.

• Non–health-sector partners represent such areas as education, agriculture and food production, community development and planning,

parks and recreation, transportation, and the media. These partners can

contribute different perspectives, as well as additional resources, to help

implement the plan and are clearly essential for success.

• The public at large and representatives of specific groups or 

settings are critical parties to public health action of any kind. Engaging these parties is also essential to the plan’s implementation

and success.

• All interested parties and stakeholders should be included in

implementation, and mechanisms for their involvement must be

established and maintained.

Five Essential Components of the Action Plan

The third requirement for a comprehensive public health strategy is

defining the action areas in which recommendations are needed. An

independent Expert Panel was convened to address each of five

components considered essential to this plan—taking action,

strengthening capacity, evaluating impact, advancing policy, and

engaging in regional and global partnerships. Each component is 

best characterized by brief statements from the five panels, indicating

their perspective on their charge and the theme of the resulting

recommendations. The linkages of these five components form 

an integrated plan (see Figure 2 in Overview). Each panel’s

recommendations are presented in Section 3. Details of the planning

process and the premises that guided each panel’s work are outlined 

in Appendix D.

• Taking action: Putting present knowledge to work (Expert Panel A).

Perspective: Acting now on what is already known must be the first

priority. The greatest need is to implement the most promising

policies and programs for heart disease and stroke prevention

immediately and to the fullest extent feasible. Effective communication

and innovative leadership, partnerships, and organizational

arrangements are required.

Theme: Federal, state, and local public health agencies urgently need

explicit mandates and adequate resources to effectively implement

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40

Public Health Action Plan to Prevent Heart Disease and Stroke

policies and programs to prevent chronic diseases and to arrest and

reverse the continuing national epidemic of heart disease and stroke.

• Strengthening capacity: Transforming the organization and

structure of public health agencies and partnerships (Expert Panel B).

Perspective: Effective action to prevent heart disease and stroke

requires transformation in how public health agencies are organized.

Strengthening the competencies and resources of the public health

workforce for the needed tasks and managing the development,

maintenance, and dynamic growth of effective partnerships are

necessary for this change. 

Theme: Public health agencies must develop and maintain new

capacities, including organizational arrangements and competencies

for CVH promotion and CVD prevention. They also need networks

of established and innovative partnerships to fulfill their mandates to

prevent heart disease and stroke.

• Evaluating impact: Monitoring the disease burden, measuring

progress, and communicating urgency (Expert Panel C).

Perspective: Action must be guided by 1) continuous, comprehensive

assessment of all aspects of the public health burden of CVD; 

2) identification of opportunities for effective intervention; and 

3) prediction and evaluation of the impact of actions taken. At present,

essential information for planning and evaluation is often unavailable

for priority populations or the population as a whole. The needed data

include key indicators of social and environmental conditions; patterns

of behavior; incidence and prevalence of risk factors, as well as the

status of their detection, treatment, and control; and incidence of first

and recurrent CVD events, case fatality, hospitalization, mortality,

disability, and survival. Data sources must be enhanced and used more

effectively for assessment, policy development, and assurance at local,

state, and national levels. Major gaps in data systems must be closed

(e.g., by monitoring incidence of risk factors and events), workforce

needs must be met (e.g., for data collection, analysis, interpretation,

reporting, and dissemination), and new data sources must be established

(e.g., to expand coverage of populations at high risk and establish a

network of sentinel communities for comprehensive population-based

monitoring and surveillance).

Theme: To guide and document progress toward national goals for

heart disease and stroke prevention, public health agencies at all levels

must establish and maintain substantially improved systems of data

collection, analysis, and reporting. These systems must meet

requirements for monitoring key Healthy People 2010 leading health

indicators, evaluating the impact and effectiveness of policies and

programs, and communicating this information rapidly. All such systems

must conform to the highest standards of data quality and reliability.
41

• Advancing policy: Defining the issues and finding the needed 

solutions (Expert Panel D).

Perspective: The effectiveness of actions taken to prevent heart 

disease and stroke in coming years can increase as the foundation 

of evidence-based public health decision making is strengthened. A

well-developed and continually updated agenda for CVD prevention

research will support this growth. This research agenda must address

critical policy issues through targeted investigations and scientific

oversight; potential research settings, funding mechanisms, and 

evaluation plans require attention as well.

For example, if atherosclerosis and high blood pressure (major causes of

heart disease and stroke) were prevented by interventions that promote

healthy lifestyles and environments in youth and throughout adulthood,

such efforts would greatly reduce the risk of the current school-aged

generation for developing CVD. Testing this hypothesis and others

related to CVH promotion and CVD prevention depends on research

that is strongly supported, effectively implemented, and adequately

sustained. Although current knowledge provides a solid base for policy

and practice, more research is needed. Methods for translating existing

knowledge into practice must be improved; current and proposed

policies and programs that create a demand and opportunity for healthy

lifestyles must be evaluated; and new data, especially on social and

environmental determinants of CVD, must be collected. These areas

correspond closely to the U.S. Department of Health and Human

Services priority area of Preventing Disease, Illness, and Injury (Priority

X of the Research Themes and Priority Research Areas).8

Theme: A prevention research agenda for heart disease and stroke

must be developed and fully implemented to rapidly expand the

nation’s ability to translate existing knowledge into practice, while

continually providing new knowledge to advance public health policy

and create more effective programs.

• Engaging in regional and global partnerships: Multiplying

resources and capitalizing on shared experience (Expert Panel E).

Perspective: Regional and global partnerships in heart disease and

stroke prevention present important opportunities for collaboration,

as described in Section 1. Contribution of material and nonmaterial

resources developed in the United States can be used to benefit global

prevention efforts. Communicating closely with regional and global

partners regarding their experiences with policies and programs in

diverse settings will be beneficial to all and will return high dividends

on investment. Contributions of research in other countries to policy

development in the United States are illustrated in Section 1. The

threat that CVD poses to human life is important nationally and

globally, especially in poorer countries. The widespread occurrence of

CVD in countries undergoing social and economic transitions, the

unaddressed needs related to CVD prevention, and the need for

A Comprehensive Public Health Strategy 
42

Public Health Action Plan to Prevent Heart Disease and Stroke

expanded use of early intervention approaches that are largely

unfamiliar all underscore the value of global cooperation.

Theme: As action to prevent heart disease and stroke gains momentum

globally, the United States must engage with regional and global 

partners to support their efforts and to gain from the resulting

worldwide growth of knowledge and practical experience.

• Linking the components: Integrating the parts and forging a plan

(All Expert Panels and the Working Group).

Taking action will be limited initially by the capacity of public health

agencies and partners to undertake the work on the scale required.

Strengthening capacity will enable them to increase the range and

intensity of action. Evaluating impact will contribute to development

of more effective policies and programs, improved identification of

best practices, and more rapid communication of new information to

the public and policy makers. This activity will increase support for

the first two components. Advancing knowledge through prevention

research will accelerate policy development by supporting critical

investigations on policy-related issues and by contributing to better

ways to disseminate effective programs widely. Prevention research

will become more common as research capacity is strengthened, data

systems for surveillance and evaluation are improved, and policy

makers increasingly recognize the value of such research. Regional

and global partnerships will contribute to progress in each of the

other four components through the shared experience of global 

partners who are addressing similar issues. 

Theme: Implementation of the plan must assure integration of all five

components in a coordinated approach that recognizes and

strengthens the potential linkages among them. Such integration and

coordination are critical to effective implementation of the plan.

References

1. American Heart Association. 2003 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. Association of State and Territorial Directors of Health Promotion and Public

Health Education (ASTDHPPHE), and Centers for Disease Control and

Prevention (CDC). Policy and Environmental Change: New Directions for Public

Health. Final Report. Atlanta, GA: ASTDHPPHE and CDC; August 2001.

4. 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.

5. 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.
6. Committee on Educating Public Health Professionals for the 21st Century,

Board on Health Promotion and Disease Prevention, Institute of Medicine of the

National Academies. Gebbie K, Rosenstock L, Hernandez LM, editors. Who

Will Keep the Public Healthy? Educating Public Health Professionals for the 21st

Century. Washington, DC: The National Academies Press; 2002.

7. Committee on Assuring the Health of the Public in the 21st Century, Board on

Health Promotion and Disease Prevention, Institute of Medicine of the National

Academies Boufford JI, Cassel CK, co-chairs. The Future of the Public’s Health in

the 21st Century. Washington, DC: The National Academies Press; 2002.

8. Research Coordination Council. Research Themes and Priority Research Areas.

Washington, DC: US Department of Health and Human Services; 2002 (in

press).

43

A Comprehensive Public Health Strategy 
44
45

Recommendations

SECTION 3. 

RECOMMENDATIONS: A CALL 

TO ACTION

Summary

The Action Plan outlines recommendations developed by five Expert

Panels that were convened by CDC to address the plan’s five essential

components. These recommendations were reviewed by a Working

Group, which determined that two of the recommendations were

paramount and should be elevated above the others as fundamental

requirements for implementing this plan (see Appendix D for details of

this process). The two fundamental requirements are followed by 22

recommendations, which are presented according to the Expert Panel

that produced them.

The Working Group also reviewed the premises that each panel used 

to guide its recommendations and determined that three of these were

relevant to all five components. These were deemed overarching

premises and precede the recommendations in this section. All of the

other premises outlined by the panels are presented in Appendix D.

Most of the recommendations are directed to the public health

community as a whole, especially public health agencies and their

partners, which are called to action by this plan. The hope is that all

interested agencies, organizations, and individuals will consider these

recommendations and the related action steps outlined in Section 4 and

will contribute their participation and support.

Overarching Premises

• All recommendations in the plan should contribute to increasing

quality and years of healthy life and eliminating health disparities, 

as well as preventing heart disease and stroke.

• Recommendations should lead to specific actions and measurable

outcomes that, when accomplished, will advance the plan. If successful

outcomes are effectively communicated, the action steps that led to

this success are likely to be replicated throughout the public health

system and society at large.

• Because the impact of public health practice is ultimately local (even

when the point of action is national or global), the elements required

to make a program effective locally should be identified. This process

should involve governmental agencies, schools, work sites,

communities, families, and other local entities.

Fundamental Requirements

The Working Group determined that two of the Expert Panels’

recommendations were paramount and should be elevated above the

others as fundamental requirements. These requirements address the
46

Public Health Action Plan to Prevent Heart Disease and Stroke

crosscutting aspects of effective communication, as well as strategic

leadership, partnerships, and organization.

Effective Communication

• The urgency and promise of preventing heart disease and

stroke and their precursors (i.e., atherosclerosis, high blood

pressure, and their risk factors and determinants) must be

communicated effectively by the public health community

through a new long-term strategy of public information and

education. This new strategy must engage national, state, and

local policy makers and other stakeholders.

Together, these partners must help the public understand three basic

messages. First, heart disease and stroke and related conditions pose

a serious threat to the health and well-being of all Americans,

especially (but not only) during the middle and older adult years.

Second, prevention is possible by reversing community-acquired

behaviors, risks, and health disparities. Third, the consequence of

failing to intensify preventive efforts is steep escalation in the burden

and cost of these diseases in the next two decades and beyond.

Success requires a communications infrastructure that includes

federal, state, and local public health agencies, tribal organizations,

and other government agencies working in partnership with the

media and other related sectors.

Communication and education are fundamental to achieving policy

and environmental changes, which are strongly recommended in 

this plan. In addition, policy makers must receive the information

necessary to appreciate the urgency of the cardiovascular disease

(CVD) epidemic and the opportunity that exists to arrest 

and reverse it. Leaders in prevention have argued for more than a

decade that a broad societal commitment is needed for effective

public health efforts to prevent heart disease and stroke. This

commitment will depend on critical stakeholders devising and

adopting a long-range strategy to convey clear, consistent, and

contemporary messages to the public and policy makers.

Strategic Leadership, Partnerships, and Organization

• The nation’s public health agencies and their partners must

provide the necessary leadership for a comprehensive public

health strategy to prevent heart disease and stroke.

Appropriate organizational arrangements and sufficient support are

needed to achieve effective collaborations among all major partners

and to implement the plan. Public health agencies must develop the

expertise to create and maintain strong partnerships to advance the

agenda for preventing heart disease and stroke at local, state, and

national levels. Both traditional and nontraditional partners,

including many beyond the health sector, are needed to fully

implement the plan.
47

Recommendations

Strong and committed public health leadership is required to undertake and sustain major new efforts sufficient to arrest and reverse the

nation’s CVD epidemic. An agency with an appropriate mission, a

tradition of relationships with official health agencies and national

organizations of public health professionals, and extensive experience

in developing and implementing population-wide and communitybased health strategies could provide the necessary leadership.

Developing and maintaining effective partnerships requires that

public health agencies acquire nontraditional skills and competencies

such as knowledge of other relevant organizations and agencies 

and expertise in communication, collaboration, and negotiation.

These skills are presently limited in many if not most public health

agencies. When these limitations are overcome, other agencies and

organizations in the health sector and in fields that indirectly affect

health (e.g., education, agriculture, transportation, community

planning) can become engaged in cardiovascular health (CVH) 

issues and activities.

Recommendations for the Five Essential

Components of the Plan

To help the public health community implement the Action Plan, specific

recommendations were developed by five Expert Panels. These panels

addressed the five essential components of the plan—taking action,

strengthening capacity, evaluating impact, advancing policy, and

engaging in regional and global partnerships. Their work was

synthesized by a Working Group into 22 recommendations, which are

presented here according to the Expert Panel that produced them.

Taking Action: Putting Present Knowledge to Work

1. Initiate policy development in CVH promotion and CVD

prevention at national, state, and local levels to assure effective

public health action against heart disease and stroke. In

addition, evaluate policies in non-health sectors (e.g.,

education, agriculture, transportation, community planning) 

for their potential impact on health, especially with respect 

to CVD.

As described in Section 1, interventions that address policy and

environmental change can have population-wide impact. Such

changes represent the coming era of chronic disease prevention

and health promotion.1 The greatest potential for sustained,

population-wide health behavior change lies in policy decisions in

communities and organizations that support heart-healthy behaviors

and in interventions that favor CVH promotion and CVD prevention. 

2. Act now to implement the most promising public health

programs and practices for achieving the four goals for

preventing heart disease and stroke, as distinguished by the
48

Public Health Action Plan to Prevent Heart Disease and Stroke

Healthy People 2010 Heart and Stroke Partnership based on

the different intervention approaches that apply. These goals

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.

Public health agencies and their partners must provide

continuous leadership to identify and recommend new and

effective interventions that are based on advances in program

evaluation and prevention research and a growing inventory of

“best practices.”

To rigorously evaluate policies and programs, new evaluation

concepts and methods must continuously be developed. Because

input to this development may arise from many sources (e.g., other

agencies and organizations, academia, participating communities),

establishing leadership responsibility for this function will be

advantageous. Taking action based on current knowledge

presupposes a well-founded inventory of programs and practices and

assessment of their potential effectiveness. Such an inventory is

required in relation to the four Healthy People 2010 Heart and

Stroke Partnership goals (which are based on the one Healthy People

2010 goal for preventing heart disease and stroke2). Selected

programs and practices must also be implemented on a sufficient

scale to permit meaningful evaluation of their impact.

3. Address all opportunities for prevention to achieve the full

potential of preventive strategies. Such opportunities include

major settings (schools, work sites, health care settings,

communities, and families), all age groups (from conception

through the life span), and whole populations, particularly

priority populations (based on race/ethnicity, sex, disability,

economic condition, or place of residence).

Only a comprehensive approach can most effectively control the

progressive development of risk factors and disease outcomes. In this

approach, multiple programs must often be coordinated if all major

risk factors are to be addressed in all settings for all population

groups. CVH leadership includes assuring that all risk factors are

adequately addressed through the available resources and stakeholder

groups and that requisite preventive and clinical programs and

services of acceptable quality are accessible and used by those who

need them.

4. Emphasize promotion of desirable social and environmental

conditions and favorable behavioral patterns in order to prevent

the major CVD risk factors and assure the fullest attainable

accessibility and use of quality health services for people with

risk factors or who develop subclinical or overt CVD. These

actions are integral to a comprehensive public health strategy

for CVH promotion and CVD prevention.
49

Recommendations

Only a comprehensive strategy can effectively address the Healthy

People 2010 goal for preventing heart disease and stroke (see

Recommendation 2). Such a strategy for CVH promotion must

emphasize the earliest aspects of CVD risk development that

jeopardize the health of the entire population (e.g., influences on

behavior related to diet; physical activity; and tobacco, alcohol, and

drug use) (see Section 2). This is the most neglected area of

intervention, and it provides the greatest opportunities both to

promote CVH and prevent the later consequences (e.g., risk factors,

clinical events). Public health officials and their partners in the

health care delivery system and other areas also must assure to the

fullest extent possible that clinical guidelines and treatment

recommendations for addressing risk factors when they are present

(i.e., primary prevention) and CVD events and conditions once they

have occurred (i.e., secondary prevention) are implemented

effectively across all population groups.

Strengthening Capacity: Transforming the

Organization and Structure of Public Health Agencies

and Partnerships

5. Maintain or establish definable entities with responsibility

and accountability for CVH programs within federal, state,

and local public health agencies, including laboratory

components.

As a preventable disease that profoundly affects mortality, disability,

and health care costs in the United States, CVD warrants visibility

and attention as a major public health problem. The large and

growing level of disparity among certain racial and ethnic

populations adds urgency to this need. Establishing the visibility of

CVH in all public health agencies will contribute to the needed

recognition of this area of responsibility.

6. Create a training system to develop and maintain appropriately

trained public health workforces at national, state, and local

levels. These workforces should have all necessary competencies

to bring about policy change and implement programs to

improve CVH promotion and decrease the CVD burden,

including laboratory requirements.

The necessary competencies go beyond traditional public health

knowledge to encompass practical skills such as developing and

maintaining partnerships and coalitions, defining and identifying the

burden and status of chronic diseases, and knowing how to incorporate

sound business practices. Few academic training opportunities to learn

these essential skills exist in currently available curricula, including

master of public health programs. New workers require on-the-job

training or other informal means to acquire these skills. Several

training options are proposed in Section 4 to meet the needs of local,

state, and national public health workers.
50

Public Health Action Plan to Prevent Heart Disease and Stroke

7. Develop and disseminate model performance standards and

core competencies in CVD prevention and CVH promotion for

national, state, and local public health agencies, including their

laboratories.

Rather than mandating specific personnel and other resources for

CVD prevention programs, setting performance standards and

competencies that public health agencies can meet through flexibility

with their own personnel and resources may be more successful.

8. Provide ongoing access to technical assistance and consultation to

state and local health agencies and partners for CVD prevention. 

Although health agencies and organizations can develop personnel

capacities through episodic training, continuous availability of

technical support through consultation and information sharing can

enhance the effectiveness of staff with sufficient previous training.

Resources are needed to assure the availability of such support.

Evaluating Impact: Monitoring the Burden, Measuring

Progress, and Communicating Urgency

9. Expand and standardize population-wide evaluation and

surveillance data sources and activities to assure adequate

assessment of CVD indicators and change in the nation’s CVD

burden. Examples include mortality, incidence, prevalence,

disability, selected biomarkers, risk factors and risk behaviors,

economic burden, community and environmental characteristics,

current policies and programs, and sociodemographic factors

(e.g., age, race/ethnicity, sex, and ZIP code).

Existing data sources do not adequately support current populationwide surveillance and evaluation priorities. Strengthening and

enhancing these data sources will contribute better information for

monitoring and improving CVH in the United States.

10. Establish a network of data systems for evaluation of policy and

program interventions that can track the progress of evolving

best practices and signal the need for changes in policies and

programs over time. This network would support the full

development, collection, and analysis of the data needed to

examine program effectiveness.

The scientific basis for public health policy and programs in heart

disease and stroke prevention must be continually strengthened. A

prerequisite for achieving this recommendation is to build data

systems that can evaluate health burdens, health practice experiences,

and the possible opportunities for new policy and program

development.
51

11. Develop the public health infrastructure, build personnel

competencies, and enhance communication systems so that

federal, state, and local public health agencies can

communicate surveillance and evaluation results in a timely

and effective manner.

Communicating health information is essential to assuring the timely

application of proven interventions for the greatest public health

benefit. Strengthening the capacity of public health systems to

collect and use information will stimulate policy development and

lead to more effective programs and a greater ability to measure their

impact.

Advancing Policy: Defining the Issues and Finding 

the Needed Solutions

12. Conduct and facilitate research by means of collaboration

among interested parties to identify new policy, environmental,

and sociocultural priorities for CVH promotion. Once the

priorities are identified, determine the best methods for

translating, disseminating, and sustaining them. Fund research

to identify barriers and effective interventions in order to

translate science into practice and thereby improve access to 

and use of quality health care and improve outcomes for patients

with or at risk for CVD. Conduct economics research, including

cost-effectiveness studies and comprehensive economic models

that assess the return on investment for CVH promotion as well

as primary and secondary CVD prevention.

