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• W1995806507 abstract "HomeJournal of the American Heart AssociationVol. 3, No. 6Challenges of Ascertaining National Trends in the Incidence of Coronary Heart Disease in the United States Open AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citations ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toOpen AccessReview ArticlePDF/EPUBChallenges of Ascertaining National Trends in the Incidence of Coronary Heart Disease in the United States Earl S. Ford, MD, MPH, Véronique L. Roger, MD, MPH, Shannon M. Dunlay, MD, MS, Alan S. Go, MD and Wayne D. Rosamond, PhD Earl S. FordEarl S. Ford Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA Search for more papers by this author , Véronique L. RogerVéronique L. Roger Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN Search for more papers by this author , Shannon M. DunlayShannon M. Dunlay Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN Search for more papers by this author , Alan S. GoAlan S. Go Division of Research, Kaiser Permanente Northern California, Oakland, CA Departments of Epidemiology, Biostatistics and Medicine, University of California, San Francisco, CA Department of Health Research and Policy, Stanford University School of Medicine, Palo Alto, CA Search for more papers by this author and Wayne D. RosamondWayne D. Rosamond Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC Search for more papers by this author Originally published3 Dec 2014https://doi.org/10.1161/JAHA.114.001097Journal of the American Heart Association. 2014;3:e001097IntroductionDespite major therapeutic advances, the public health burden associated with coronary heart disease (CHD) remains enormous with approximately 525 000 people predicted to have a new myocardial infarction (MI) in 2013, ≈15.4 million estimated to be living with CHD in 2013, and ≈1 346 000 people hospitalized in 2009 for CHD.1There are a variety of ways to measure the population impact of a disease including prevalence, associated morbidity and mortality, quality of life, health care utilization, and economic costs, and one of the most critical is disease incidence. From a surveillance perspective in the United States, the national vital statistics data system provides information about the death rate for CHD, various national data systems provide estimates of hospitalizations for CHD and outpatient visits for CHD, and national data systems provide data about levels of risk factors for CHD. The data systems allowing for estimates of prevalent CHD are less robust as they rely primarily on self‐reported information.A particularly glaring gap in our knowledge base has been the lack of nationally representative data to measure the incidence of CHD. Measuring incidence of a disease is particularly salient because incidence (1) is a key measure in helping to define the burden of a disease and identify high‐risk populations, (2) provides valuable information in helping decision makers set public health priorities, and (3) is a more relevant measure to assess the collective influence of risk factors in a population than prevalence. Consequently, tracking incidence of a disease in populations can: (1) yield timely data about potentially unfavorable changes in incidence that may prompt a search for explanations and corrective actions to redirect the course of a disease in a population, (2) provide valuable feedback in assessing efforts to control a disease, and (3) generate useful information for updating priorities regarding health promotion and disease prevention. The reasons why a national surveillance system to track CHD incidence in the United States has never been developed are not entirely clear but may relate to the cost and complexity of implementing such a system.Our objective is to review the fragmented data that may have bearing on incidence of CHD in the United States. Because national data about incident CHD are not readily available, we will examine various facets of CHD epidemiology—including mortality, hospitalizations and case‐fatality, prevalence, risk factors, and predicted risk—that may provide insights about national trends in the incidence of CHD. Incidence, prevalence, and mortality are interrelated,2, 3 and, hence, we will explore data for the latter two important population surveillance parameters. Declining mortality rates have been postulated as possible evidence for declining incidence rates, and, therefore, we examine published trends in mortality as well as in case‐fatality rates that have bearing on overall mortality rates from CHD. Furthermore, trends in hospitalizations for MI have often been used as a surrogate measure for trends in incidence of this condition, and consequently, we review national and regional data on this topic. Because the sum total of risk factors for CHD drive the incidence of this disease, we assess trends in individual risk factors as well as predicted risk calculated from major CHD risk factors. Finally, we review regional data about trends in CHD incidence from community surveillance and cohort studies.MortalityThe category “diseases of the heart” has long been and continues to be the leading cause of death in the United States based on data from death certificates.4 After increasing during the first part of the 20th century, the mortality rate attributed to CHD peaked during the late 1960s and reversed course starting a prolonged and continuing decline.5, 6 From 1980 through 2009, age‐adjusted CHD mortality has decreased by 66% among men and 67% among women (Figure 1). Furthermore, age‐adjusted rates decreased by 60% among African American women, 