The importance of policy, environmental, and sociocultural

determinants of risk factors and CVD has only been recognized

recently and requires intensified investigation. Innovative

approaches are needed to advance CVH promotion policy. For

example, research is needed to assess community-wide interventions

aimed at maintaining and restoring low blood cholesterol levels and

low blood pressure, which help prevent atherosclerosis and high

blood pressure. To quickly and effectively translate science into

practice and improve health outcomes, researchers must identify

barriers and implement interventions that prove successful. As the

U.S. population ages over the coming decades, the economic aspects

of CVD health care (e.g., managing risk factors, events, disabilities,

and long-term dependency) will become an even greater problem.

Prevention effectiveness research must provide current and

projected estimates of the cost to prevent and treat each CVD risk

factor and outcome, singly and in integrated multifactor approaches,

and determine the cost-effectiveness of current interventions.

13. Design, plan, implement, and evaluate a comprehensive

intervention for children and youth in school, family, and

community settings. This intervention must address dietary

imbalances, physical inactivity, tobacco use, and other

Recommendations
52

Public Health Action Plan to Prevent Heart Disease and Stroke

determinants in order to prevent development of risk factors

and progression of atherosclerosis and high blood pressure.

The need to focus on prevention early in life is compelling. First,

very early experience (even in utero or during early postnatal life)3

may contribute to risk for adult CVD and determine vulnerability to

later effects from factors such as weight gain or low income. Second,

many health behaviors are established in childhood and youth, when

they are more susceptible to change. Third, biological CVD risk

factors such as blood cholesterol level and blood pressure and

behavioral risk factors such as tobacco use track from childhood into

adult life, and family history of CVD predicts CVD risk factors in

children and adolescents. Fourth, preclinical CVD in the form of

atherosclerosis is already present in youth, and its extent and severity

are increased by the presence of these risk factors. Fifth, emerging

evidence on biomarkers of risk may point to specific groups

especially likely to benefit from intervention. The evidence outlined

here indicates that critical, early periods exist when CVD risk can be

detected and treated, and research is needed to define these periods

more precisely and to demonstrate the impact of population-wide

interventions.

14. Conduct and facilitate research on improvements in

surveillance methods and data collection and management

methods for policy development, environmental change,

performance monitoring, identification of key indicators, and

capacity development. Address population subgroups in various

settings (schools, work sites, health care, communities) at local,

state, and national levels. Additionally, assess the impact of new

technologies and regulations on surveillance systems and the

potential benefit of alternative methods.

Existing surveillance systems do not collect sufficient data in many of

these areas. Thus, the ability to make evidence-based improvements

in policy and capacity development is limited. Declining survey

response rates and increased cell phone use, caller identification

technologies, and privacy protections impede collection of data

representative of many target populations. Because future

innovations could produce communication methods more useful for

data collection, methodological research must continue to adapt.

15. Conduct and support research to determine the most effective

marketing messages and educational campaigns to create

demand for heart-healthy options, change behavior, and

prevent heart disease and stroke for specific target groups and

settings. Create and evaluate economically viable CVD

prevention ventures (e.g., in food production, manufacturing,

marketing).

The need for more effective communication about the potential

for effective CVH promotion and CVD prevention is widely

acknowledged. Research on this topic can contribute substantially
53

Recommendations

to the impact of marketing and public education about heart disease

and stroke and increase the return on investment. Strengthening the

market for heart-healthy commercial ventures is essential. For

example, change in the nation’s dietary patterns may require

extensive change in food production, processing, marketing, and

consumption. Research collaborations that bring interested parties

together should achieve a major—if gradual—transition in which

public interest and demand for healthy options continue to provide

a sustainable economic market for the food industry.

16. Initiate and strengthen training grants and other approaches,

such as training workshops and supervised research opportunities,

to build the competencies needed to implement the CVD

prevention research agenda.

Current training programs in prevention research are too few and

too small to develop the large cadre of skilled researchers needed to

conduct the program effectiveness research and other investigations

recommended in this plan. Training grants in other areas have

proven that this approach can work.

Engaging in Regional and Global Partnerships:

Multiplying Resources and Capitalizing on 

Shared Experience

17. Engage with regional and global partners to mobilize resources

in CVH promotion and CVD prevention, develop and

implement global CVH policies, and establish or strengthen

liaison with the partners identified in these recommendations.

Global partnerships should be strengthened to develop CVH policy

and programs that will advance both U.S. and global agendas for

enhancing CVH. These efforts can build on existing partnerships,

thereby increasing the net investment of effort and resources, and

draw on the strengths of the public health community.

18. Address inequalities in CVH among developed and developing

countries, rich and poor people within countries, and men 

and women of all ages. Work with national and global partners

to assess the impact of globalization and trade policies on 

global CVH.

Inequalities strongly influence CVH nationally and globally, and

eliminating them is a cardinal goal of public health interventions

aimed at promoting CVH. Globalization affects many aspects of

health among people in the United States and worldwide. Current

information on how globalization, including trade policies and

practices, affects CVH is inadequate. Better information is needed to

determine how the positive forces of globalization can be harnessed

to benefit CVH nationally and globally.
54

Public Health Action Plan to Prevent Heart Disease and Stroke

19. Develop a strategy to promote use of the media to support

CVH globally.

Media channels are powerful health promotion tools that are

underused in CVH promotion and CVD prevention. In fact, their

messages sometimes serve countervailing interests. Partnership with

the global media can help mobilize the use of these capacities to

promote CVH.

20. Strengthen global capacity to develop, implement, and evaluate

policy and program interventions to prevent and control heart

disease and stroke. Involve all relevant parties—governmental

and nongovernmental, public and private, and traditional and

nontraditional partners—in a systematic and strategic approach.

Improvements in a country’s ability to develop or expand its activities

in policy and program interventions can best be made if the

organizations with experience in this area contribute their expertise.

Thus, public health agencies in the United States and their partners

can play a significant role in supporting global efforts to prevent and

control heart disease and stroke. In addition, partnerships limited

only to organizations and agencies within the health sector will be

less effective, especially globally, because effective interventions must

be multidimensional. Further, the potential for expanding resources

and commitments to preventive policies and programs increases as

participation grows.

21. Strengthen the global focus of public health agencies in the

United States and their partners on CVH and increase their

participation in partnerships intended to a) develop and

implement standards for adequate monitoring of health, social,

and economic indicators and b) develop the ability to effectively

disseminate and translate information into policy and action.

A set of standard elements that could or should be collected in a

monitoring system is needed. Through technical assistance, public

health agencies in the United States and their partners could

contribute to this development.

22. Promote and support research on implementing and evaluating

CVH policy interventions in diverse settings where different

social and economic development and health transition

experiences offer contrasting conditions for testing new

intervention approaches.

Current research on policy interventions and their impact on 

CVH promotion and CVD prevention, nationally and globally, is

insufficient to provide adequate assurance of their effectiveness.

Policy research tools should be developed, and emerging policy

interventions that could be useful to the United States and its global

partners should be identified and evaluated continually.
References

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

Health Education (ASTDHPPHE), and Centers for Disease Control and

Prevention (CDC). Policy and Environmental Change: New Directions for Public

Health. Final Report. Atlanta, GA: ASTDHPPHE and CDC; August 2001.

2. 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.

3. Barker DJP, editor. Fetal and Infant Origins of Adult Disease. London: British

Medical Journal; 1992.

55

Recommendations
56
57

Implementation

SECTION 4. 

IMPLEMENTATION: MOBILIZING

FOR ACTION

Summary

Section 3 presented two fundamental requirements and 22 specific 

recommendations for which action can significantly accelerate progress 

in preventing heart disease and stroke over the next two decades. To have

this impact, each recommendation must be linked with concrete action

steps for practical implementation. Such action steps were initially

proposed by the Expert Panels, and then reviewed by CDC, a Working

Group, and a National Forum convened to help develop this Action Plan.

This section presents specific action steps as they correspond to the

fundamental requirements and recommendations in Section 3. To

indicate their potential impact, the steps are followed by brief

descriptions of the outcomes expected from their implementation.

Public health agencies must play leading roles in implementing many 

or most of the proposed action steps. All steps are addressed implicitly, 

if not explicitly, to these agencies. All will require broad participation 

by partner organizations and agencies—public and private—as well as

the public health community as a whole. All action steps are directed 

to all interested and potentially contributing parties. Such partners’

commitments are not assumed at this stage of development. Interested

organizations and agencies can make these decisions after they have

reviewed the plan and identified the areas where they can make the

greatest contributions.

This section concludes with a discussion of the immediate need for

action, including the initial steps required and the issues that must be

addressed, as well as the need for ongoing review, periodic evaluation,

and adaptation to future conditions.

Fundamental Action Steps

The two fundamental requirements of this plan and their corresponding

action steps address the crosscutting aspects of effective communication, 

as well as strategic leadership, partnerships, and organization.

Effective Communication

• Assess requirements for effective messages. Set the agenda for a

long-term, national public information strategy that conveys the

importance and feasibility of prevention. Craft clear and compelling

messages that capture public attention, help people understand

cardiovascular health (CVH) and its risks, and support healthy

behavioral changes. Include a social marketing strategy to identify

audiences, develop effective national messages, and determine media
58

Public Health Action Plan to Prevent Heart Disease and Stroke

avenues (e.g., peer-reviewed journals, CDC’s Morbidity and Mortality

Weekly Report, community report cards). Communicate consistent

CVH information and messages to the public, health professionals,

and policy makers.

• Communicate effectively at national and state levels to gain

consensus on messages and create public demand for heart-healthy

options to prevent heart disease and stroke. Work with partners

whose roles include education of key stakeholders. Engage local,

state, and national policy makers, including new stakeholders.

• Collect information and monitor research systematically from

national, state, and local levels to facilitate sharing of knowledge 

and experience in developing educational campaigns as part of this

continuing strategy.

Expected Outcomes

• Communication needs and opportunities are assessed and used to

guide initial development of the long-term public information

strategy anticipated by the plan. 

• Multiple audiences are identified and reached with consistent

CVH information and messages. Exposures are targeted and

repetitive, reach and maintain critical intensity, neutralize

negative messages from special interests, and include expression

in popular humor as a measure of public awareness and interest.

An effective and sustained communication program exists and is

developing appropriate public messages about CVH.

• Public health agencies are promoting continuing development of

appropriate educational materials.

Strategic Leadership, Partnerships, and Organization

• Broaden, strengthen, and sustain public health partnerships as an

essential force for implementing and institutionalizing the plan.

Include public health agencies at all levels (national, state, and local)

and a range of other federal, state, and local agencies (e.g., education,

agriculture, transportation, housing, environment, tribal

organizations); private organizations (e.g., faith-based organizations,

business, labor, media, foundations); and academia (e.g., schools of

public health, departments of preventive and community medicine,

family practice, pediatrics, internal medicine, geriatrics).

• Convene public health agencies at all levels to help develop

implementation plans at state and local levels.

• Continue to encourage state health departments to foster internal

partnerships and collaborations with complementary CVH-related

programs. Allow flexible use of funding to facilitate these important

links.

• Explore and enhance the relationships public health agencies have

with existing CVH policy coalitions and consider the need for new

ones to support the goals of the plan.
59

Implementation

Expected Outcomes

• Partnerships supporting the plan are strengthened or

established, forming an inclusive array of interests

representing all relevant sectors of society.

• State and local public health officials, federal health care

systems, and tribal organizations are convened to help

implement the plan.

• Support for CVH partnership activities is strengthened,

and technical assistance in partnership development and

management is available to state and local public health

agencies and other interested constituencies. Agencies

have expanded the number and diversity of internal and

external CVH collaborations. Available funds are used

effectively to support coordination among programs.

• Existing CVH policy coalitions are strengthened.

Action Steps for the Five Essential Components

The 22 recommendations presented in Section 3 require specific action

steps to guide implementation of the plan. This section outlines action

steps proposed by the Expert Panels and synthesized by the Working

Group. They are presented in the same order as the plan’s five essential

components, which are taking action, strengthening capacity, evaluating

impact, advancing policy, and engaging in regional and global

partnerships. Each group of action steps is followed by expected

outcomes that indicate their potential impact.

Taking Action: Putting Present Knowledge to Work

1. Initiate policy development.

• Establish active collaboration among public health agencies,

clinical preventive service providers, and other partners at all

levels (e.g., purchasers of health care insurance, insurers,

providers of care, health counselors, patient groups) to

implement effective policies and programs that address CVH

promotion and primary and secondary prevention of

cardiovascular disease (CVD).

• Develop and regularly update simulation models to address the

expected health and economic benefits to society from investing

in heart disease and stroke prevention.

• Conduct health impact assessments of national policies and

provide a framework to states to conduct these assessments at the

state level.

Expected Outcomes

• Through technical assistance, consultation, and cooperative

arrangements, partners who deliver CVH promotion and

CVD prevention programs and services at all levels are

receiving active support and incentives. These partners are

developing and implementing more effective policies that

address the full spectrum of intervention approaches
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Public Health Action Plan to Prevent Heart Disease and Stroke

represented in the action framework in Section 2 and reflect

current knowledge of the efficacy and safety of therapeutic

interventions.

• Comprehensive economic modeling of the CVD burden and

the potential impact of preventive policies and programs is

ongoing and supports policy development and

implementation.

• National, state, and local policies are regularly identified and

subject to health impact assessments with specific attention

to their potential effects on CVH and other chronic diseases

of public health concern.

2. Implement best practices.

• Review, revise if appropriate, and rigorously apply criteria for

identifying model programs. In the meantime, implement

current programs and evaluate them against these criteria.

• Identify and disseminate information about model programs that

include all elements of best practices for a population-based

approach to CVH. Test the synergistic effects of composite

programs.

• Generate and test new intervention models by funding new

demonstration projects. Share materials and experiences in order

to continually develop, implement, and evaluate best practices.

Expected Outcomes

• Criteria appropriate for identifying best practices in CVH

promotion and CVD prevention are established and are

being used. Programs considered the most promising are

implemented as expeditiously as possible, with adequate

provision for rigorously evaluating these programs in

accordance with accepted criteria.

• These criteria are applied continually to identify model

CVH/CVD programs, especially those in which multiple

components are coordinated and integrated for maximum

impact. These model programs are being disseminated.

• Innovative demonstration programs are being funded and

rigorously evaluated. The resulting experiences are

communicated rapidly and effectively to facilitate program

replication and dissemination.

3. Address prevention in all settings, life stages, and priority 

populations.

• Develop, implement, and evaluate programs to address

opportunities for CVH promotion and CVD prevention in the

full array of multiple settings (e.g., schools, work sites, health

care settings, other community sites), during all life stages

(gestation; infancy and childhood; adolescence; and early, middle,

and late adulthood), and among all priority populations (as

defined by excessive health burdens or needs).
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Implementation

Expected Outcomes

• A matrix of settings, life stages, and at-risk populations is

developed and disseminated as a tool for identifying policy

and program needs and opportunities. Model policies and

programs to address the demonstrated needs and

opportunities are identified (or developed) and evaluated.

These model policies and programs are disseminated for

implementation at national, state, and local levels.

4. Accept the full scope of public health responsibility.

• Accept accountability of public health agencies, their partners,

and society as a whole for addressing the full spectrum of

opportunities to prevent heart disease and stroke as part of a

comprehensive public health strategy.

• Collaborate with partners in related fields (e.g., nutrition, physical

activity, tobacco control, substance abuse), including those

working to detect and treat risk factors (e.g., hyperlipidemia, 

high blood pressure, smoking, diabetes, obesity). Support

programmatic activities in schools, work sites, health care

settings, and community sites and for priority populations.

• Establish or strengthen collaborations with the Centers for

Medicare & Medicaid Services, the National Committee for

Quality Assurance, and other partners positioned to improve

access to and use of high-quality care for patients with or at risk

for CVD.

Expected Outcomes

• CVH programs are recognized as having responsibility 

and accountability for a comprehensive public health 

strategy that addresses the full array of approaches to CVH

promotion and CVD prevention, to help achieve the four

Healthy People 2010 Heart and Stroke Partnership goals

for preventing heart disease and stroke.

• The needed partnerships and collaborations are in place at

national, state, and local levels to support these activities.

• Partnerships are strengthened or established with the full

array of organizations and agencies committed to effectively

delivering high-quality health services (including preventive

services) as part of a comprehensive public health strategy.

Strengthening Capacity: Transforming the

Organization and Structure of Public Health Agencies

and Partnerships

5. Establish CVH entities within public health agencies.

• Transform public health agencies at all levels so they can

effectively prevent heart disease and stroke.

• Establish or strengthen identifiable CVH units in public health

agencies at all levels. These units should be able to effectively

reach all communities and have all necessary capacities for

preventing heart disease and stroke, including new competencies
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Public Health Action Plan to Prevent Heart Disease and Stroke

in policy and environmental change, population-wide health

promotion and behavioral change for risk factor prevention, and

early detection and control of risk factors.

Expected Outcomes

• Public health agencies throughout the nation are undergoing

the changes needed to expand their roles and meet the new

challenges of preventing heart disease and stroke and other

chronic conditions of public health concern.

• Every state and territorial health agency has an identifiable

unit or locus of responsibility for CVH policy and programs.

These agencies are able to provide support and assistance in

CVH activities to all local health agencies within their

jurisdictions. Through increased and creative collaborations,

public health agencies and their partners are strengthening

their efforts to promote CVH and prevent risk factors and

first CVD events.

6. Reinvent innovative training resources and opportunities.

• Develop training resources, including technical assistance and

materials, to enable states to train staff in state and local health

departments and in partner organizations and agencies, assuring

that they have core competencies and meet performance

standards in CVH. These include changes in organizational

structure, skills in incorporating best practices, and assurance of

partnership effectiveness.

• Establish training in the following set of skills, which are

essential to an effective public health workforce:

- Developing and maintaining partnerships and coalitions.

- Promoting community mobilization for effective action.

- Using health communications effectively.

- Defining and identifying the burden and status of chronic

diseases.

- Preventing and managing risk factors.

- Formulating and executing policy and environmental

approaches to intervention.

- Organizing effective prevention programs.

- Leading diverse community organizations.

- Conducting culturally appropriate interventions targeted to 

priority populations.

- Using sound business practices and strategic planning to

improve public health.

• Consider a variety of options for training personnel. Possibilities

include the following:

- Schools of public health and other professional schools in

health fields.

- Train-the-trainer programs (e.g., in the use of data for health

planning, health promotion, primary and secondary

prevention, program planning, and evaluation, including

population-based interventions).

- A certificate program in CVH.

- CVH training at Prevention Research Centers.
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Implementation

- CVH training programs with standard curricula.

- An expanded year-round program implemented with state and

local health agencies.

- Joint school health/public health courses.

- Regional networks for education and training.

- Internet training programs.

- Continuing education, including training in information

technology.

• Involve numerous partners, such as directors of state chronic

disease programs, voluntary associations, and academic

institutions, in the development of training programs. Sample

activities include the following:

- Allow all state and local health agencies access to training and

development opportunities, information, and materials

regardless of their funding status.

- Provide state and local health personnel and partners access to

professional development opportunities.

- Tailor training programs to the concerns, interests, and needs

of local, state, and national constituents.

- Provide training in chronic disease prevention to personnel

from diverse organizations, including governmental agencies,

public health and education, schools of public health, and

nongovernmental health organizations.

Expected Outcomes

• A comprehensive CVH training function is developed and

coordinated among all interested parties, providing a

resource for state and local health agencies.

• Model curricula and educational programs (e.g., Web-based,

video training packages) are available, including those needed

for developing nontraditional skills. Trainees in target areas

are meeting established goals.

• Training programs for CVH public health personnel are

identified. State and regional networks for CVH training and

education are established to coordinate training needs with

available resources.

• Model education and training programs are being developed

and disseminated to state and local health agencies and

partners.

7. Develop and disseminate standards.

• Develop performance standards and cultural competency

guidelines for public health agencies and partners. Include

maintenance of laboratory capacity and standardizations. Share

these with schools of public health and other educational sources

for health professionals and encourage their adoption in

curricula.

• Identify mechanisms (e.g., technical assistance, dedicated funding

and staff) that enable local and state health departments to meet

standards.
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Public Health Action Plan to Prevent Heart Disease and Stroke

Expected Outcomes

• Performance standards and cultural competency guidelines

for CVH programs are established to help public health

agencies transcend “business as usual” and undertake new

directions in public health practice. Existing mandates are

maintained, and efforts are expanded in early intervention

(i.e., policy and environmental change; behavioral change;

and prevention, detection, and control of risk factors).

Laboratory capacity to address emerging issues is enhanced.

Public health agencies are communicating with schools of

public health and other training programs regarding training

and curriculum requirements for public health personnel

working in CVH and related program areas.

• Public health agencies are receiving technical assistance in

monitoring and improving cultural competency in CVH and

related program areas.

8. Provide technical support.

• Develop and maintain a cadre of educated practitioners and

technical experts who can support intervention needs in CVH

promotion and CVD prevention (i.e., surveillance, trend analysis,

behavior change, community development). Draw these

practitioners and experts from local, state, and national public

health agencies, as well as from voluntary health associations,

academia, foundations, and a variety of industries. Assure the

means for keeping their skills up-to-date (e.g., through meetings

and Web-based curricula).

• Develop materials and tools to promote CVH at local and state

levels.

• Strengthen the internal communications infrastructure of public

health agencies for chronic disease programs as they make other

general infrastructure improvements. 

Expected Outcomes

• A register of recognized experts willing to provide

technical and policy assistance to local, state, and federal

health agencies and other CVH partners is established and

maintained. Use of the registry is supported and

monitored. Training and educational opportunities are

provided, and the registered experts use them. 

• State and local health agency needs for CVH promotional

materials and an educational “toolbox” are being met. 

• A public health communications infrastructure supportive

of CVH (and other chronic disease) activities is in place

and is continually adopting newer, more effective

communications technology.
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Implementation

Evaluating Impact: Monitoring the Burden, Measuring

Progress, and Communicating Urgency

9. Expand and standardize population-wide data sources and

activities.

• Define the characteristics of surveillance and evaluation systems

at minimal, desirable, and optimal levels. Establish an inclusive

framework and set of indicators on the basis of 1) a review of

existing surveillance and evaluation frameworks (e.g., the World

Health Organization’s STEPwise approach, Canada’s recent

development of surveillance priorities); 2) the new requirements

for monitoring policy and environmental change; behavioral

change; biomarkers of CVD risk; and risk factor prevention,

detection, and control; and 3) input from national, state, and

local stakeholders and partner organizations. Include social and

environmental science and policy experts and those who collect,

analyze, or use relevant data.

• Assess the adequacy of current systems on the basis of these

characteristics and the need for dynamic, interactive data access

and use. Include the experts and stakeholders described in the

previous action step.

• Convene public health agencies and partners to determine the

mechanisms and costs needed to fill identified information gaps.

Improve existing data sets and develop new ones as needed, 

with attention to timeliness, sustainability, and standardization.

Address standardization of data systems across states, approaches

to active or passive data collection, ongoing versus episodic 

data collection requirements, availability of data from health 

care insurers, and the paramount importance of incidence data 

for monitoring progress in preventing heart disease and stroke.

Devise common data formats, data management policies 

and practices, and methods for controlling interconnected 

data systems.

• Use data to plan health programs and to communicate consistent

messages about the urgency of preventing heart disease and

stroke. Enhance the incorporation of current CVH data into

broader social indicator reports, using model programs and tested

tools, formats, and templates for communicating and

disseminating this information.

Expected Outcomes

• A framework is reviewed and established for assessing data

requirements for monitoring and evaluating the

comprehensive public health strategy. It includes a

mechanism for periodic updates and reassessments.

• An initial inventory of health indicators (including

applicable leading health indicators from Healthy People

2010) and relevant surveillance and evaluation data sources

is completed and disseminated to appropriate agencies and

organizations for review and comment.
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Public Health Action Plan to Prevent Heart Disease and Stroke

• A group has convened and formulated a detailed

implementation plan for developing the monitoring and

evaluation data systems needed to support the Action Plan.

• As the available data are used to communicate CVH

messages, their strengths and limitations and the current

systems for managing and coordinating these data are

continuously monitored. System development is advanced

and adapted to changing needs.

10. Establish data systems for evaluation of policy and program

interventions.

• Assure that resources are allocated when projects or model

programs are first funded by public health agencies and partners

(e.g., personnel or financial set-asides) to permit adequate

evaluation of outcomes and costs.

• Develop guidelines for public health agencies and partners for

content and format of such evaluations, especially in the new

areas of policy and environmental change; behavioral change;

and risk factor prevention, detection, and control.

Expected Outcomes

• Evaluation is an expected component of every public health

program aimed at preventing heart disease and stroke. No

program proceeds without commitment to support this

component.

• Tools are widely available to support evaluations and the

timely communication of their findings. This allows the most

effective interventions to be replicated quickly. Mechanisms

for disseminating and reviewing evaluation results are

strengthened to assure that the knowledge and experience

gained are applied in future policies and programs.

11. Develop professional staff capacity for monitoring and

evaluation.

• Strengthen the surveillance and program evaluation functions of

public health agencies through enhanced staffing and resources,

especially for monitoring policy and environmental change;

behavioral change; and risk factor prevention, detection, and

control.

• Provide guidance to state and local health agencies and partners

regarding capacity requirements for surveillance and evaluation

activities.

• Establish resources to support program evaluation through

training, consultation, technical assistance, and partnerships to

develop logic models, methodology, data collection, and

reporting.

Expected Outcomes

• Professional staff development for monitoring and

evaluation, especially in the new areas required by the plan, is
67

Implementation

a priority for all public health agencies, which have expanded

their capacity for advancing methods and practices in CVH

program evaluation.

• State and local public health agencies are receiving help in

determining what capacities they need to evaluate their

programs.

• A plan for meeting these requirements is developed and

implemented.

Advancing Policy: Defining the Issues and Finding 

the Needed Solutions 

12. Conduct and facilitate policy and environmental research.

• Focus on preventing atherosclerosis and high blood pressure.

Develop and support a collaborative, detailed, and

interdisciplinary research agenda and a new framework for

policy, environmental, and behavioral research to determine

which interventions (separately or in combination) will best

affect atherosclerosis and high blood pressure and their

contribution to the burden of heart disease and stroke. Support

both targeted and investigator-initiated research. 

• Support research to determine the best ways to implement and

disseminate the most effective policy, environmental, or

behavioral change interventions to prevent heart disease and

stroke. Identify social and cultural factors that promote or inhibit

the sustainability of interventions, especially among populations

affected by disparities in CVD risk (based on race/ethnicity,

income, or place of residence).

• Conduct research to answer questions such as the following:

What are the social and structural factors in various settings and

sectors that affect CVH status more than individual

characteristics? What are specific antecedent factors associated

with specific components of risk (e.g., food intake, physical

activity, adherence to preventive medical care)? What are the

social and cultural determinants of food consumption and

physical activity among children and families? How do these

factors differ by characteristics such as age, income, or race?

What is the public health importance of currently available

genetic and other biomarkers of risk or disease?

• Develop and support a collaborative research agenda that focuses

on health outcomes. Establish effective interventions to

overcome barriers and improve access to and use of high-quality

medical services for patients with or at risk for heart disease and

stroke.

• Support prevention effectiveness research to determine what

combinations of effective interventions (e.g., policy,

environment, individual) at what doses, in what settings (e.g.,

family, school, work site, health care, community), at what life

stages, and among which priority populations are most effective

in preventing, detecting, and controlling CVD risk factors.
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Public Health Action Plan to Prevent Heart Disease and Stroke

• Express strong support for this new research agenda with 

the help of partners positioned to educate key stakeholders, 

to help policy makers recognize its value, and to assure its

implementation and the continual advancement of resulting

policies and programs.

Expected Outcomes

• A research agenda specific to the major focus of preventing

atherosclerosis and high blood pressure is developed and

implemented.

• A detailed research agenda is developed and supported, in

alignment with the Research Themes and Research Priority

Areas of the U.S. Department of Health and Human

Services, with special emphasis on policy and environmental

change related to CVH promotion and CVD prevention. 

• A broad array of relevant research questions is developed and

prioritized to balance the research agenda.

• The research agenda includes studies to identify potential

points of intervention to improve preventive services and

access to and use of these services. This agenda supports the

four goals for preventing heart disease and stroke as

distinguished by the Healthy People 2010 Heart and Stroke

Partnership. These goals are prevention of risk factors,

detection and treatment of risk factors, early detection and

treatment of heart attacks and strokes, and prevention of

recurrent cardiovascular events.

• The research agenda includes studies involving the proposed

matrix of settings, life stages, and priority populations to

determine the most effective interventions within and across

populations (including population-wide approaches and

those aimed a specific subgroups).

• The research agenda is supported by education to assure that

funding is a national priority.

13. Prevent risk factors in youth and beyond.

• Develop and support detailed research agendas that specifically

address prevention in youth and early adulthood. Include studies

that assess the impact of known interventions in preventing risk

factors, atherosclerosis, and high blood pressure. 

• Identify subclinical indicators of CVD and potentially useful

genetic and other biomarkers that can be applied in population

studies and prevention programs. Work with appropriate health

service and industry partners.

• Identify other outstanding concerns in preventing risk factors. 

Expected Outcomes

• A detailed research agenda is developed and supported to design,

implement, and evaluate intervention programs to prevent CVD

risk factors, atherosclerosis, and high blood pressure, beginning

in childhood. 
69

Implementation

• This agenda includes research to develop assessment

methods for subclinical atherosclerosis and to evaluate new

candidate biomarkers in population studies, especially during

adolescence and early adulthood.

• The agenda includes research on underlying determinants of

CVD risk factors. Examples include how fetal development

affects later risk and how nutrition and physical activity affect

obesity, blood lipids, and blood pressure.

14. Conduct and facilitate monitoring and evaluation research.

• Support monitoring and evaluation research to determine how

best to measure policy and environmental change interventions. 

• Incorporate these measures into surveillance systems. 

• Respond to technological developments and regulations that

restrict access to personal health information to assure the

appropriate levels of participation and representation in

surveillance activities. 

Expected Outcomes

• The research agenda includes studies of methods and data

requirements for monitoring and evaluating approaches to

policy and environmental change.

• Surveillance methods that incorporate the relevant data

elements are developed and implemented.

• Methods that assure adequate participation rates and

representative population samples are continuously

investigated, addressing technical and policy concerns about

access to health information.

15. Conduct and support marketing research.

• Support marketing research on how to inform the public

effectively and bring about health behavioral change.

• Support research to demonstrate the economic feasibility of and

appropriate business models for private-sector investment in

prevention (e.g., in food production, manufacturing, or marketing).

Expected Outcomes

• The research agenda includes studies of what influences the

way people respond to population-wide and individual

interventions to prevent heart disease and stroke in the

community at large, in specific cultural communities, and in

specific organizational settings.

• The research agenda includes studies of how consumer

products could be changed to support policies and programs

to reduce risk for heart disease and stroke and still be viable

commercially. This research includes partners in business 

and industry.

16. Strengthen the prevention research workforce.

• Inventory current prevention research training programs and

research opportunities in view of the expanding need for new

health research skills. 
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Public Health Action Plan to Prevent Heart Disease and Stroke

• Emphasize policy and environmental change, health behavioral

change, and risk factor prevention when seeking to identify

training needs and develop responsive plans.

Expected Outcomes

• Workforce requirements for establishing and maintaining

broad-based CVH prevention research programs are

documented. Training programs to meet current and future

requirements are identified and evaluated.

• Gaps in training resources are identified, and detailed plans

for filling them are developed. Resources are identified and

committed to support the needed training in CVH

prevention research.

Engaging in Regional and Global Partnerships:

Multiplying Resources and Capitalizing on 

Shared Experience

17. Provide global leadership, partnerships, and organization.

• Develop and effectively support a global mission and vision of

the United States for CVH.

• Inventory existing and potential partners for global CVH

collaboration, with support from public health agencies and other

partners. Include governmental agencies, nongovernmental

organizations, and foundations (e.g., especially the World Health

Organization, World Heart Federation, and World Bank).

• Evaluate current CVH research and training programs of these

potential partners. Evaluate their interest in receiving information

and technical support from public health agencies to enhance

these programs and in planning joint projects or programs.

Include entities with policy roles that might conflict with CVH

priorities, but who could become effective partners (e.g., the food

and agriculture sector).

Expected Outcomes

• A statement of the U.S. position, role, and interest

regarding global CVH needs and opportunities has 

been published and serves as a point of reference for

partnership development in this area.

• Inventories of existing regional and global CVH

partnerships, potential nontraditional CVH partnerships, and

foundations that support international activities for medical

and public health training are established and maintained.

• An inventory of current agendas for integrated CVH

research, linked with other chronic conditions of public

health importance, is established and maintained. Joint

projects with regional and global partners are planned and

implemented.
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Implementation

18. Establish and support global policies.

• Establish a partnership for global heart disease and stroke that

develops, monitors, and evaluates global CVH strategy.

• Focus on eliminating inequalities in CVH in the United States and

globally, and assess the contribution of this country’s global

strategy in reducing CVH inequalities worldwide. 

• Assess the impact of globalization and trade policies (e.g., related

to tobacco, food and agriculture, and pharmaceuticals) on

national and international trends in CVD and suggest

improvements that could favorably affect CVH.

Expected Outcomes

• A partnership on global CVH strategy is established. Its

implementation plan is guided by a commitment to work

toward eliminating inequalities in CVH.

• A framework to assess progress on equity in national and

global CVH programs is being used.

• Study results are published on the impact of globalization

and trade policies (especially those related to tobacco, food,

and pharmaceuticals) on CVH, as well as the opportunities to

harness these policies to promote CVH nationally and

globally.

19. Develop a global communications strategy.

• Establish relationships between transnational media organizations

and public health agencies and partners to identify models of

collaboration that can help improve media content and coverage

on the need for global CVH promotion and CVD prevention.

• Effectively communicate to health professionals throughout 

the world that they should promote CVH by supporting 

effective policies and by serving as role models for positive

behavioral patterns.

Expected Outcomes

• Consensus development meetings are conducted among

CVH partners and media representatives. Better CVH

messages are communicated through the media.

• Programs are undertaken to reach health professionals

throughout the world with effective messages about their

role in preventing heart disease and stroke.

20. Strengthen global capacity.

• Develop tailored programs to 1) assist and support decision

makers interested in developing and implementing effective

national policies, 2) develop methodology and tools to analyze

the health impact of policy interventions, and 3) analyze the

social and economic costs of heart disease and stroke and the

benefits of preventing them.

• Promote the exchange of information and experiences on policies

that promote CVH.
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Public Health Action Plan to Prevent Heart Disease and Stroke

• Collect existing tools for assessing policy and environmental

change and program effectiveness, synthesize an integrated

assessment tool, apply this tool to identify best practices, and

increase information sharing through technology.

• Develop and implement strategies to assure that changes that

support the Action Plan are institutionalized.

Expected Outcomes

• Development of capacity for heart disease and stroke

prevention is recognized as a long-term requirement for

transforming public health agencies. The proposed training

programs and workshops are available and being used.

International conferences are conducted on the economics of

heart disease and stroke prevention and the links between

economic conditions and CVH.

• Information and experience related to CVH promotion are

effectively disseminated and applied (e.g., the International

Action on Cardiovascular Disease: A Platform for Success,

published by the World Heart Federation and the

International Heart Health Society).

• Tools for analyzing how policies affect the global dimensions

of CVH are developed and disseminated.

• Capacity is developed in a way that assures institutionalization

of change.

21. Strengthen global monitoring and evaluation.

• Inventory existing surveys, programs, and agreements relevant to

global activities in heart disease and stroke prevention and control.

• Identify existing programs that could be expanded and areas

where new collaborations could be created. This activity could be

conducted by organizations such as CDC, the World Health

Organization (WHO), the World Heart Federation, the Pan

American Health Organization, and the InterAmerican Heart

Foundation.

• Support monitoring of heart disease and stroke globally by

working with existing and new partners (especially WHO) to

develop standard data elements. These elements should include

1) mortality, morbidity, and risk factors; 2) nontraditional

elements such as clinical factors (e.g., patterns of diagnosis,

treatment, use); 3) preventive and health promotion programs;

and 4) social, cultural, environmental, and policy factors. Assure

effective dissemination of the resulting information and its

translation into action.

Expected Outcomes

• A Web-based inventory is available and routinely updated.

• New regional and global collaborative activities are

established, and new opportunities are being identified.

• Guidelines for standard data collection and methods for

planning and evaluating heart disease and stroke prevention
73

Implementation

and control programs are developed and being used. Training

programs for technical assistance/collaboration on CVD

projects are receiving needed financial support.

22. Promote and support global research.

• Collaborate in developing a research agenda on CVH policy.

Identify appropriate international partners to design research and

mobilize resources.

Expected Outcomes

• Public health agencies are actively designing and conducting

policy research to identify best practices for preventing heart

disease and stroke in diverse socioeconomic settings, both

nationally and globally.

Steps Toward Implementation

To make the Action Plan a reality, action is needed now. Mobilizing this

action requires detailed plans of implementation; methods for measuring

short-, mid-, and long-term outcomes and impacts; and a process for

oversight and evaluation.

Close collaboration with public health agencies at state, territorial, 

local, and tribal levels is needed. These collaborations can 1) promote

development of specific implementation plans; 2) align partnerships 

to broaden and deepen the base of support for the Action Plan and

strengthen overall capacity; 3) provide comprehensive, timely, and

accurate data to guide policy and decision makers, health professionals,

and the public; and 4) provide appropriate interaction among partners 

in the scientific community to advance prevention effectiveness research

to evaluate policies and programs.

Review, Evaluation, and Adaptation 

to Future Conditions

To assure long-term success, the need to review and evaluate all aspects

of the plan and adapt it to future conditions must be anticipated. For

example, we must consider the projected demographic shift toward an

increasingly older U.S. population and the expected increase in demand

for health services by the population as a whole. These recognized

factors were considered when the recommendations for this plan were

developed. However, other contingencies resulting from unforeseen

social and economic forces may require significant adaptations over the

next two decades.

For this and other reasons, an explicit evaluation process must be designed

and implemented. This evaluation plan must include the following

elements: 1) a comprehensive logic model as the basis for evaluation; 

2) short-, mid-, and long-term evaluation criteria; 3) key indicators and 

data systems; 4) procedures for evaluation, as well as for reporting and
updating key assumptions and projections; and 5) responsibility and

authority for revising the plan. Substantial work remains to be done to

develop detailed implementation plans for each of the Action Plan’s five

essential components and to initiate the needed actions. But great progress

has been made by bringing the plan to completion at this stage.

The Action Plan provides a view of the current reality concerning the

nation’s burden of heart disease and stroke, a vision of a future in which

the epidemic occurrence of these conditions has been controlled, and 

an understanding of the wide range of intervention approaches that can

and must be applied to achieve this vision. The plan also identifies key

issues and proposes recommendations and specific action steps in five

essential areas. This information is presented in the context of a

comprehensive public health strategy to prevent heart disease and stroke

in the United States and contribute to similar efforts with global partners.

By implementing these recommendations, the nation’s public health

agencies—strengthened by a broad array of partnerships reflecting

society’s interest in preventing these diseases—can undergo significant

positive transformation in their roles and accomplish major progress in

preventing heart disease and stroke. Expanding from traditional roles 

to embrace new opportunities for health impact, through policy and

environmental change and health behavioral change, these agencies 

can succeed in making sure that the nation is as healthy as possible.

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Public Health Action Plan to Prevent Heart Disease and Stroke
A-1

APPENDIX A: GLOSSARY

The following brief definitions or explanations apply to technical or common terms used

specifically in the Action Plan. For more detailed definitions, standard reference works should

be consulted.

acute case management: an intervention approach in which individual cardiovascular 

disease (CVD) events (e.g., heart attack, heart failure, stroke) are treated as they occur.

age-adjusted death rate: the number of deaths occurring per 100,000 population per year,

calculated in accordance with a standard age structure to minimize the effect of age differences when rates are compared between populations or over time.

Alzheimer’s disease: the most common cause of dementia, or decline in mental function,

characterized by degeneration of nerve cells and loss of brain substance, most common

among people older than age 65 years.

assessment: the obligation of every public health agency to monitor the health status and

needs of its community regularly and systematically; one of the three core functions of 

public health.

assurance: the guarantee of governments that agreed-upon, high-priority, personal and

community health services will be provided to every member of the community by qualified

organizations; one of the three core functions of public health.

atheroma: a concentrated area of mushy material within the wall of an artery, often 

encrusted or hardened (sclerosed) by deposited calcium, that is the pathological hallmark 

of atherosclerosis.

atherosclerosis: a pathological condition affecting the medium-sized and larger arteries,

especially those that supply the heart (the coronary arteries), the brain (the carotid and 

cerebral arteries), and the lower extremities (the peripheral arteries), as well as the aorta;

underlies the occurrence of heart attacks, many strokes, peripheral arterial disease, and 

dissection or rupture of the aorta.

behavioral change: an intervention approach that uses public information and education to

promote behavioral patterns favorable to health for the population as a whole; also includes

interventions (e.g., counseling) at the group or individual level for the same purpose.

behavioral patterns: habits of living (e.g., diet, physical activity, smoking) that influence

health.

blood cholesterol: the blood concentration of a family of lipid or “fatty” molecular compounds obtained directly from the diet or produced in the body from fatty dietary components; a necessary factor in development of atherosclerosis; total cholesterol concentration is

classified as “high” if it is ≥200 mg/dl. Subtypes of cholesterol differ in their relation to CVD

risk, with high-density lipoprotein (HDL) cholesterol considered “good,” and low-density

(LDL) cholesterol considered “bad.”

Glossary
A-2

Public Health Action Plan to Prevent Heart Disease and Stroke

blood pressure: see high blood pressure.

cardiovascular disease prevention: a set of interventions designed to prevent first and

recurrent CVD events (e.g., heart attack, heart failure, stroke). For CVD, primary prevention

refers to detection and control of risk factors, whereas secondary prevention includes long-term

case management for survivors of CVD events. CVD prevention complements cardiovascular

health (CVH) promotion.

cardiovascular disease(s): may refer to any of the disorders that can affect the circulatory

system, but often means coronary heart disease (CHD), heart failure, and stroke, taken

together.

cardiovascular health: a combination of favorable health habits and conditions that protects

against development of cardiovascular diseases.

cardiovascular health promotion: a set of interventions designed to reduce a population’s

risk for CVD through policy, environmental, and behavioral changes; also supports other

approaches that apply to people who have suffered recognized CVD events (e.g., by facilitating public access to emergency care or by fostering social/environmental and behavioral

changes that reinforce secondary CVD prevention); sometimes identified with primordial CVD

prevention; complements CVD prevention.

carotid arteries: the four main arteries of the head and neck, which supply blood to the

brain and elsewhere in the head.

case fatality rate: the proportion of cases of a disease event ending in death within a defined

interval (e.g., 41% of those experiencing a first heart attack die within 28 days of onset of 

the attack).

cerebral arteries: blood vessels connecting the internal carotid arteries with the brain.

cerebral hemorrhage: rupture of a cerebral blood vessel, characterized by accumulation of

blood at the site of the rupture and loss of blood supply beyond the point of rupture, often

leading to a sudden focal loss of brain function or stroke.

cholesterol: see blood cholesterol.

chronic kidney (renal) disease: long-term impairment of kidney function often leading 

to high blood pressure or kidney failure; may be treated with medication, kidney transplantation, or dialysis.

circulatory system: the network of arteries, veins, capillaries, and lymphatic vessels throughout the body, including the heart, that pumps blood to the lungs and peripheral tissues.

comprehensive public health strategy: an approach to a major health problem in the 

population that identifies and employs the full array of potential public health interventions,

including health promotion and disease prevention.

congestive heart failure: see heart failure.
A-3

core functions of public health: the three main areas of responsibility of official public

health agencies as defined by the Committee for the Study of the Future of Public Health:

assessment, policy development, and assurance.

coronary arteries: the arteries that supply blood to the heart muscle and whose narrowing

or occlusion constitutes coronary heart disease and can precipitate a heart attack.

coronary heart disease: heart disease caused by impaired circulation in one or more 

coronary arteries; often manifests as chest pain (angina pectoris) or heart attack.

CVD prevention: see cardiovascular disease prevention.

CVH promotion: see cardiovascular health promotion.

diabetes (or diabetes mellitus): a metabolic disorder resulting from insufficient production

or utilization of insulin, commonly leading to cardiovascular complications.

diastolic blood pressure: see high blood pressure.

dietary imbalance: a pattern of dietary intake that lacks a desirable combination and overall

intake of foods and nutrients to promote good health (e.g., excessive intake of saturated fat,

salt, total calories).

disparities: see health disparities.

economic development: the long-term process of economic growth in developing countries

or economically disadvantaged areas of developed countries; can influence the health of residents favorably or unfavorably.

emergency care: treatment for people who have experienced a first or recurrent acute CVD

event (e.g., heart attack, heart failure, stroke) designed to increase their probability of survival and to minimize associated damage or disability.

end-of-life care: treatment for late or terminal complications of CVD designed to minimize

suffering and preserve the dignity of those treated.

epidemiology: the study of the causes and prevention of disease in populations or communities, making it the main source of evidence for public health decision making.

evidence-based medicine: the use of agreed-upon standards of evidence in making clinical

decisions for treating individual patients or categories of patients.

evidence-based public health: the use of agreed-upon standards of evidence in making

decisions about public health policies and practices to protect or improve the health of 

populations.

health disparities: differences in the burden and impact of disease among different populations, defined, for example, by sex, race or ethnicity, education or income, disability, place of

residence, or sexual orientation.

Glossary
A-4

Public Health Action Plan to Prevent Heart Disease and Stroke

Healthy People 2010: a document that presents health-related goals and objectives for the

United States to be achieved by the year 2010.

Healthy People 2010 Heart and Stroke Partnership: established to achieve the Healthy

People 2010 goal for preventing heart disease and stroke. The members of the partnership

divided this goal into four separate ones: prevention of risk factors, detection and treatment

of risk factors, early detection and treatment of heart attacks and strokes, and prevention of

recurrent cardiovascular events. This partnership was established by the American Heart

Association/American Stroke Association, Centers for Disease Control and Prevention,

Centers for Medicare & Medicaid Services, National Institutes of Health, and Office of

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

heart attack: an acute event in which the heart muscle is damaged because of a lack of blood

flow from the coronary arteries, typically accompanied by chest pain and other warning signs

but sometimes occurring with no recognized symptoms (i.e., “silent heart attack”).

heart disease: any affliction that impairs the structure or function of the heart (e.g., atherosclerotic and hypertensive diseases, congenital heart disease, rheumatic heart disease, and

cardiomyopathies).

Heart Disease and Stroke Control Program: a program established by the National

Heart Act of 1948 through which the federal government supported state efforts to prevent

and control heart disease and stroke; terminated in 1970.

Heart Disease and Stroke Prevention Program: a CDC program initiated in 1998 that

supports states in their efforts to prevent heart disease and stroke; for more information see

www.cdc.gov/cvh/stateprogram.htm.

heart failure: impairment of the pumping function of the heart as the result of heart disease;

heart failure often causes physical disability and increased risk for other CVD events.

high blood pressure: a condition in which the pressure in the arterial circulation is greater

than desired; associated with increased risk for heart disease, stroke, chronic kidney disease,

and other conditions; blood pressure is considered “high” if systolic pressure (measured at

the peak of contraction of the heart) is ≥140 mm Hg or if diastolic pressure (measured at the

fullest relaxation of the heart) is ≥90 mm Hg.

high-risk approach: an intervention strategy that targets only people with the highest levels

of recognized CVD risk factors for the purpose of reducing their level of risk to that of the

most favorable level in the population; distinct from and complementary to the populationwide approach.

hypertension: see high blood pressure.

hypertensive heart disease: abnormality in the structure and function of the heart caused

by long-standing high blood pressure; often manifests as heart failure.

incidence: the number of new cases of disease occurring in a population of given size within

a specified time interval (e.g., the average annual incidence of stroke for women in

Rochester, Minnesota, during 1985–1989 was approximately 120/100,000 population).

individual approach: see high-risk approach.
A-5

Inter-Society Commission for Heart Disease Resources: a commission established

under U.S. Public Law 89-239 as part of the Regional Medical Programs Service; responsible for producing guidelines defining optimal medical resources and care for the prevention

and treatment of cardiovascular diseases in the United States.

life cycle: the course of human development from conception until death, including gestation; infancy; childhood; adolescence; and early, middle, and late adulthood; important for

targeting health promotion and disease prevention efforts to the distinct needs of people in

each phase.

long-term case management: an intervention approach that targets survivors of CVD

events; designed to reduce disability and the risk for recurrent events.

modifiable characteristics: factors related to CVD risk that are amenable to change (e.g.,

diet, physical activity, smoking), in contrast to those that are intrinsic to the individual (e.g.,

age, sex, race, genetic traits).

mortality: rate of death expressed as the number of deaths occurring in a population of

given size within a specified time interval (e.g., 265 annual deaths from heart disease per

100,000 U.S. Hispanic women, 1991–1995).

obesity: usually defined in terms of body mass index (BMI), which is calculated as body

weight in kilograms (1 kg = 2.2 lbs) divided by height in meters (1 m = 39.37 in) squared;

adults with a BMI of ≥30.0 kg/m2 are considered “obese,” and those with a BMI of 25–29.9

kg/m2 are considered “overweight.” In children, overweight is defined as BMI greater than

the 95th percentile value for the same age and sex group.

overt disease: for CVD, disease with signs or symptoms that are recognizable by the 

affected individual or health care provider.

overweight: see obesity.

peripheral arteries: arteries in the upper and lower extremities (arms and legs).

peripheral arterial disease: mainly atherosclerosis of the extremities; especially important

in the lower extremities; also called peripheral vascular disease.

physical inactivity: lack of habitual activity sufficient to maintain good health, resulting in

an unfavorable balance between energy intake and expenditure and fostering the development of overweight or obesity and other risk factors for heart disease and stroke.

plaque: the characteristic manifestation of atherosclerosis located in the arterial wall and

extending into the lumen or channel of the artery; plaque can disturb or restrict blood flow

and is prone to fissure or rupture, thus precipitating formation of blood clots that can cause

an acute coronary event.

policy and environmental change: an intervention approach to reducing the burden of

chronic diseases that focuses on enacting effective policies (e.g., laws, regulations, formal and

informal rules) or promoting environmental change (e.g., changes to economic, social, or

physical environments).

Glossary
A-6

Public Health Action Plan to Prevent Heart Disease and Stroke

population-based observations: health data that pertain to a defined, usually large, population (e.g., vital statistics, surveillance, results of population surveys).

population-wide approach: an intervention strategy that targets the population as a whole

without regard to the risk levels of various subgroups; distinguished from and complementary

to the high-risk approach.

prevalence: the frequency of a particular condition within a defined population at a 

designated time (e.g., 12.6 million Americans living with heart disease in 1999 or 36.4% of

African American men aged 20–74 years found to have hypertension in a survey conducted in

1988–1994).

prevention research: aims to prevent disease and promote health by developing and 

disseminating strategies applicable to public health programs and policies.

preventive dose: the intensity and duration of appropriate public health interventions needed to achieve their goals; similar to the dose and duration of medical treatment sufficient to

control or cure an illness.

primary CVD prevention: a set of interventions, including the detection and control of risk

factors, designed to prevent the first occurrence of heart attack, heart failure, or stroke

among people with identifiable risk factors; this approach corresponds most directly to the

objectives of goal 2 for preventing heart disease and stroke of the Healthy People 2010 Heart

and Stroke Partnership.

primordial CVD prevention: a set of interventions targeting people without risk factors 

or CVD (including the maintenance or restoration of favorable social and environmental

conditions and the promotion of healthy behavioral patterns) to prevent development of risk

factors; this approach corresponds most directly to the objectives of goal 1 for preventing

heart disease and stroke of the Healthy People 2010 Heart and Stroke Partnership. Although

this approach was originally intended to apply to whole societies to prevent the first appearance of epidemic levels of risk factors, the term is commonly used in the sense of “early intervention” to prevent risk factors in individuals even in populations where risk factors are

already epidemic; in the Action Plan, “CVH promotion” is used as equivalent 

to “primordial prevention.”

priority populations: groups at especially high risk for CVD (e.g., those identified by sex,

race or ethnicity, education, income, disability, place of residence, or sexual orientation).

randomized controlled trial: an experimental study of an intervention, most often a medical treatment, in which study participants are randomly assigned to treatment or comparison

groups; much less often, communities rather than individuals are the units used to form

treatment and comparison groups.

rehabilitation: an intervention approach designed to limit disability among survivors of

CVD events and reduce their risk for subsequent events.

risk behavior: a behavioral pattern associated with increased frequency of specified health

problems; for example, high salt intake, smoking, and binge drinking are all associated 

with CVD.
A-7

risk factor: an individual characteristic associated with increased frequency of specified

health problems; for example, high LDL cholesterol, high blood pressure, and diabetes are

all associated with CVD.

risk factor detection and control: an intervention approach that targets people with identifiable risk factors; includes both screening or other methods of detection and long-term 

disease management through changes in lifestyle, behavior, medication (when necessary).

secondary CVD prevention: a set of interventions aimed at survivors of acute CVD events

(e.g., heart attack, heart failure, stroke) or others with known CVD in which long-term case

management is used to reduce disability and risk for subsequent CVD events; this approach

corresponds most directly to the objectives of goal 4 for preventing heart disease and stroke

of the Healthy People 2010 Heart and Stroke Partnership.

stroke: sudden interruption of blood supply to the brain caused by an obstruction or the

rupture of a blood vessel.

subclinical disease: presence of one or more forms of CVD (e.g., atherosclerosis, coronary

heart disease) detectable only by special examination (e.g., ankle-arm blood pressure ratio,

carotid artery ultrasound examination, electrocardiogram) and not recognizable from signs

or symptoms expressed by the affected person.

survival: remaining alive for a specified period (e.g., beyond the 28-day definition of case

fatality) after a CVD event.

tertiary CVD prevention: an intervention approach included in secondary prevention, as 

it is used in the Action Plan; sometimes distinguished as reducing disability among survivors

of CVD events through rehabilitation; this approach combined with secondary prevention

corresponds most directly to the objectives of goal 4 for preventing heart disease and stroke

of the Healthy People 2010 Heart and Stroke Partnership.

vascular cognitive impairment: loss of mental function that occurs in association with a

stroke, sometimes followed by dementia.

Glossary
A-8
B-1

Goals and Objectives

APPENDIX B: NATIONAL GOALS AND OBJECTIVES 

The matrix in this appendix matches the Healthy People 2010 objectives most pertinent to heart disease

and stroke with the four goals identified by the Healthy People 2010 Heart and Stroke Partnership.

These goals are based on Chapter 12, Heart Disease and Stroke, of Healthy People 2010. In addition to the

16 objectives listed in this chapter, 48 objectives in other chapters could, if addressed, help to achieve the

four goals.

Objectives from Chapter 12, Heart Disease and Stroke

12-1 Coronary heart disease (CHD) deaths X X X X

12-2 Knowledge of symptoms of heart attack and importance of calling 911 (D*) X

12-3 Artery-opening therapy (D) X

12-4 Bystander response to cardiac arrest (D) X

12-5 Out-of-hospital emergency care (D) X

12-6 Heart failure hospitalizations X

12-7 Stroke deaths X X X X

12-8 Knowledge of early warning symptoms of stroke (D) X X 

12-9 High blood pressure X X X

12-10 High blood pressure control X X 

12-11 Action to help control blood pressure X X

12-12 Blood pressure monitoring X X 

12-13 Mean total blood cholesterol levels X X X

12-14 High blood cholesterol levels X X X 

12-15 Blood cholesterol screening X X X 

12-16 LDL-cholesterol level in CHD patients (D) X

Objectives from Chapter 1, Access to Quality Health Services

1-3 Counseling about health behaviors X X X X

1-7 Core competencies in health provider training (D) X X X X

1-10 Delay or difficulty in getting emergency care (D) X

1-11 Rapid prehospital emergency care (D) X

Objectives from Chapter 4, Chronic Kidney Disease

4-2 Cardiovascular (CVD) deaths in persons with chronic kidney failure X X

Objectives from Chapter 5, Diabetes

5-2 New cases of diabetes X

5-4 Prevent diabetes X

5-7 Cardiovascular deaths in persons with diabetes X X X

Objectives from Chapter 7, Educational and Community-Based Programs

7-2 School health education X X X X

7-5 Worksite health promotion programs X X X X

7-8 Satisfaction with patient education (D) X X X X

7-10 Community health promotion programs (D) X X X X

7-11 Culturally appropriate community health promotion X X X X

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

Goal 1

Prevention of

risk factors

Goal 4

Prevention 

of recurrent 

cardiovascular

events

Goal 3 

Early detection

and treatment of

heart attacks

and strokes

Goal 2 

Detection and

treatment 

of risk factors
Public Health Action Plan to Prevent Heart Disease and Stroke

Objectives from Chapter 11, Health Communication

11-1 Households with Internet access X X X X

11-2 Health literacy (D) X

11-4 Quality of Internet health information sources X X X X

11-6 Satisfaction with providers' communication skills (D) X X X X

Objectives from Chapter 19, Nutrition and Overweight

19-1 Healthy weight in adults X X

19-2 Obesity in adults X X X

19-3 Overweight or obesity in children and adolescents X X

19-5 Fruit intake X

19-6 Vegetable intake X

19-8 Saturated fat intake X

19-9 Total fat intake X

19-11 Calcium intake X

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

Objectives from Chapter 22, Physical Activity and Fitness

22-1 No leisure-time physical activity X X

22-2 Moderate physical activity X X

22-3 Vigorous physical activity X X

22-6 Moderate physical activity in adolescents X

22-7 Vigorous physical activity in adolescents X

22-11 Television viewing X

22-13 Worksite physical activity and fitness X X 

22-14 Community walking X X

22-15 Community bicycling X X

Objectives from Chapter 23, Public Health Infrastructure

23-1 Public health employee access to Internet (D) X X X X

23-3 Use of geocoding in health data systems X X X X

23-10 Continuing education and training by public health agencies (D) X X X X

23-16 Data on public health expenditures (D) X X X X

Objectives from Chapter 27, Tobacco Use

27-1 Adult tobacco use X X

27-2 Adolescent tobacco use X

27-3 Initiation of tobacco use (D) X X X X

27-4 Age at first use of tobacco X

27-5 Smoking cessation by adults X X X

27-10 Exposure to environmental tobacco smoke X

27-16 Tobacco advertising and promotion targeting adolescents and young adults (D) X X X X

27-17 Adolescent disapproval of smoking X X X X

* Developmental (D) objectives provide a vision for a desired outcome or health status. All other objectives are considered measurable objectives, which provide direction for action.

Source: US Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health and Objectives for Improving Health.

2nd ed. 2 vols. Washington, DC: US Government Printing Office; November 2000.

B-2

Goal 1

Prevention of

risk factors

Goal 4

Prevention 

of recurrent 

cardiovascular

events

Goal 3 

Early detection

and treatment of

heart attacks

and strokes

Goal 2 

Detection and

treatment 

of risk factors
C-1

APPENDIX C: PROFILES OF THE CO-LEAD AGENCIES

FOR THE HEALTHY PEOPLE 2010 HEART DISEASE

AND STROKE FOCUS AREA

The Centers for Disease Control and Prevention and the National Institutes of Health are

co-lead federal agencies responsible for undertaking activities to move the nation toward

achieving the Healthy People 2010 goal for preventing heart disease and stroke and for reporting progress on the objectives for this focus area over the next decade. The following profiles

highlight the work of these agencies in heart disease and stroke prevention. An exhaustive

account of these and related activities is beyond the scope of this document, but further 

details and updates can be obtained from each agency’s Web site.

Centers for Disease Control and Prevention (CDC)

www.cdc.gov

CDC is recognized as the lead federal agency for protecting the health and safety of people

at home and abroad, providing credible information to enhance health decisions, and promoting health through strong partnerships. CDC serves as the national focus for developing

and applying disease prevention and control, environmental health, and health promotion

and education activities designed to improve the health of the people of the United States.

National Center for Chronic Disease Prevention 

and Health Promotion

CDC’s National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) is at the forefront of the nation’s efforts to prevent and control chronic diseases. 

The center conducts studies to better understand the causes of chronic diseases, supports

programs to promote healthy behaviors, and monitors the health of the nation through surveys. Critical to the success of these efforts are partnerships with state health and education

agencies, voluntary associations, private organizations, and other federal agencies. Together,

the center and its partners are working to create a healthier nation.

Chronic diseases—such as heart disease, cancer, and diabetes—are the leading causes of

death and disability in the United States. These diseases account for 7 of every 10 deaths 

and affect the quality of life of 90 million Americans. Although chronic diseases are among

the most common and costly health problems, they are also among the most preventable.

Adopting healthy behaviors such as eating nutritious foods, being physically active, and avoiding tobacco use can prevent or control the devastating effects of these diseases.

In the area of cardiovascular health (CVH), the center established in October 2000 the

Cardiovascular Health Coordinating Committee, whose primary responsibility is communication and coordination among the several NCCDPHP divisions most actively engaged in

CVH: the Divisions of Adult and Community Health, Adolescent and School Health,

Diabetes Translation, and Nutrition and Physical Activity and the Office on Smoking and

Health. Highlights of relevant programs in these divisions are outlined in the following 

sections.

Profiles
State Heart Disease and Stroke Prevention Program

In 1998, Congress funded CDC to launch a nationwide effort to help states develop the

capacity, commitment, and resources necessary for a comprehensive program to prevent

death and disability from heart disease and stroke and to improve the cardiovascular health 

of all Americans. CDC funds states for basic implementation or at a lower capacity-building

level. Program priorities include the following:

• Prevent and control high blood pressure and high blood cholesterol levels.

• Improve quality of care to prevent and manage high blood pressure, stroke, 

and heart disease.

• Get people to appropriate emergency care quickly.

• Eliminate health disparities (e.g., based on geography, gender, race or ethnicity, 

or income).

• Promote heart health in a variety of settings (health care facilities, work sites, schools,

and communities) through education and policy and environmental changes.

CDC works with partners both inside and beyond the health sector to address the Healthy

People 2010 objectives for preventing heart disease and stroke. Partners include other federal

agencies (e.g., Centers for Medicare & Medicaid Services, National Institutes of Health),

national health organizations (e.g., American Heart Association/American Stroke Association,

National Stroke Association), and professional groups (e.g., American College of Cardiology).

Surveillance of Heart Disease and Stroke

As part of its national leadership, CDC supports and conducts the surveillance necessary to

build a strong foundation of science for preventing heart disease and stroke. The resulting

data can be used to guide state and local public health programs. For example, the recently

released Atlas of Stroke Mortality: Racial, Ethnic and Geographic Disparities in the United States

presents detailed national and state maps with county-level data of local disparities in heart

disease and stroke death rates for the nation’s five largest racial and ethnic groups. This publication is the third in a series on cardiovascular health, following Women and Heart Disease:

An Atlas of Racial and Ethnic Disparities in Mortality and Men and Heart Disease: An Atlas of

Racial and Ethnic Disparities in Mortality.

In 2001, CDC established the Paul Coverdell National Acute Stroke Registry to design and

test prototypes to measure the delivery of acute care for stroke. Eight sites are developing

prototypes for statewide, hospital-based registries that are expected to improve hospitals’

delivery of the critical emergency care that can prevent permanent disabilities from stroke.

Prevention Research Centers (PRCs) Program 

In 1984, Congress authorized the secretary of the U.S. Department of Health and Human

Services (HHS) to create a network of academic health centers to conduct applied public health

research. The first three centers were funded two years later. CDC was selected to administer

the PRC network and to provide leadership, technical assistance, and oversight. 

Individual behaviors and environmental factors cause many chronic diseases as well as

injuries and some infections. Prevention researchers develop strategies to help people reduce

risk factors in their lives and their communities. By involving community members, academic

researchers, and public health agencies, the PRCs find innovative ways to promote health

and prevent disease. Together, these partners design, test, and disseminate strategies—often

as new policies or recommended public health practices. 

C-2

Public Health Action Plan to Prevent Heart Disease and Stroke
PRCs are associated with schools of public health, medicine, or osteopathy and are located

throughout the country. Each center conducts at least one core research project with an

underserved population that has a disproportionately large burden of disease and disability.

The centers also work with partners on special interest projects defined by CDC and other

HHS agencies. Expertise gained from this work makes the centers competitive for research

funding from other sources.

PRCs are a national resource for developing effective prevention strategies and applying

those strategies at the community level. Each center encourages interaction among faculty

from different disciplines (e.g., education, social work, psychology, nursing), whose expertise

is essential to solving complex health and psychosocial problems. 

Behavioral Risk Factor Surveillance System (BRFSS)

The BRFSS is a state-based system of health surveys established in 1984 by CDC.

Information on health risk behaviors, clinical preventive health practices, and health care

access, primarily related to chronic disease and injury, is obtained from a representative 

sample of adults in each state. For most states, the BRFSS is the only source for this type of

information. Currently, data are collected monthly in all 50 states, the District of Columbia,

and Puerto Rico; annual point-in-time surveys are conducted in the Virgin Islands and

Guam. Interviews are completed each year with more than 200,000 adults, making the

BRFSS the largest telephone health survey in the world. In addition to being a unique source

of risk behavior data for states, the BRFSS is also useful for measuring progress toward

Healthy People 2010 national objectives. Seven of the 10 leading health indicators for 2010

can be assessed through the BRFSS.

As the demand for data has increased, so has the number of requests to add questions to the

survey. Currently, almost every division in NCCDPHP and other CDC Centers, Institutes,

and Offices has questions on the BRFSS. Interest in the BRFSS has also grown outside CDC.

Other federal agencies, such as the Health Resources and Services Administration (HRSA),

the Administration on Aging (AoA), and the Department of Veterans Affairs (VA), have added

questions. Requests for technical assistance also have come from other countries that are

eager to develop similar surveillance systems, notably China, Australia, Canada, and Russia.

The World Health Organization (WHO) is developing a model surveillance system based on

the BRFSS for export to any country.

As the BRFSS data have become more useful, the demand for more local data (i.e., district-,

county-, or city-level data) has increased. This demand led to the Selected Cities Project, in

which data from the 1997–2000 BRFSS were used to calculate estimates for selected urban

areas in the United States with at least 300 respondents. This project has yielded estimates

for nearly 200 metropolitan areas for the 1997–1999 combined data. The 2000 data provided

estimates for 100 metropolitan areas. Preliminary results showed that the prevalence of certain behaviors varied across cities, not unlike the differences found across states. Variation in

prevalence was also observed when cities were compared with their surrounding metropolitan areas and with the rest of the state. Plans are to add the new weights soon to the BRFSS

public-use data file, allowing researchers outside CDC to analyze data for metropolitan

areas. This new use of BRFSS data fills a critical public health need for local surveillance

data to support targeted program implementation and evaluation, and these data should help

cities to better plan and direct their prevention efforts.

C-3

Profiles
Racial and Ethnic Approaches to Community Health (REACH) 2010

REACH 2010 is the cornerstone of CDC’s efforts to eliminate racial and ethnic disparities in

health, one of the two overarching goals of Healthy People 2010. Launched in 1999, REACH

2010 is designed to eliminate disparities in the following six priority areas: cardiovascular 

disease, immunizations, breast and cervical cancer screening and management, diabetes, 

HIV infections/AIDS, and infant mortality. The racial and ethnic groups targeted are African

Americans, American Indians, Alaska Natives, Asian Americans, Hispanic Americans, and

Pacific Islanders.

REACH 2010 is a two-phase, 5-year demonstration project that supports community coalitions in designing, implementing, and evaluating community-driven strategies to eliminate

health disparities. Each coalition comprises a community-based organization and three other

organizations, of which at least one is either a local or state health department or a university

or research group.

During a 12-month planning phase, REACH 2010 grantees use local data to develop a 

community action plan that addresses one or more of the six priority areas and targets one 

or more racial and ethnic minority groups. During the 4-year implementation phase, community coalitions carry out activities outlined in their community action plans and evaluate

program activities. 

Evaluating REACH 2010 programs is critically important in determining their effectiveness

in reducing health disparities. Working with its grantees and partners, CDC has developed

an evaluation model to guide the collection of national data. This model evaluates programs

on their effectiveness in the following areas: building community capacity, developing targeted actions, improving health systems and agents of change, decreasing risk behaviors and

increasing protective behaviors, and reducing disparity-related illness and death.

REACH 2010 projects are empowering community members to transform their neighborhoods into places that encourage people to adopt and sustain healthy behaviors and to avoid

risk behaviors. Through close collaboration with community members and creative partnerships with public and private organizations, CDC will continue to spearhead the country’s

efforts to eliminate health disparities by carrying out the lessons learned from the REACH

2010 projects in communities across the country.

School Health

Every school day, 53 million young people attend nearly 117,000 schools across our nation.

Because of the size and accessibility of this population, school health programs are one of the

most efficient means to reach young people and prevent/address behaviors that lead to serious health problems. CDC began an initiative in 1992 to support coordinated school health

programs in the states that promote healthy behavior, such as eating nutritious foods, being

physically active, and avoiding tobacco use. These programs aim to reduce young people’s

risk for developing chronic diseases later in life. 

CDC funding and assistance enable state departments of education and health to work

together efficiently, respond to changing health priorities, and use limited resources effectively to meet a wide range of health needs among the state’s school-aged population.

CDC has also established a national framework to support these programs. More than 40

national, nongovernmental education and health organizations work with CDC to develop

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model policies, guidelines, and training to help states establish high-quality school health

programs. Through this national framework and in collaboration with health and education

partners, CDC helps funded states provide young people with information and skills needed

to choose healthy behaviors. The eight components of a coordinated school health program

include health education, nutrition services, physical education, health services, health promotion for staff, counseling and psychological services, a healthy school environment, and

parent and community involvement. 

Since 1991, the Youth Risk Behavior Surveillance System (YRBSS) has provided data on

health-related behaviors, such as tobacco use, physical activity levels, and fruit and vegetable

intake, among young people. Developed by CDC with federal, state, and private-sector partners, this voluntary system includes a national survey of high school students plus surveys

conducted by state and local education and health agencies. The YRBSS provides vital information to improve health programs.

Because national efforts for coordinated school health programs have been hampered by a

lack of information on school health policies and programs, CDC has conducted the School

Health Policies and Programs Study (SHPPS). SHPPS provides valuable answers to questions about programs in areas such as health education, physical education, and school food

service at state, district, school, and classroom levels.

To help schools plan and implement effective health policies and programs, CDC has 

published guidelines for school health programs. These guidelines are based on a synthesis

of theory, research, and best practices and were developed jointly by scientific experts, 

school practitioners, and appropriate national organizations. To help schools implement

these guidelines, CDC has developed several tools, including The School Health Index: A 

Self-Assessment and Planning Guide, and supported development of other tools, such as Fit,

Healthy, and Ready to Learn: A School Health Policy Guide, which was produced by the National

Association of State Boards of Education.

Diabetes Prevention and Control

CDC provides leadership and funding to diabetes prevention and control programs nationwide. CDC also works with many partners to provide data for sound public health decisions,

inform the public about diabetes, and ensure good care and education for Americans with

diabetes. CDC provides support to states, territories, and the District of Columbia for core

diabetes control programs and more substantial support to some states for comprehensive

programs.

Timely data and public health research are essential for understanding how diabetes affects

different populations and for improving quality of care. CDC analyzes information from several national data sources, including the BRFSS, and explores ways to collect better diabetes

data on groups most at risk. To translate scientific data into higher-quality care, CDC works

with many research partners, including the National Diabetes Laboratory. CDC also works

with managed care organizations and community health centers to

• Assess how accepted standards of diabetes care are applied by health care providers and

in clinical care settings. 

• Explore variations in the quality of diabetes care provided. 

• Develop and test strategies to move existing care practices closer to optimal standards.

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Educating others about diabetes is a priority at CDC. The National Diabetes Education

Program (NDEP) has a network of more than 200 public and private partners that provide

education to improve treatment, promote early detection, and prevent the onset of diabetes.

The NDEP is sponsored by CDC and the National Institutes of Health, and many NDEP

products are available on the Internet (www.ndep.nih.gov).

CDC also develops new resources for health professionals, people with diabetes, and 

communities, including Diabetes Today, a train-the-trainer program that allows health 

professionals and community leaders to develop a community plan for preventing the 

complications of diabetes. 

Nutrition and Physical Activity

Beginning in fiscal year 2001, Congress appropriated funds that allow CDC to help states

plan and initiate nutrition and physical activity programs to help prevent and control obesity

and other chronic diseases. With further funding, CDC will help to expand these programs

and will support research to increase physical activity and improve nutrition in states and

communities.

In 1995, CDC's landmark publication, Physical Activity and Health: A Report of the Surgeon

General, brought together the results of decades of research on physical activity and health.

Among its findings were that physical activity need not be strenuous to produce benefits and

that inactive people can improve their health by becoming moderately active on a regular

basis. The implications of these findings compel CDC to ensure that physical activity

receives the attention and commitment given to other important public health issues. CDC

research is strengthening knowledge of the role of physical activity and nutrition in health.

To further address these issues, CDC has established a nationwide framework for coordinated health education programs in schools. Inactivity and unhealthy diets are among the risk

behaviors that these programs address. CDC has also collaborated with national health and

education organizations to develop guidelines and materials to help schools promote healthy

eating and physical activity. 

Since the 1950s, the infrastructure to support walking and bicycling in the United States has

been neglected. Trips made by walking or cycling have declined by more than 40% since

1977. CDC's Active Community Environments Initiative (ACES) works with partners to 

promote the development of accessible recreation facilities, including more opportunities 

for walking and cycling.

The National 5-A-Day program, which is a comprehensive, coordinated national nutrition

program designed to increase consumption of fruits and vegetables to five or more servings

each day by the year 2010, is implementing recommendations from a recent comprehensive

review. The most significant recommendations were to strengthen and expand the program’s

organizational structure to include new partners and to support research, surveillance, and

applied public health programs to increase vegetable and fruit consumption. The National

Cancer Institute, the U.S. Department of Agriculture, and CDC are currently defining the

roles and responsibilities of each partner in the new model.

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Well-Integrated Screening and Evaluation for Women 

Across the Nation (WISEWOMAN)

WISEWOMAN is a CDC-funded program that helps women in need gain access to screening and lifestyle interventions that can reduce their risk for heart disease and other chronic

diseases. Eligible women are 40–64 years old and have little or no health insurance. Many

are from racial and ethnic minority populations. WISEWOMAN is the result of 1993 

legislation that expanded the services offered within the National Breast and Cervical 

Cancer Early Detection Program (NBCCEDP). Through the NBCCEDP, CDC helps

states, territories, and tribal organizations provide potentially life-saving screening for 

breast and cervical cancers to low-income and uninsured women. Through WISEWOMAN

projects and community partnerships, women participating in the NBCCEDP are offered

screenings and interventions for obesity, sedentary behavior, poor dietary habits, high blood

pressure, high cholesterol, and smoking. Some projects also screen women for diabetes or

osteoporosis, because these conditions also are affected by nutrition and physical activity.

WISEWOMAN staff also provide referrals when treatment is needed.

Smoking and Health

CDC provides national leadership for a comprehensive, broad-based approach to reducing

tobacco use. A variety of federal, state, and local government agencies; professional and voluntary organizations; and academic institutions have joined together to advance this comprehensive approach, which involves

• Preventing young people from starting to smoke. 

• Eliminating exposure to secondhand smoke. 

• Promoting quitting. 

• Identifying and eliminating disparities in tobacco use among different population groups.

Essential elements of this approach include state- and community-based interventions, countermarketing, policy development, surveillance, and evaluation. These activities target

groups (e.g., young people, racial and ethnic minority groups, people with low incomes or

low levels of education, and women) at highest risk for tobacco-related health problems. 

CDC supports programs to prevent and control tobacco use in all 50 states, 7 territories, 

7 tribal organizations, and the District of Columbia. Supplemental funding is provided to

some programs to identify tobacco-related disparities and develop strategic plans for reducing them. CDC also funds national networks to promote prevention and control efforts

among organizations that serve priority populations; provides grants to states for coordinated school health programs that include components for preventing tobacco use; and provides

technical assistance to help states plan, establish, and evaluate tobacco control programs. 

CDC recently released several publications to help states manage their tobacco control 

programs, including Best Practices for Comprehensive Tobacco Control Programs, Reducing Tobacco

Use: A Report of the Surgeon General, and Investment in Tobacco Control: State Highlights 2002.

Guidance is also offered through CDC’s Guidelines for School Health Programs to Prevent

Tobacco Use and Addiction and the Guide to Community Preventive Services: Tobacco Use

Prevention and Control.

To strengthen the scientific foundation for preventing and controlling tobacco use, CDC

examines trends, health effects, and economic costs. Examples include the U.S. Surgeon

General’s reports on the health consequences of tobacco use, published since 1964; CDC’s

air toxicants laboratory, which is developing and applying laboratory technology to prevent

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death and disease from tobacco use and exposure to secondhand smoke; and the school-based

Global Youth Tobacco Survey (GYTS), developed by WHO and CDC to track tobacco use

among young people in over 140 countries using a common methodology and a core questionnaire. In addition, CDC’s National Tobacco Information Online System (NATIONS)

provides country-level data on tobacco use and its health effects, laws and regulations, and

economics, and CDC’s State Tobacco Activities Tracking and Evaluation (STATE) System

provides similar state-level data.

CDC researches, develops, and distributes tobacco and health information nationwide. It also

distributes hundreds of thousands of publications and video products each year and provides

information and databases through its Web site. Through its Media Campaign Resource

Center and its interactive database, CDC provides high-quality counteradvertising materials

and technical assistance to help state and local programs conduct media campaigns to prevent

tobacco use.

CDC’s health communication messages continue to focus on reducing smoking among

young people while increasing the emphasis on helping people to quit, reducing exposure to

secondhand smoke, and reducing disparities. In partnership with other federal, state, and

local agencies, CDC communicates key tobacco messages through the media, schools, and

communities. 

As the only WHO Collaborating Center on Global Tobacco Prevention and Control in

North America, CDC implements international studies, conducts epidemiologic research,

and provides international assistance on reducing tobacco use. 

National Center for Environmental Health (NCEH)

The National Center for Environmental Health (NCEH) is dedicated to serving the global

community by providing leadership, through science and service, to promote health and quality

of life by preventing and controlling disease, disability, and death resulting from interactions

between people and their environment. NCEH activities most directly related to CVH include

laboratory programs, such as the Lipid Standardization Program, and the Public Health

Genomics Program.

Lipid Standardization Program (LSP)

CDC developed and maintains reference methods and serum-based reference materials for

total cholesterol (TC), high-density lipoprotein cholesterol (HDLC), low-density lipoprotein

cholesterol (LDLC), and triglycerides (TG). In 1957, CDC began efforts to standardize cholesterol measurement and became the first to develop a standardization program designed to

improve and normalize clinical test results. In 1961, CDC, in collaboration with the National

Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health, developed and continues to maintain a three-phase LSP to provide an accuracy-based standard for measuring

TC, HDLC, LDLC, and TG in national and international lipid laboratories.

The LSP’s standardization efforts extend to a variety of clinical trials and population studies,

including the

• Multiple Risk Factor Intervention Trial (MRFIT).

• Framingham Heart Study.

• Lipid Research Clinics-Coronary Primary Prevention Trial (LRC-CPPT).

• Women’s Health Initiative.

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• West of Scotland Coronary Prevention Study (WOSCOPS).

• Air Force/Texas Coronary Atherosclerosis Prevention Study (AFCAPS/TexCAPS).

• National Health and Nutrition Examination Surveys (NHANES).

Each year, about 100 domestic and international laboratories participate in the LSP and

receive about 16,000 individual vials of fresh-frozen serum reference samples to assess 

laboratory performance.

As a result of frequent and responsive assessments of laboratory performance, CDC ensures

the accuracy and uniformity of population-study and clinical-trial data, regardless of the testing method or the analytical system used. These clinical investigations provide cardiovascular

medicine with a reliable scientific database for evaluating risk factors associated with CVD.

This database provides the basis for the National Cholesterol Education Program’s (NCEP’s)

intervention strategy to reduce morbidity and mortality from CVD. CDC’s Lipid Reference

Laboratory is the cornerstone of the National Reference System for Cholesterol to which all

cholesterol measurements are traceable, thus ensuring reliable testing results in the nation’s

clinical laboratories.

Cholesterol Reference Method Laboratory Network (CRMLN)

CDC established the CRMLN to help manufacturers calibrate diagnostic products used 

for lipid and lipoprotein testing. CDC researchers believe that working with manufacturers

is the most effective way to improve and standardize these measurements within clinical 

laboratories and to achieve the NCEP’s goals. CRMLN laboratories use CDC reference

methods or designated comparison methods (DCMs) that are closely linked to CDC reference

methods. Manufacturer certification is based on the analysis of fresh samples from patients by

both the diagnostic test method and the CRMLN laboratory. Manufacturers who successfully

complete the comparison are issued a Certificate of Traceability, which is valid for two years.

Manufacturers are encouraged to repeat the certification on a regular basis. This approach

ensures that diagnostic products are properly calibrated and traceable to the accuracy base

maintained by CDC.

C-Reactive Protein Standardization Program

CDC convened a forum for manufacturers of high sensitive C-reactive protein (hs-CRP)

assays to identify measurement problems, discuss the need for developing a reference

method and materials, and plan approaches for methodology improvement and standardization. CDC conducted a major study to evaluate various materials for their applicability and

commutability as potential reference materials for calibration and standardization of hs-CRP.

CDC co-sponsored with NHLBI, the American College of Cardiology, the American Heart

Association, and the American Association for Clinical Chemistry a special focus workshop

to address issues concerning the appropriate clinical use of hs-CRP in predicting risk for

CVD. This led to publication in 2003 of the American Heart Association/CDC Scientific

Statement, Markers of Inflammation and Cardiovascular Diseases: Application to Clinical and

Public Health Practice. CDC is helping the College of American Pathologists (CAP) implement proficiency testing surveys for hs-CRP and Lp(a) as part of its efforts to establish a

cardiac risk survey program.

Homocysteine Standardization Program

CDC is addressing the need for accurate and precise laboratory measurements of plasma

homocysteine on many fronts. Using a CDC reference method, the laboratory measures

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plasma homocysteine levels in samples obtained from participants in the NHANES. In 1998,

CDC conducted an international laboratory comparison study for plasma homocysteine with

14 laboratories to evaluate method differences. In 2000, CDC helped the CAP develop its

first homocysteine survey. CDC continues to provide confirmation values for each CAP

homocysteine survey on the basis of results obtained using the CDC reference method. 

CDC is collaborating with the Mayo Clinic to evaluate a mass spectrometry method that 

the Mayo Clinic developed as a potential high-order reference method. CDC is also collaborating with the National Institute of Standards and Technologies to support reference materials development. CDC participates in the International Federation of Clinical Chemistry

Working Group for Homocysteine Standardization. CDC continuously evaluates new assays

for measuring homocysteine and publishes evaluation results in professional journals.

Genomics and Disease Prevention 

To move beyond gene discovery to public health action requires additional research and planning. Clinical and epidemiologic studies are needed to assess the interaction between genetics

and environment in causing disease and to evaluate the clinical validity and utility of genetic

tests. Public health policies are needed to address related social, ethical, and legal issues and to

guarantee access to genetic services. Training the public health workforce and keeping the

public informed are also important components of a plan to integrate genetics into public

health. CDC’s activities in genomics and disease prevention reflect the enormity of the challenge facing public health today. They are based on a commitment to meet the challenge to

use genetic information to improve health and prevent disease in the 21st century.

In October 2001, CDC established Centers for Genomics and Public Health in schools of

public health at the Universities of Michigan, North Carolina, and Washington. The centers

will help build the knowledge base on genomics and public health, focusing on chronic diseases with modifiable environmental risk factors such as diet, exercise, or exposure to chemicals. They will also provide training and technical assistance to local, state, and regional public

health organizations. The Center at the University of Michigan is focused on cardiovascular

diseases.

In collaboration with CDC, the Chronic Disease Directors convened a Genomics and

Chronic Disease Summit in Atlanta in early 2002 to focus on emerging human genetic information relevant to prevention of cardiovascular disease, as well as asthma, cancer, diabetes,

and obesity.

CDC is evaluating family history as a tool for assessing risk and influencing early detection

and prevention of common diseases, including coronary heart disease, stroke, and hypertension. Coordinated by CDC’s Office of Genomics and Disease Prevention (OGDP), this 

collaborative effort includes several CDC programs and NIH institutes, including CDC’s

Cardiovascular Health Branch and NHLBI, respectively. 

A CDC-wide working group has developed a proposal for analyzing DNA samples collected

in the NHANES III to determine the prevalence of genotypes of potential public health

importance in a nationally representative, population-based sample and demographic subgroups. The proposal encompasses genes in pathways considered important in the pathogenesis and progression of cardiovascular diseases, including folate and homocysteine

metabolism, lipid metabolism, blood pressure regulation, and hemostasis.

Epidemiological research is needed to understand how modifiable risk factors (e.g., diet,

chemical exposures, infections, lifestyle) interact with genetic factors in the causation and

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progression of cardiovascular disease and to suggest ways that this information can help 

target disease prevention efforts. Through the 1999 Prevention Research Initiative, CDC

funded the University of Texas Houston Health Science Center to study gene-environment

interactions related to cardiovascular disease in over 15,000 African American and white men

and women aged 45–64 years who participated in the multicenter Arteriosclerosis Risk in

Communities (ARIC) Study conducted by NHLBI.

CDC supports the Stroke Prevention in Young Women Study, a population-based casecontrol study in Maryland and the District of Columbia that seeks to identify behavioral and

genetic factors that may help explain the increased risk for stroke among African American

women. CDC funds the Oregon Sudden Unexplained Death Study, which tracks all cardiac

arrests that occur in Multnomah County, Oregon, and assesses the determinants of sudden

death. 

National Center for Health Statistics (NCHS)

As the nation’s principal health statistics agency, NCHS compiles statistical information to

guide actions and policies to improve the health of our people. NCHS is a unique public

resource for health information—a critical element of public health and health policy.

NCHS health statistics are used to

• Document the health status of the population and of important subgroups.

• Identify disparities in health status and use of health care by race, ethnicity, socioeconomic status, region, and other population gradients.

• Describe people’s experiences with the health care system.

• Monitor trends in health status and health care delivery.

• Identify health problems.

• Support biomedical and health services research.

• Provide information for making changes in public policies and programs.

• Evaluate the impact of health policies and programs.

Working with partners throughout the health community, NCHS uses a variety of approaches

to efficiently obtain information from the sources most able to provide information. The center collects data from birth and death records, medical records, interview surveys, and through

direct physical exams and laboratory testing. NCHS is a key element of our national public

health infrastructure, providing important surveillance information that helps identify and

address critical health problems.

NCHS employs a variety of data collection mechanisms to obtain accurate information from

multiple sources. This process provides multiple perspectives to help understand the population’s health, influences on health, and health outcomes.

National Vital Statistics System (NVSS)

The NVSS provides the nation’s official vital statistics data on the basis of the collection and

registration of birth and death events at the state and local level. The NVSS provides the

most complete and continuous data available to public health officials at the national, state,

and local levels and in the private sector. Vital statistics are a critical component of our

national health information system, allowing us to monitor progress toward achieving health

and welfare reform goals. 

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Examples of NVSS data include

• Number of teen births.

• Prenatal care and birthweight.

• Risk factors for adverse pregnancy outcomes.

• Firearm-related mortality in teens.

• Infant mortality rates.

• Leading causes of death.

• Life expectancy.

• Firearm-related mortality.

National Health Care Survey (NHCS)

The NHCS is a family of surveys that collects data from health care establishments about the

use of services across the major sectors of the U.S. health care system. These data may be

used to profile changes in the use of health care resources, patterns of disease, and the impact

of new medications and technologies. Information on the characteristics of providers, facilities, and patients allows researchers to study shifts in the delivery of care across the health

care system, variations in treatment patterns, and patient outcomes.

Provider sites surveyed include

• Hospitals.

• Nursing homes.

• Emergency departments.

• Hospital outpatient departments.

• Office-based physicians.

• Ambulatory surgery centers.

• Home health agencies.

• Hospices.

National Health and Nutrition Examination Survey (NHANES)

The NHANES is NCHS’s most in-depth and logistically complex survey, designed to assess

the health and nutritional status of Americans. This comprehensive survey combines personal

interviews with standardized physical and dental examinations, diagnostic procedures, and lab

tests for approximately 5,000 persons each year. 

The survey provides information related to

• Diseases.

• Health risk factors.

• Genetics and health.

• Diet and nutritional health status.

• Oral health.

• Environmental exposures.

• Obesity and physical fitness.

National Health Interview Survey (NHIS)

The NHIS provides information annually on the health status of the U.S. civilian noninstitutionalized population through confidential interviews conducted in households. The NHIS is

the nation’s largest household health survey, providing data for analysis of broad health

trends, as well as the ability to characterize persons with various health problems, determine

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barriers to care, and compare racial and ethnic populations’ health status, health-related

behaviors, and risk factors.

Health topics addressed annually include

• Health status and disability.

• Insurance coverage.

• Access to care.

• Use of health services.

• Immunizations (child).

• Health behaviors.

• Injury.

• Ability to perform daily activities.

Additional topics addressed in 2002 include

• Alternative medicine.

• Arthritis.

• Disability and secondary conditions.

• Environmental health.

• Vision and hearing.

National Institutes of Health

www.nih.gov

National Heart, Lung, and Blood Institute

Cardiovascular Disease Research and Outreach Efforts

The National Heart, Lung, and Blood Institute (NHLBI) provides leadership for a national

program in diseases of the heart, blood vessels, lung, and blood; blood resources; and sleep

disorders. Since October 1997, the NHLBI has also had administrative responsibility for the 

NIH Woman's Health Initiative. 

The Institute plans, conducts, fosters, and supports an integrated and coordinated program

of basic research, clinical investigations and trials, observational studies, and demonstration

and education projects. Research is related to the causes, prevention, diagnosis, and treatment of heart, blood vessel, lung, and blood diseases and of sleep disorders. The NHLBI

plans and directs research in development and evaluation of interventions and devices related

to prevention, treatment, and rehabilitation of patients suffering from such diseases and disorders. It also supports research on clinical use of blood and all aspects of the management of

blood resources. Research is conducted in the Institute's own laboratories and by scientific

institutions and individuals supported by research grants and contracts. 

For health professionals and the public, the NHLBI conducts educational activities, including

development and dissemination of materials in the aforementioned areas, with an emphasis

on prevention. 

The NHLBI supports research training and career development of new and established

researchers in fundamental sciences and clinical disciplines to enable them to conduct basic

and clinical research related to heart, blood vessel, lung, and blood diseases; sleep disorders;

and blood resources through individual and institutional research training awards and career

development awards. The Institute coordinates relevant activities in these areas, including

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the related causes of stroke, with other research institutes and federal health programs.

Relationships are maintained with appropriate institutions and professional associations;

international, national, state, and local officials; and voluntary agencies and organizations.

Each year, the NHLBI assesses progress in the scientific areas for which it is responsible and

updates its goals and objectives. As new opportunities are identified, the Institute expands

and revises its areas of interest. Throughout the process, the approach used by the Institute is

an orderly sequence of research activities that includes

• Acquisition of knowledge.

• Evaluation of knowledge.

• Application of knowledge.

• Dissemination of knowledge.

Several components of the Institute are engaged in research and education activities aimed at

the prevention and control of cardiovascular disease (CVD). Highlights of activities are summarized in the following sections.

Division of Heart and Vascular Diseases

The Division of Heart and Vascular Diseases (DHVD) plans and directs a coordinated

research program on the causes of heart and vascular diseases and on their prevention, diagnosis, and treatment. Fundamental biomedical research is emphasized. Multidisciplinary programs are supported to advance basic knowledge of disease and to generate the most effective

methods of clinical management and prevention. Clinical trials are an important part of the

research program; they provide an opportunity to test and apply promising preventive or therapeutic measures.

Research in atherosclerosis encompasses the etiology, pathogenesis, diagnosis, prevention, 

and treatment of the disorder. Programs include pathobiology and genetics of the vasculature;

vascular growth and angiogenesis; interactions of the vascular wall with systemic and humoral

factors promoting atherogenesis; and lesion progression, complication, and regression.

Targeted areas involve characterization of atherosclerotic plaque prone to rupture, pathogenesis of abdominal aortic aneurysms, the role of homocysteinemia in atherosclerosis, mechanisms of atherosclerosis in various vascular beds, and research on atherosclerotic lesions 

using human autopsy tissue. Additional studies focus on pathobiological determinants of atherosclerosis, cardiovascular complications of diabetes mellitus, vessel-wall calcification, the

role of infectious agents in atherosclerosis, immunobiology of the vessel wall, hormone

replacement therapy on atherosclerosis, and effect of protease inhibitors on atherosclerosis

development in human immunodeficiency virus (HIV) infection. Of special interest is understanding atherosclerosis risk among minorities. 

Studies related to hypertension focus on identifying and characterizing genes involved with

hypertension; elucidating regulation mechanisms associated with blood pressure control;

identifying causative factors of essential hypertension as well as rare forms of high blood

pressure; examining mechanisms by which high blood pressure increases the risk of, or

occurs concomitantly with other diseases, such as kidney failure, stroke, diabetes, atherosclerosis, preeclampsia, and left ventricular hypertrophy; and developing preventive strategies as

well as novel interventions for hypertension. Additional areas of interest include understanding the biological underpinnings of salt sensitivity; identifying neurological mechanisms

responsible for long-term control of blood pressure and functional neurological changes that

result in essential hypertension; and understanding the basis of target-organ damage in

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hypertension. Of special interest is eliminating health disparities among minorities and

between men and women. 

Basic and clinical studies on arteriogenesis (formation of new arteries), angiogenesis (formation of new blood vessels), and the biology and pathophysiology of blood vessel structure and

function in the cerebral, coronary, and peripheral vascular beds are designed to increase

understanding of how oxygen, nutrient, and fluid exchange occurs within vessels; how vascular inflammatory response originates and contributes to CVD; how blood flow within the tissues is autoregulated; how vascular smooth muscle contraction is altered; how new vessels

are formed; and how vascular remodeling is orchestrated. Scientists are investigating ways to

control the inflammatory response in blood vessels, manipulate mechanisms that regulate

blood flow, and stimulate the formation of new blood vessels (especially after an ischemic

event in the brain, heart, or a limb).

Gene transfer is being used to deliver growth factors to the myocardium to promote development of new blood vessels. Clinical trials are under way to test the safety and efficacy of this

approach in humans. Ultimately, these studies should offer insight into developing new therapeutic agents for ischemic disease.

Research in cardiovascular medicine is focused on new strategies to ameliorate disease

through improving risk stratification and management and developing novel drugs and therapies. In addition to risk factor reduction, healthy lifestyles and behaviors are emphasized. The

preventive and therapeutic potential of nutrition and exercise are currently being evaluated.

To date, hormone replacement trials consistently demonstrate lack of benefit with regard to

cardiovascular outcomes despite benefits suggested by fundamental and observational data.

Devices are used to prevent fatal consequences of ventricular fibrillation in patients at high

risk of sudden death, improve ventricular function in heart failure patients with intraventricular conduction delays, and improve survival in selected end-stage heart failure patients who

are ineligible for heart transplantation. The development of drug-eluting stents holds promise

of significant reduction of restenosis even in patients with a tendency for a hypercellular

response to coronary interventions. Current projects encompass developing new strategies for

acute and chronic heart disease, cardiomyopathies of different etiologies (i.e., ischemic, valvular, genetic, metabolic, and HIV-related), peripheral vascular disease, aortic aneurysms, and

restenosis after percutaneous coronary interventions. Examples of therapies and approaches

include diet, exercise, and pharmacologic management of dyslipidemias, genetic susceptibility

and directed treatment, diagnosis and management of arrhythmias; surgical and medical management of heart failure; and novel imaging of atherosclerosis. Studies also seek to understand

and reduce disparities associated with minority and women’s cardiovascular health. 

Division of Epidemiology and Clinical Applications

The Division of Epidemiology and Clinical Applications (DECA) plans, directs, and evaluates research on the causes, prevention, diagnosis, and treatment of CVD, as well as on the

need for technological development in the acquisition and application of research findings. It

supports epidemiologic studies, clinical trials, demonstration and education research, disease

prevention and health promotion research, and basic and applied research in behavioral

medicine. 

Research in the prevention of CVD encompasses clinical trials, community intervention

studies, prevention trials, nutrition studies, health education research, and behavioral medicine studies. DECA supports a number of multicenter prevention and education trials to test

the efficacy and effectiveness of, and demonstrate the capability of, prevention strategies

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designed to reduce cardiovascular risk factors. Major studies include determining the effectiveness of school- and home-based interventions to reduce development of CVD risk factors

in children, especially those from minority populations; examining the effects of dietary patterns, sodium intake, and other lifestyle factors on blood pressure; and comparing the efficacy of various treatments to prevent major cardiovascular events in adults with diabetes.

Studies on increasing the implementation of interventions known to be effective are of particular interest.

Clinical trials are used to evaluate the effectiveness of various medical procedures and therapeutic agents in patients with coronary heart disease, hypertension, and heart failure.

Examples include assessing the long-term safety and efficacy of an angiotensin converting

enzyme inhibitor to prevent major CVD events in patients with documented normal ventricular function, testing the ability of selected antihypertensive and lipid-lowering drugs to prevent heart attack among individuals at high risk for hypertension and coronary heart disease

(CHD), and comparing the use of an implantable cardiac defibrillator to conventional pharmacologic therapy to improve survival among heart failure patients.

Research in behavioral medicine focuses on biopsychologic and sociocultural factors involved

in heart, lung, and blood diseases. Areas of interest include central nervous system regulation

of the cardiovascular system; identification of psychosocial factors (social support, depression,

and hostility) affecting disease etiology, treatment, and rehabilitation; and effects of psychosocial and behavioral interventions on risk factors (smoking, adverse diet, physical inactivity), disease outcomes, and quality of life. Study participants are from all levels of health and

from all ages and racial groups. 

Investigators are conducting long-term epidemiological studies of heart and vascular, lung,

and blood diseases in defined populations in the United States and other countries. These

studies focus on the development and progression of CVD risk factors in children and young

adults, the development and progression of atherosclerosis measured noninvasively or at

autopsy in middle-aged or older adults, and the development and progression of overt cardiovascular and pulmonary disease in older adults. Areas of emphasis include genetic and environmental influences on CVD and its risk factors; trends in incidence, prevalence, and

mortality from CVD, stroke, peripheral vascular disease, congestive heart failure, and cardiomyopathy; and relationships between insulin, insulin resistance, and overt diabetes and

CVD and its risk factors. Another area of interest is the incidence of and mortality from cardiovascular, lung, and blood diseases. Research strategies apply family, longitudinal, demographic, and vital statistics to study their natural history, etiology, and epidemiology.

Genetic epidemiology has become an increasingly important component of the DECA

Research Program. Several long-term studies of twins, multiple generations, Native

Americans, and blacks focus on related individuals to estimate heritability and identify genes

that contribute to the development of CVD risk factors and CVD. Other long-term studies

are storing DNA and testing candidate genes from unrelated individuals. In addition to examining associations between CHD risk factors and development of atherosclerosis, heart failure,

cardiomyopathy, and stroke in adults and the elderly, investigators will seek to identify and

characterize genes related to CHD and atherosclerosis and to determine how they interact

with environmental factors in the development of disease. Additional studies are underway to

identify genetic factors influencing coronary and aortic calcification and individual variability

in the inflammatory response and to investigate gene-environment interaction, collaborative

approaches to linkage analysis, and population screening for genetic diseases.

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Public Health Action Plan to Prevent Heart Disease and Stroke
The research program also focuses on understanding the relationships between insulin,

insulin resistance, overt diabetes, and CVD and its risk factors. Scientists are attempting to

find and characterize genes linked to risk factors that are associated with insulin resistance

syndrome and diabetes. Research strategies include family and longitudinal studies in racially

diverse populations.

Office of Prevention, Education, and Control

The NHLBI Office of Prevention, Education, and Control (OPEC) coordinates the translation and dissemination of research findings and scientific consensus to health professionals,

patients, and the public, so that information can be adapted for and integrated into health

care practice and individual health behavior. To accomplish its mission, OPEC established

health education programs and initiatives that address high blood pressure, high blood cholesterol, asthma, early warning signs of heart attack, obesity, and sleep disorders. The programs use two strategies: one focuses on individuals at high risk; the other focuses on the

general public. The four largest programs have coordinating committees consisting of

national medical, public health, and voluntary organizations and of other federal agencies.

These committees help to plan, implement, and evaluate program efforts in professional,

patient, and public education.

The National High Blood Pressure Education Program (NHBPEP) was initiated in 1972 to

reduce death and disability related to high blood pressure through professional, patient, and

public education programs. It is a cooperative effort among the NHLBI, professional and

voluntary health agencies, and state health departments that has served as a model for

national health education programs and continues to be adopted by other national and international groups. Special attention is directed to reducing health disparities among people

with hypertension. 

Since the program’s inception, the number of people with hypertension who are aware of

their condition has increased fourfold, and four times as many people are receiving treatment

and controlling their disease. Data from the National Health and Nutrition Examination

Surveys (NHANES) indicate that over the past four decades, mean systolic blood pressure has

declined by 10 mmHg and age-adjusted mortality rates from heart disease and stroke have

decreased by 50% and 60%, respectively.

The NHBPEP is focused on translating research results to improve medical care outcomes

and the public’s health. It is committed to raising public awareness of the importance of

adopting a heart-healthy lifestyle. Research has identified steps that individuals can take to

control their blood pressure and to lower their risk for heart disease. For example, certain

dietary habits can decrease blood pressure and can prevent it from rising. The DASH

(Dietary Approaches to Stop Hypertension) diet—rich in fruits and vegetables, low in saturated and total fat and cholesterol, and containing low-fat dairy products—has been shown

to be beneficial for individuals who have high blood pressure and for those who wish to prevent high blood pressure. Combined with a reduced salt intake, the diet can further lower

blood pressure.

In 2002, community and professional activities focused on updating the Primary Prevention

Report, encouraging communities to hold local events to mark May as National High Blood

Pressure Education Month, and redesigning and expanding the Your Guide to Lowering High

Blood Pressure Web page. The NHLBI initiated the development of a major repositioning

strategy, which will include new partners, to enhance its position as the U.S. leader in high

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blood pressure prevention and control, raise the importance of high blood pressure on the

national public agenda, and reach individual audiences by designing activities directed 

specifically to them.

The National Cholesterol Education Program (NCEP) was initiated in 1985 to educate

health professionals and the public about high blood cholesterol as a risk factor for CHD 

and about the benefits of lowering cholesterol levels to reduce illness and deaths from CHD.

From 1983 through 1995, the percentage of the public who had their cholesterol checked

rose from 35% to 75%, showing that 70 to 80 million more Americans were aware of their

cholesterol levels in 1995 than in 1983. Moreover, in 1995, physicians reported initiating diet

and drug treatment at much lower cholesterol levels than in 1983. Major elements of the

NCEP guidelines for detection and treatment have become established practice.

NHANES III (1988–1994) data demonstrate that the NCEP's dual strategy—one emphasizing the need for detection and treatment for individuals whose high blood cholesterol places

them at increased risk for CHD and the other encouraging heart-healthy eating patterns 

to lower average cholesterol levels for the general public—has had a substantial effect on

measured blood cholesterol levels of U.S. adults. Since 1978, the intake of saturated fat, total

fat, and cholesterol among the general public decreased significantly, resulting in an impressive decline in average blood cholesterol levels. The prevalence of high blood cholesterol in

the U.S. population has also fallen significantly. Cholesterol levels in adolescents likewise

have declined.

In 2002, the NCEP focused its attention on disseminating the new Adult Treatment Panel III

(ATP III) Guidelines on managing high cholesterol in adults. It developed a Web-based kit of

materials derived from the guidelines to support cholesterol education for Cholesterol Month

2002 and throughout the year. An ATP III Opinion Leader Dissemination kit was distributed

to influential members of the medical community to encourage them to use the guidelines and

communicate their importance to professional colleagues. The NCEP is producing a new

patient booklet on therapeutic lifestyle changes based on the ATP III recommendations.

Additional activities include developing an action plan for reducing lifetime risk for CHD and

convening an international conference on scientific issues that should be addressed in developing cardiovascular guidelines. The NHLBI, the American College of Cardiology, and the

American Heart Association issued a clinical advisory on the use and safety of statins—specifically focusing on myopathy—in response to concerns that arose after cerivastatin was voluntarily withdrawn from the market by its manufacturer. The advisory provides reassurance that the

benefits of statins far outweigh the risks if patients are properly selected and attention is paid to

possible side effects. 

The National Heart Attack Alert Program (NHAAP) was initiated in June 1991 to reduce

morbidity and mortality from acute myocardial infarction (AMI), including out-of-hospital

cardiac arrest, through education of health professionals (e.g., physicians, nurses, and emergency medical services personnel), patients, and the public about the importance of rapid

identification and treatment of individuals with heart attack symptoms. In 1997, the program's scope was broadened to include early identification and treatment of individuals with

acute coronary syndromes such as unstable angina. Since its inception, the program has

taught health care providers in emergency departments and emergency medical services systems about the importance of reducing the interval between a heart attack and treatment.

Available treatments, if administered soon after heart attack symptoms start, can save lives

and minimize heart muscle damage in heart attack survivors. 

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Public Health Action Plan to Prevent Heart Disease and Stroke
In 2001, the NHAAP, in partnership with the American Heart Association, the American

Red Cross, and the National Council on Aging, launched a major campaign to urge physicians and health care providers to educate their patients about heart attack risk, warning

signs, and steps to survival. As part of the campaign to increase awareness of the need to act

fast when someone may be having a heart attack, the NHLBI established its Act in Time to

Heart Attack Signs Web page with educational materials for health professionals, patients,

and the public.

The NHLBI Obesity Education Initiative (OEI) began in January 1991 to inform the public

and health professionals about the health risks associated with overweight and obesity. Obesity

is not only an independent risk factor for CVD, but also a contributor to high blood pressure

and high blood cholesterol and is related to sleep apnea.

In 2002, 50 at-risk communities belonging to the NHLBI Hearts N’ Parks project, made a

3-year commitment to create model community-based programs to increase the number of

children, adults, and seniors practicing heart-healthy behaviors. The project’s goal is to

reduce obesity, improve nutritional status, and increase physical activity. The American

Dietetic Association, in partnership with the project, is providing nutrition consultation. A

Hearts N’ Parks Web page has been established with information on the program. 

The NHLBI Women’s Heart Health Education Initiative was launched in 2001 in response 

to the Women’s Health Research and Prevention Amendments, Public Law 105-304, which

requires the Institute director “to expand, intensify, and coordinate research and related activities, including information and educational programs, with respect to heart attack, stroke,

and other cardiovascular diseases in women.” The Heart Truth—a campaign directed at

women 40–60 years old and health professionals—was launched in 2002 to increase awareness

about heart disease, improve detection and treatment of risk factors by health professionals,

and motivate national and community organizations to become involved in heart health education. Special attention is given to minority women who are at increased risk for developing

CVD. 

As a key part of its response to the Healthy People 2010 national health objectives, the

NHLBI initiated a new funding mechanism to establish CVD educational outreach programs in high-risk communities. The program—Enhanced Dissemination and Utilization

Centers (EDUCs)—is a partnership between the NHLBI and local communities to eliminate cardiovascular health disparities and increase quality and years of health in underserved

populations. In 2001, the Institute awarded EDUCs to high-risk health service areas in

Arkansas, North Carolina, Texas, Virginia, and West Virginia to conduct educational projects targeting populations at greatest risk for heart disease and stroke. Multiple strategies to

prevent and control CVD risk factors and to promote heart-healthy behavior have been

designed specifically for different age groups, ranging from childhood to adulthood. Six

additional EDUCs were awarded to areas in Maryland, Ohio (2), Colorado, Nebraska, and

North Carolina in 2002.

A major goal of the Institute is to eliminate health disparities and to increase the quality and

years of healthy life of all Americans. Through partnerships with groups that have special

ties and access to targeted populations, the NHLBI is extending its outreach and educational 

activities to underserved communities. The Institute is collaborating with the Baltimore City

Cardiovascular Health Partnership on a project that has a two-pronged strategy consisting of

a population-wide public education campaign and a targeted subgroup outreach and educational approach to build and reinforce positive cardiovascular health lifestyle skills and

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behaviors. The targeted population consists of blacks who reside in Baltimore City public

housing developments.

The Institute’s Salud para su Corazón (Health for Your Heart) Initiative, a community-based

heart health program for Latinos, is expanding across the United States. Trained local lay

health workers (promotores), applying values and culture of the communities and mobilizing

partners, teach people how to reduce their risk of developing CVD. As advocates for change,

they have increased the number of Latinos in their communities who are engaging in hearthealthy behaviors. In 2002, the NHLBI and the Health Resources and Services

Administration signed an interagency agreement to expand the program to communities

along the Texas–Mexico border and along the southern border areas of California and New

Mexico. 

The NHLBI-Indian Health Service Partnership to Strengthen the Heartbeat of American

Indian and Alaskan Native Communities is a collaborative effort to educate three tribal communities—the Ponca Tribe of Oklahoma, the Bristol Bay Area in Western Alaska, and the

Laguna Pueblo in New Mexico—about cardiovascular health and to reduce their risk for

CVD. In 2002, tribal heart health teams received training on topics related to cardiovascular

health, including physical activity, obesity, smoking prevention, nutrition, high blood cholesterol, and high blood pressure, as well as on theories of team building, evaluation, and community interaction and intervention. Since then, they have initiated community outreach

education activities on cardiovascular health and disease. In addition, they have developed

connections with local organizations to aid them with their missions.

Asian Americans and Pacific Islanders are a diverse and heterogeneous group with varying

levels of CVD risk factors, acculturation, and socioeconomic status and with different cultures, languages, immigration histories, and community norms related to health and wellbeing. In 2002, the NHLBI, along with the Asian and Pacific Islander American Health

Forum, conducted health assessments among Americans of Philippine, Vietnamese, and

Cambodian heritage to obtain information on their knowledge of and attitudes toward CVD

and its risk factors, disease prevention, and health behaviors. The assessments will guide 

the Institute in its development of culturally and language-appropriate materials and activities for these groups.

National Institute of Neurological Disorders and Stroke 

Stroke Research and Outreach Efforts

The National Institute of Neurological Disorders and Stroke (NINDS) is the nation's leading supporter of biomedical research on disorders of the brain and nervous system. The

NINDS also supports basic, clinical, and population-based research to identify and study the

causes, biology, prevention, early detection, and treatment of stroke. Through years of dedicated study, researchers supported by the NINDS have amassed a significant knowledge base

about stroke. 

• Landmark Clinical Studies

For the past 25 years, the NINDS has been encouraging and supporting major multicenter, randomized, controlled clinical trials evaluating medical and surgical interventions to

prevent and treat stroke. More than a score of trials, involving more than 20,000 participants, have assessed antiplatelet agents, anticoagulants, thrombolysis, carotid endarterectomy, hormone replacement, and psychosocial interventions. This large investment of

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Public Health Action Plan to Prevent Heart Disease and Stroke
public research dollars is justified by the huge public health burden caused by stroke,

which costs billions of dollars yearly in the United States, and the likely savings in health

care dollars garnered by the results of NINDS-sponsored clinical trials.

NINDS-sponsored clinical trials are flagship studies in many areas of stroke, influencing

treatment decisions daily in clinics throughout the world. The North American

Symptomatic Carotid Endarterectomy Trial (NASCET) and the Asymptomatic Carotid

Atherosclerosis Study (ACAS) provided guidance on when carotid endarterectomy is indicated for patients with cervical carotid stenosis. The Stroke Prevention in Atrial

Fibrillation (SPAF) I, II, and III trials showed which antithrombotic therapy should be

given to prevent stroke in patients with atrial fibrillation. 

The NINDS t-PA Stroke Trial resulted in the first FDA-approved acute treatment to

reduce disability from stroke. Until the completion of that trial in 1995, physicians had

nothing to offer their patients that could reduce brain injury from stroke. 

• Stroke in Minorities

Stroke remains the third leading cause of mortality in the United States and a leading

cause of adult disability; however, the burden of stroke is even greater among minority

racial and ethnic groups because of its higher incidence and mortality in these populations. Initial evidence suggests that African Americans may experience more severe

strokes and greater residual physical deficits. 

The NINDS 5-Year Strategic Plan on Minority Health Disparities called for a planning

panel and workshop to generate a set of recommendations to guide NINDS efforts in

research, research capacity building, and outreach to reduce and eliminate disparities in

stroke. A Stroke Disparities Planning Panel was held in June 2002, and a follow-up

workshop was held in November 2002 to identify specific research needs and areas of

opportunity. 

The NINDS is proceeding along several fronts to reduce or eliminate racial disparities in

stroke, including support of a large number of research projects that focus on minorities.

Additionally, as a result of the Stroke Disparities Workshop, several new prevention and

intervention programs are underway or planned. 

• Outreach

The NINDS has been working with investigators, clinicians, and private groups such as

the American Heart Association and the National Stroke Association to determine the

steps that should be taken to educate the public and the medical community about the

need for rapid diagnosis and treatment of stroke. Especially emphasized are the specific

benefits of the acute stroke treatment, t-PA. The NINDS organized a historic meeting, a

National Symposium on Rapid Identification and Treatment of Acute Stroke, in

December 1996. The symposium drew more than 400 professionals representing wide

areas of the health care system to draft guidelines on how to treat stroke on an emergency basis. The participants made recommendations for change in five key areas: prehospital systems, emergency departments, acute hospital care, hospital systems, and

public education. The proceedings from the meeting were published and distributed

nationally in an effort to increase the number of stroke patients who can benefit from

treatment and the number of hospitals that can offer rapid treatment to their patients. 

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Building on the enthusiasm and spirit of cooperation generated by the symposium, the

NINDS assumed leadership of the Brain Attack Coalition, an umbrella group of several

national organizations that work together to launch major stroke education campaigns. 

The latest effort is called Know Stroke. Know the Signs. Act in Time. The Know Stroke campaign is a multifaceted public education program designed to raise awareness of the signs

and symptoms of stroke and the need to act quickly to seek medical care. It includes public

service advertising, media outreach, and community education. Through a variety of voluntary organizations and federal partners, the NINDS has distributed hundreds of thousands of brochures and posters and more than 1,000 community education kits. These

organizations are using Know Stroke materials in educational sessions at hospitals, senior

centers, and other places that serve those at the highest risk for stroke. 

As a follow-up to the 1996 symposium, the NINDS hosted a national Stroke Symposium

entitled Improving the Chain of Recovery for Acute Stroke in Your Community in December

2002. About 400 participants from many organizations attended this meeting, which was

designed to address the problem of the relatively few number of patients nationwide who

are receiving acute treatment for their strokes. Both the American Stroke Association and

the National Stroke Association were co-sponsors of the meeting. The attendees were to

develop workable plans of action to get more stroke patients treated rapidly. The NINDS

will publish the symposium task force reports and post them on the Web, in order to provide practical information that can be used by the medical community for years to come.

The result will be improved treatment for the nation’s stroke patients.

New Programs

• Specialized Program of Translational Research in Acute Stroke (SPOTRIAS)

The NINDS has initiated a new concept called Specialized Programs of Translational

Research in Acute Stroke (SPOTRIAS). The objective of this innovative model is to

facilitate translation of basic research findings into clinical practice. This is done in settings where patients with acute ischemic and hemorrhagic stroke are evaluated and treated very rapidly after the onset of their symptoms. The intent of the SPOTRIAS is to

support a collaboration of clinical researchers from different specialties whose collective

efforts will lead to new approaches to early diagnosis and treatment of acute stroke

patients. Training and career development will be part of the SPOTRIAS program.

• Human Genetics Resource Center: DNA and Cell Line Repository

To support its mission of reducing the burden of neurological illnesses and to support

outstanding investigators funded through its research programs, the NINDS has established a Human Genetics Resource Center: DNA and Cell Line Repository. 

The goal of the repository will be the elucidation of genetic factors associated with neurological diseases, including stroke. Genetic studies of neurological disorders are increasing in number and complexity. Such studies require a large and diverse sample and

accompanying information base. Thus, a repository of DNA samples, immortalized cell

lines (from which DNA can be extracted continuously), and accompanying clinical and

pedigree data is clearly an invaluable resource for the neuroscience community.

• Stroke Progress Review Group

The large body of research knowledge acquired over the years, coupled with new technologies, is providing a wealth of new scientific opportunities. At the same time, increasC-22

Public Health Action Plan to Prevent Heart Disease and Stroke
ing research needs and scientific opportunities required that the NINDS determine the

best uses for its resources. In order to address these issues and to fulfill a Congressional

request, the NINDS set out to develop a national plan for basic and clinical research in

stroke. In 2001, the Institute formed the Stroke Progress Review Group (SPRG), consisting of 30 nationally and internationally recognized stroke experts. The SPRG identified

topics to be addressed through a large Roundtable Meeting, whose participants identified

gaps in stroke knowledge and set research priorities. The SPRG members and other participants of the meeting issued a report reflecting the energy and enthusiasm of the clinical, research, industrial, and advocacy communities for identifying effective prevention

strategies and treatments for stroke.

The comprehensive report from this meeting will serve as a guide for planning research

in stroke prevention, diagnosis, treatment, and rehabilitation for the coming years.

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D-1

APPENDIX D: DEVELOPMENT OF 

A PUBLIC HEALTH ACTION PLAN TO 

PREVENT HEART DISEASE AND STROKE

In 2001, CDC initiated development of A Public Health Action Plan to Prevent Heart Disease and

Stroke. The concept of the plan and the process for its development were presented at the First

National CDC Prevention Conference on Heart Disease and Stroke on August 24, 2001, in

Atlanta. Valuable input was received, especially from the Cardiovascular Health Council of the

Chronic Disease Directors (CDD), who identified representatives to join in the planning

process. This appendix outlines this process and identifies the many partners who participated.

Organization

The planning process for the Action Plan included several key partners, public health experts,

and heart disease and stroke prevention specialists in the United States and abroad. These

participants were asked to contribute in several ways, including as members of a Working

Group, one of five Expert Panels, or a National Forum. The figure illustrates the organizational structure for the planning process, which included CDC Core Staff.

Development of the Plan

Expert

Panel

Chairs

Expert

Panel

Chairs

Other CDC

Leaders

65+ National and 

International

Orgs/Agencies

Partners

(MOUs)

Partners

(MOUs)

National Forum Other State and

Territorial

Organizations

PRCP,

AHA/CEP PRCP,

AHA/CEP

CDC,

CIOs,

CVHCC

ASTHO

ASTDHPPHE

CVH Council

CDC Core Staff

(Planning Office)

Organizational Structure of the Action Plan Planning Process

Working Group

Note: Abbreviations used in the figure are identified in the text or the participants list.
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Public Health Action Plan to Prevent Heart Disease and Stroke

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 actions 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.

CDC Core Staff

The CDC Core Staff was responsible for coordinating the overall planning process. This

staff works for the Associate Director for Cardiovascular Health Policy and Research in 

the Office of the Director, Division of Adult and Community Health, National Center for

Chronic Disease Prevention and Health Promotion, Centers for Disease Control and

Prevention (OD/DACH/NCCDPHP/CDC). An outside contractor helped CDC with 

meeting arrangements and other logistical details.

Expert Panels

CDC convened five Expert Panels, each to address one of the five essential components of 

the Action Plan. The panels identified relevant concerns and problems, proposed solutions,

and offered recommendations appropriate to their topics. The Working Group then

reviewed these recommendations. The synthesized recommendations are presented in

Section 3 of this plan. The corresponding action steps are presented in Section 4.

The titles and topics for the five Expert Panels were as follows:

• Panel A: Policy and Programs

Taking action: Putting present knowledge to work.

• Panel B: Capacity Development and Support

Strengthening capacity: Organization and structure of public health agencies and 

partnerships.

• Panel C: Monitoring, Evaluation, and Communication

Evaluating impact: Monitoring the burden, measuring progress, and communicating

urgency.

• Panel D: Research in CVH Promotion and CVD Prevention

Advancing policy: Defining the issues and finding the needed solutions.

• Panel E: Global Cardiovascular Health

Engaging in regional and global partnerships: Multiplying resources and capitalizing on

shared experience.

Each Expert Panel had 16–22 members, including the following:

• Experts from outside CDC nominated from multiple sources and invited to participate 

on a particular panel based on the specific contribution they would make to the process.

• Members nominated by the Cardiovascular Health Council, CDD, which is part of the

Association of State and Territorial Health Officers (ASTHO).

• The Cardiovascular Health Coordinating Committee (CVHCC), made up one or more

representatives from each of the five NCCDPHP divisions that deal most directly with

cardiovascular health: the Division of Adult and Community Health (DACH), the

Division of Adolescent and School Health (DASH), the Division of Diabetes Translation

(DDT), the Division of Nutrition and Physical Activity (DNPA), and the Office on

Smoking and Health (OSH).
D-3

• NCCDPHP’s Associate Director for Cardiovascular Health Policy and Research and the

CDC Core Staff.

Working Group

The Working Group was responsible for initial critical review of the draft outline of the 

plan and the development process. Members also formulated the instructions for the Expert

Panels, nominated members for the National Forum, and reviewed the final reports of the

Expert Panels. In addition, they assessed the proposed implementation process and considered all input from the National Forum in preparing the final document. The 36-member

Working Group included the following:

• The chairs of the Working Group and each of the five Expert Panels.

• Representatives from the Cardiovascular Health Council, CDD.

• Representatives from the five NCCDPHP divisions that deal most directly with 

cardiovascular health.

• Representatives from CDC’s National Center for Environmental Health (NCEH) and

National Center for Birth Defects and Developmental Disabilities (NCBDDD).

• Each partner working with CDC under a current memorandum of understanding (MOU)

in the area of heart disease and stroke. These include one MOU with the American Heart

Association (AHA) and American Stroke Association (ASA); the Centers for Medicare &

Medicaid Services; the Office of Public Health and Science and the Office of Disease

Prevention and Health Promotion, Department of Health and Human Services; and the

National Heart, Lung, and Blood Institute and the National Institute of Neurological

Disorders and Stroke, National Institutes of Health. CDC also has MOUs with the

Ministry of Health and Welfare Canada and with the National Stroke Association.

• Representatives from CDC’s Prevention Research Center Program (PRCP).

• Representatives from other national health professional organizations.

• NCCDPHP’s Associate Director for Cardiovascular Health Policy and Research and the

CDC Core Staff.

National Forum

National Forum participants were responsible for reviewing the draft plan from the perspectives of a wide range of partners, constituencies, and other interested parties. They also were

asked to assess priorities for the many proposed action steps and to consider the potential

contributions of partners to implementing the plan. The National Forum comprised the 

following participants:

• All members of the Working Group.

• Representatives from additional state and territorial organizations.

• Additional new partners.

• Additional representatives of the CVH research community.

• Additional CDC staff members from other Centers, Institutes, and Offices (CIOs).

• Other appointees as recommended during the planning process.

General Process and Format

The CDC Core Staff was responsible for overall planning and for executing production of

the plan, including preparation of working drafts of all materials and the final draft for publication. The CDC Core Staff established and maintained Internet communications about the

process and interim products to make the material widely accessible and to encourage broadbased input. A contractor was responsible for logistical arrangements for all meetings.

Development of the Plan
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Public Health Action Plan to Prevent Heart Disease and Stroke

The Working Group met first in December 2001 to provide input to the draft outline, draft

implementation plan, and Expert Panel instructions and to recommend members for the

National Forum. During its second meeting in late May 2002, members reviewed and discussed the reports of the five Expert Panels and the implementation plan. Based on this discussion, the CDC Core Staff prepared a draft of the plan for review by the National Forum.

Each Expert Panel was convened for two meetings, the first during January–February 2002

and the second during March–May 2002. These meetings included preliminary discussions,

interim work, and final discussions, which led to completed position papers for each panel

that will be published separately.

In preparation for the first meeting, panelists received selected background material and 

were asked to prepare a written statement on their topics. This material was compiled and

distributed to all members of each panel before the meeting. During the first meeting, 

participants discussed their designated component of the plan and identified approximately

five issues of foremost importance regarding that component. This discussion facilitated

development of a set of premises, which each panel used as the basis for their recommendations. These premises are as follows:

Panel A: Policy and Programs

• Policy development for cardiovascular health (CVH) promotion and cardiovascular 

disease (CVD) prevention must proceed under a comprehensive framework that recognizes the full array of cardiovascular disorders (e.g., heart attack, heart failure, stroke, 

vascular dementia) and the need to establish strategic links with efforts to prevent other

chronic conditions of public health concern (e.g., obesity, diabetes, pulmonary disease,

cancer).

• For maximum impact, community-wide interventions must address all appropriate 

settings, all opportunities throughout the life span, and the total U.S. population, with

added emphasis on populations at high risk.

• A comprehensive public health strategy must focus on preventing major risk factors and

assuring services to detect and control them once they develop. This strategy must also

support efforts to widely implement guidelines for early identification and treatment of

acute CVD events and prevention of recurrent events.

• The ideal program should be 1) national in scope, with state and local adaptation and

implementation; 2) based on strategic partnerships, both innovative and established; 3)

comprehensive with respect to CVD development and intervention approaches; and 4)

responsive to community concerns.

Panel B: Capacity Development and Support

• Preventing heart disease and stroke requires a robust and effective public health infrastructure. Recent events have underscored the need for improved public health infrastructure in the United States. The current public health infrastructure urgently needs 

to be transformed to allow initiation of programs that are large enough and have the 

necessary competencies to achieve the goals of the plan. Such competencies include technical as well as political capacity (i.e., to develop policies, partnerships, and a societal commitment to prevent heart disease and stroke). Both aspects are essential. Technical

capacity does not assure its own implementation, and a societal commitment cannot succeed without technical capacity.

• The public health capacities needed to prevent and manage CVD and other chronic 

diseases differ from those needed for communicable disease control. CVD presents 

special challenges because of its roots in societal conditions, its protracted duration of
D-5

Development of the Plan

development, its varied manifestations, and the need for a continuum of intervention

approaches (from CVH promotion through the full spectrum of primary and secondary

CVD prevention). Thus, addressing chronic diseases such as CVD requires an infrastructure of technical expertise and policies different from traditional public health agency

models.

• The goals of this plan can best be met by recognizing the needed contributions of a diverse

and culturally competent workforce.

• Capacity should be developed specifically to eliminate racial, ethnic, and geographic 

disparities in heart disease and stroke, through development of resources and competencies

that address the causes of these disparities.

• Capacity should be developed at multiple levels, including local (i.e., city, county), state,

tribal, and national. Challenges and opportunities unique to each should be considered. All

levels should engage communities where people live, work, learn, and play.

• These recommendations can be supported by the accumulated knowledge and experience

in public health practice and prevention research, which is sometimes derived from randomized trials but more often depends on other types of evidence (like many public health

decisions).

Panel C: Monitoring, Evaluation, and Communication

• Surveillance is needed at national, state, and especially local levels, with indicators 

established for community and individual measures.

• A strong focus is needed on current and future uses of new data.

• Publicly funded CVH programs must conduct process and outcome evaluations. Privately

funded programs should be encouraged to do the same.

• When planning surveillance and evaluation, three questions must be answered: What are

the minimum data requirements? What additional data are highly desirable? What is the

ideal scope of data collection? These answers are needed to develop appropriate interventions for CVD, to monitor the factors leading to CVD development, and to assess the

impact of interventions on the population. These answers are also critical for setting 

priorities for data collection systems.

Panel D: Research in CVH Promotion and CVD Prevention

• A research agenda for heart disease and stroke prevention must recognize the opportunities for research throughout the life span. Conditions that lead to CVD development 

(e.g., atherosclerosis, high blood pressure) can result from exposures during childhood,

adolescence, or even gestation. Risk factor levels generally progress throughout adulthood.

Many older adults remain at high risk for continued progression of atherosclerosis and

high blood pressure or recurrence of heart attacks or strokes unless adequate preventive

measures are taken. Thus, preventive measures are important in childhood and adolescence (or earlier) and throughout early, middle, and later adult years.

• The concept of best practices is well established in public health and involves systematic

review and assessment of available knowledge in accordance with accepted criteria. An

appropriate review of the extensive knowledge and experience that already exists from 

public health practices in preventing heart disease and stroke would advance CVD best

practices and help shape the prevention research agenda.

• The distinction between policy, environmental, and individual approaches to addressing

CVD should be recognized. All are appropriate, and each has elements especially suited to

particular settings.

• New prevention research will continually be needed to identify and evaluate current and

proposed interventions, especially those related to policy and environment, which have

rarely been investigated. Prevention effectiveness studies are needed to investigate inter-
Public Health Action Plan to Prevent Heart Disease and Stroke

D-6

ventions, addressing such aspects as the percentage of disease occurrence that can be prevented, costs and cost-effectiveness, feasibility (strengths/weaknesses/opportunities/threats), 

specific target populations, multiple levels (local, state, national), multiple settings (communities, work sites, schools, families), specific behaviors or health states studied as outcomes (e.g., smoking cessation, obesity), and effects of varied combinations of approaches

(e.g., in a comprehensive model program).

• Important determinants of cardiovascular risk, including social and environmental conditions, have been investigated much less than personal behaviors (e.g., dietary imbalance,

physical inactivity, smoking). These determinants require prominent attention in the

research agenda.

• The infrastructure needed for such research includes multiple agencies and organizations

at national, state, and local levels (including federal agencies, national voluntary organizations, and foundations). The roles of these and other potential partners in implementing

the research agenda are an important aspect of implementing the plan.

Panel E: Global Cardiovascular Health

• A public health strategy for CVH promotion and CVD prevention is guided by commitment to the social values of health as a human right, equity, solidarity, participation, and

accountability.1

• Cooperating on global CVD control and CVH promotion is imperative and urgent.

Partners in this plan recognize the strategic need for strong U.S. involvement in global

CVH issues.

• The basic needs of vast numbers of people continue to be unmet, and the resulting health

challenges leave many people without hope. A more optimistic view recognizes and

responds to the importance of a global context in addressing health and security. Better

health—achieved through improvements in basic living conditions, income, education,

and social services (including health care)—is a key element to achieving a better and safer

world for everyone. Without these elements, better CVH cannot be fully achieved.

• With current knowledge and resources, a world that is substantially free from epidemic

heart disease and stroke can be envisioned. Eliminating health inequalities and increasing

the quality and years of healthy life are strategic goals for the global community in this

century.

• To progress, we must maximize the use of all resources in our globalized, interconnected,

and interdependent world. Despite the current picture of world affairs, our commitment

to improving health conditions, especially CVH, offers the hope of a better future.

• The first four components of this plan (taking action, strengthening capacity, evaluating

impact, and advancing policy) can also apply to global CVH promotion. Global recommendations in these areas must 1) correspond to global needs; 2) correspond to capacities

and resources of CDC and its partners; 3) contribute to advancing national CVH or

enrich the plan itself; and 4) reflect the underlying values and correspond to the stated

vision of the plan.

• Based on the preceding criteria for global recommendations, CDC is assumed to be the

primary agency to support their implementation, in conjunction with regional and global

partners. The recommendations are directed accordingly.

The second meeting of each panel focused on making specific recommendations for the

Action Plan. Areas of consensus and difference were identified, and salient points were incorporated in a set of recommendations and corresponding action steps. The recommendations

and action steps constituted the primary products of the Expert Panels. These were used to

prepare the draft plan, after synthesis by the Working Group.
The National Forum was appointed in spring and summer 2002 and received the draft plan

in August 2002. The members met September 4, 2002, to discuss the proposed action steps

and the interests of their respective agencies, organizations, and constituencies in implementing the plan. The Working Group then made its final revisions to the draft plan.

Reference

1. Advisory Board of the First International Conference on Women, Heart Disease and Stroke. The

2000 Victoria Declaration on Women, Heart Diseases and Stroke. Victoria, Canada: Advisory Board of the

First International Conference on Women, Heart Disease and Stroke; May 8–10, 2000.

D-7

Development of the Plan
Public Health Action Plan to Prevent Heart Disease and Stroke

Robert Beaglehole

Gerald Berenson

Crystelle Fogle

Philip B. Gorelick

Robert Kaplan

Thomas E. Kottke

Russell V. Luepker

David MacLean

George A. Mensah

Gary Myers

Terry Pechacek

Linda Redman

Dawn Satterfield

Tom Schmid

Jennifer Smith

Howell Wechsler

Deedy Buric

Gerald Cooper

Adolfo Correa

Janet Croft

William Dietz

Robinson Fulwood

Wayne Giles

Meighan Girgus

Matthew Guidry

Dan Hanley

Rosemarie Henson

Gary Hogelin

Lloyd Kolbe

Brick Lancaster

Ellen Magnis

Margaret Malone

Christopher Maylahn

George A. Mensah

Joanne Mitten

Gary Myers

F. Javier Nieto

Thomas A. Pearson

Elizabeth Puckett

James Raczynski

Rose Marie Robertson

Wayne Rosamond

Eduardo J. Sanchez

Dan Sadler

Patti Shwayder

Patricia Turner

Gregory Taylor

Frank Vinicor

Joan Ware

Nancy Watkins

Elinor Wilson

Expert Panel A: Policy and Programs

Chair

Elizabeth Puckett

Members

Working Group

Chair

David C. Goff, Jr.

Consultant

Betty Sue Flowers

Members

Action Plan Participants

Expert Panel B: Capacity Development and Support

Chair

Thomas A. Pearson

Members

Stephanie Bailey

Carolyn Fisher

Diana Hawkins

George A. Mensah

Brian O’Connor

Alonzo Plough

Kristin Pope

Charlene Sanders

Suzanne Smith

Jody Stones

Lois Voelker

Nancy Watkins

Fran Wheeler

D-8
D-9

Expert Panel E: 

Global Cardiovascular Health

Chair

Elinor Wilson

Members

Samira Asma

Ricardo Granero

Kurt Greenlund

Jo Anne Grunbaum

Sonja Hedlund

Samer Jabbour

Becky Lankenau

Shanthi Mendis

George A. Mensah

K. Srinath Reddy

Linda J. Redman

Sylvie Stachenko

James F. Toole

Lois Voelker

Pam Wilson

Zhi-Jie Zheng

Expert Panel C: Monitoring, Evaluation, 

and Communication

Chair

Christopher Maylahn

Members

Ruth Bonita

Janet Croft

Linda Geiss

Jo Anne Grunbaum

Yuling Hong

Rochelle Hurst

Sara Huston

Laura Kann

Nora Keenan

Laura Kettel Khan

George A. Mensah

Michael Schooley

Petra Todd

Wendy Wattigney

Andy Wielgosz

Sheree Williams

Expert Panel D: Research in CVH Promotion 

and CVD Prevention

Chair

Wayne Rosamond

Members

Gloria Beckles

Richard Cooper

Adolfo Correa

Janet Croft

Jo Anne Grunbaum

Phil Huang

Nora Keenan

Steven Kelder

Beverly Kingsley

Lewis Kuller

Shiriki Kumanyika

Catherine Law

Anne-Marie Malarcher

Dyann Matson Koffman

Henry McGill

George A. Mensah

Michael Pratt

Steven Teutsch

Debra Wigand

Development of the Plan
D-10

Public Health Action Plan to Prevent Heart Disease and Stroke

Darwin R. Labarthe Miriam M. Fay Juanita Chukwura

Alliance of Community 

Health Plans

Cia Byrnes, Vice President for Medical

Affairs and Government Programs

American Academy of Family Physicians

Erik Lindbloom, Representative

American Academy of Neurology

Walter Koroshetz, Chair, Stroke Task Force

American Academy of Pediatrics

Frank Galioto, Jr., Member, Committee on

Cardiology

American Association of Diabetes

Educators

Kathy Berkowitz, President

American College of Cardiology

Cary Sennett, Senior Associate Executive

Vice President

American College of Preventive

Medicine

Jordan Richland, Executive Director

American Diabetes Association

Nathaniel Clark, National Vice President,

Clinical Affairs

American Dietetic Association

Judy Dausch, Senior Manager for

Regulatory Affairs

American Heart Association

(AHA)/American Stroke 

Association (ASA)

Rose Marie Robertson, 

Past President, AHA

Katherine Krause, Executive Vice

President, AHA

Mark Schoeberl, Vice-President,

State Advocacy & Health

Initiatives, Department of

Advocacy, AHA

Vickie Peters, Director, Strategic

Planning, AHA

Suzanne Smith, Advocacy

Consultant, AHA

F. Javier Nieto, Chair, Research

and Training Task Force,

Scientific Council on

Epidemiology and Prevention

(CEP), AHA

Ellen Magnis, Director, ASA

Meighan Girgus, Vice President, ASA

Larry Goldstein, Chair, ASA

American Legacy Foundation

Lyndon Haviland, Chief Operating Officer

American Public Health Association

Mohammad Akhter, Executive Director

Association of Black Cardiologists

Malcolm Taylor, President

B. Waine Kong, Chief Executive Officer

Association of Schools 

of Public Health

Tamara Burnette, Executive Assistant

Association of State and Territorial

Directors of Health Promotion and

Public Health Education

Joanne Mitten

Association of State and Territorial

Health Officials

Kathleen Nolan, Senior Director for

Prevention Policy

National Forum Participants

CDC Core Staff
D-11

Association of State and Territorial

Public Health Nutrition Directors

Denise Ferris, President

Canadian Institutes of Health Research,

Institute of Circulatory and 

Respiratory Health

Arun Chockalingam, Assistant Director

Centers for Medicare & Medicaid

Services, Quality Improvement Group

Eugene Freund, Senior Clinical Advisor

Chinese Task Force

Michael Wong, Chair

Candice Wong

Chronic Disease Directors,

Cardiovascular Health Council

Jennifer Smith, Chair

Council of Chief State School Officers

Stephanie Yun, Project Assistant

Foundation for Accountability

Susan Prows, Senior Director

Health Canada

Gregory Taylor, Director, Disease

Intervention Division

Nancy Porteous, Senior Policy

Analyst

Health Research and Educational Trust

Phillip Kletke, Director, Health Systems

Studies

HealthPartners, Center for Health

Promotion

Nico Pronk, Vice President

Heart and Stroke Foundation of Canada

Elinor Wilson, Chief Science Officer; Chair,

Expert Panel E

Human Resources and Services

Administration, Bureau of Primary

Health Care, Division of Community 

and Migrant Health

Richard Bohrer, Director

Indian Health Service

Nathaniel Cobb, Principal

Consultant for Chronic Disease;

Co-Director, National 

Epidemiology Program

James Galloway, Director, Native

American Cardiology Program

InterAmerican Heart Foundation

Beatriz Champagne, Executive Director

International Society for Hypertension in

Blacks

John Flack, President

International Stroke Society

James F. Toole, President

Jacobs Institute of Women's Health

Robyn Lipner, Executive Director

Kaiser Permanente, Care Management

Institute

William Caplan, Director of Clinical

Development

Mass PRO

Kenneth LaBresh, Associate Medical

Director

National Association for Sport and

Physical Education

Kim Graber, President

National Association of County and City

Health Officials (NACCHO)

Stephanie Bailey, Director of

Health, Metro

Nashville/Davidson County

Health Department

Alonzo Plough, Director,

Seattle–King County

Department of Public Health

National Civic League

Drew O'Connor, Director of Community

Services

National Committee for Quality

Assurance

Donna Pillittere, Senior Health Care

Analyst, Measures Development

Development of the Plan
Public Health Action Plan to Prevent Heart Disease and Stroke

National Governors Association

Joan Henneberry, Director, Health Policy

National Heart, Lung, and Blood

Institute

Robinson Fulwood, Senior Manager, Public

Health Program Development

National Indian Health Board

Lenna Aoki, Consultant

National Institute of Diabetes and

Digestive and Kidney Diseases

Saul Malozowski, Senior Advisor for Clinical

Trials and Diabetes Translation

National Institute of Neurologic

Disorders and Stroke, Office of Science

Policy and Planning

Patricia Turner, Program Analyst 

National Stroke Association

Deedy Buric, Vice President of Program

Development

New York State Department 

of Health, Bureau of Health Risk

Reduction

Christopher Maylahn, Director

North Carolina Department of Health

and Human Services, Division of Public

Health, Cardiovascular Health Unit

Elizabeth Puckett, Head; Chair, Expert

Panel A

Northwestern University Medical School,

Department of Preventive Medicine

Jeremiah Stamler, Professor Emeritus,

Keynote Lecturer

Pan American Health Organization

(PAHO), Division of Health Promotion

and Protection

Maria Cerqueira, Director

Partnership for Prevention

John Clymer, President

Pulmonary Hypertension Association

Lorie Simmons, Director, Advocacy and

Awareness

Smart Growth America

Don Chen, Executive Director

Society for Public Health Education

(SOPHE)

Patrick Stieg, Ambassador

Society of State Directors of Health,

Physical Education and Recreation

Sharon Murray, Executive Director

St. Luke's Episcopal Health Charities

Patricia Gail Bray, Director of Research

Texas Department of Health

Eduardo J. Sanchez, Commissioner of

Health

University of Alabama at Birmingham,

Center for Health Promotion,

Department of Health Behavior, School

of Public Health

James Raczynski, Director

University of North Carolina at Chapel

Hill, Department of Epidemiology

Wayne Rosamond, Associate Professor;

Chair, Expert Panel D

University of Rochester Medical Center,

Department of Community and

Preventive Medicine

Thomas A. Pearson, Professor; Chair,

Expert Panel B

U.S. Department of Education,

Department of Safe and 

Drug-Free Schools

Jennifer Medearis, Policy Analyst

U.S. Department of Health and Human

Services, Office of Disease Prevention

and Health Promotion

Matthew Guidry, Deputy Director for

External Affairs

Utah Department of Health, Utah

Cardiovascular Health Program

Joan Ware, Director

D-12
D-13

Wake Forest University School of

Medicine, Department of Public Health

Sciences and Internal Medicine

David C. Goff, Jr., Professor; Chair,

Working Group

Washington Business Group on Health,

Center for Prevention and Health

Services

Michael Britt, Manager

World Bank

Division of Health, Nutrition and Population

Daniel Miller, Health Specialist

Latin America and Caribbean Regional Office

Isabella Danel, Senior Public

Health Specialist

World Health Organization,

Noncommunicable Disease and Mental

Health Cluster

Derek Yach, Executive Director

World Heart Federation

Mario Fernando Camargo Maranhaõ,

President

Centers for Disease Control and

Prevention (CDC)

Office of The Director

Martha F. Katz, Deputy Director

for Policy and Legislation

National Center for Birth Defects and

Developmental Disabilities

Adolfo Correa, Medical 

Epidemiologist

National Center for Chronic Disease 

Prevention and Health Promotion

James S. Marks, Director

Janet Collins, Deputy Director

Connie Carmack, Acting Deputy Associate

Director for Planning 

Virginia S. Bales, Director, 

Division of Adult and Community 

Health (DACH)

Janet Croft, Epidemiologist,

Cardiovascular Health Branch, DACH

William Dietz, Director, Division of

Nutrition and Physical Activity

Wayne Giles, Associate Director for

Science, DACH

Rosemarie Henson, Director, Office on

Smoking and Health (OSH)

Lloyd Kolbe, Director, Division of

Adolescent and School Health

Brick Lancaster, Chief, Program Services

Branch, OSH

Margaret Malone, Deputy Branch Chief,

Cardiovascular Health Branch, DACH

George A. Mensah, Chief, Cardiovascular

Health Branch, DACH

Terry Pechacek, Associate Director for

Science, OSH

Frank Vinicor, Director, Division of

Diabetes Translation

Nancy Watkins, Health Education

Specialist, Cardiovascular Health Branch,

DACH

National Center for Environmental Health

Gary Myers, Chief, Clinical Chemistry

Branch

Gerald Cooper, Research Medical Officer,

Clinical Chemistry Branch

CDC Core Staff

Darwin R. Labarthe, Associate Director

for Cardiovascular Health Policy and

Research, DACH

Miriam M. Fay, ASPH/CDC Research

Fellow, DACH

Juanita Chukwura, Program Analyst, DACH

Development of the Plan
D-14
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