57% among African American men, 68% among white women, and 67% among white men (Figure 2). CHD mortality was defined as International Classification of Diseases (ICD)‐9 codes 410‐414 and 429.2 or ICD‐10 codes I20‐I25. Regional studies such as the Framingham Heart Study, the Minnesota Heart Survey, Honolulu Heart Program, and the Atherosclerosis Risk in Communities Study (ARIC) also described declining rates of CHD mortality.7, 8, 9, 10, 11 The factors contributing to the decline have been debated, and a combination of treatment and improvements in population levels of risk factors for CHD has been credited with lowering the CHD mortality rate.12, 13, 14, 15, 16, 17 The declining mortality rates raised the prospect of declining incidence rates. Because mortality rates are subject to a number of influences such as disease severity, case fatality, changes in risk factors, improved treatment, and incident or new cases,18 declining mortality rates alone cannot automatically be equated with declining incidence rates.Download PowerPointFigure 1. Age‐adjusted mortality rates from CHD for adults aged ≥25 years, United States. Results were generated with WONDER using the Compressed Mortality File of the National Vital Statistics System. For the period 1979–1999, International Classification of Diseases 9 codes 410‐414 and 429.2 were used. For 2000–2009, International Classification of Diseases codes I20‐O25 were used. Results were age‐adjusted to the projected year 2000 US population. CHD indicates coronary heart disease.Download PowerPointFigure 2. Age‐adjusted mortality rates from CHD for adults aged ≥25 years, by race and gender, United States. Results were generated with WONDER using the Compressed Mortality File of the National Vital Statistics System. For the period 1979–1999, International Classification of Diseases 9 codes 410‐414 and 429.2 were used. For 2000–2009, International Classification of Diseases codes I20‐O25 were used. Results were age‐adjusted to the projected year 2000 US population. AAF indicates African‐American females; AAM, African‐American males; CHD, coronary heart disease; OF, other females; OM, other males; WF, white females; WM, white men.HospitalizationsSeveral large data sets have provided information about trends in hospitalizations for MI (Table 1).Table 1. Large Studies of Trends in Hospitalization Rates for Myocardial Infarction in the United StatesReferenceData SourceStudy PeriodChange in Rates (Per 100 000)Discharge DiagnosisValidation of Discharge DiagnosesNallamothu19Acute Care Tracker Database2002–2005309 to 266PrincipalNoFang20National Hospital Discharge Survey1979–1981 to 1985–1987215 to 342PrincipalNo1985–1987 to 2003–2005342 to 242Chen21Medicare fee‐for‐service beneficiaries2002–20071131 to 866PrincipalNoWang22National inpatient sample2001–2007314 to 222PrincipalNoBased on the Acute Care Tracker data base, a proprietary administrative database that included 458 US hospitals, rates of hospitalization for MI based on principal diagnosis ICD‐9 codes decreased from 309 in 2002 to 266 per 100 000 population in 2005.19 The numbers of total discharges and coronary revascularizations compared reasonably well with estimates from the National Hospital Discharge Survey, but the diagnoses of MI were not specifically validated. An analysis of data from the National Hospital Discharge Survey showed that the rate of hospitalizations for MI using the first‐listed diagnosis code increased from 215 in 1979–‐1981 to 342 per 100 000 population in 1985–‐1987, remained relatively level until 1996, and then declined to 242 per 100 000 population in 2003–‐2005.20 No validation of discharge diagnoses was done. The rate of hospitalizations for MI using principal diagnosis codes among Medicare fee‐for‐service beneficiaries dropped from 1131 in 2002 to 866 per 100 000 person‐years in 2007.21 Discharge diagnoses were not validated. An analysis of data from the National Inpatient Sample of the Healthcare Cost and Utilization Project from 2001 to 2007 found that the rate of hospitalization from MI based on the principal diagnosis dropped from 314 to 222 per 100 000 population, and decreases were observed in most demographic subgroups.22 The validity of the discharge diagnoses over time remained untested in this data set. However, these studies were not able to identify incident CHD or to examine the impact of changes in diagnostic criteria for MI on hospitalization rates. Furthermore, validation of hospitalizations for MI diagnostic codes has generally not been done in these studies.Case‐FatalitySeveral measures of case‐fatality rates can be conceptualized in terms of time frame: in‐hospital mortality, 28‐ or 30‐day mortality, and 1‐, 2‐, 3‐, and 5‐year mortality (Table 2).Table 2. Selected Studies of Changes in Case‐Fatality Rates for Hospitalizations for Myocardial Infarction or Incident Coronary Heart Disease in the United StatesReferenceStudyCHD EventPeriodChanges in Case‐Fatality Rate (%)In‐Hospital28‐Day30‐Day3‐Months1‐Year2‐Year3‐Year5‐YearElveback7Rochester, MNIncident MI1965–1969 to 1970–197518.0 to 9.340.0 to 34.0Gillum23Minnesota Heart SurveyAny MI1970–1980Men: 16.7 to 11.9Women: 16.6 to 12.2Pell24Du Pont CompanyIncident MI1957–195930.41972–197434.81981–198324.3Goldberg25Worcester Heart Attack StudyAny MI hospitalization1975–198422.2 to 15.1Incident MI1975–198420.1 to 12.6Reed9Honolulu Heart ProgramIncident CHD1966–1985↑↑Keil26Pee Dee, SCAny MI1978–1985Total: 14 to 9.9WM: 12.3 to 7.4WW: 20.0 to 7.0BM: 17.7 to 17.4BW: 9.1 to 29.4McGovern18Minnesota Heart SurveyIncident MI hospitalization1985–1990Men: 13 to 10Men: 21 to 18Women: 15 to 12Women: 29 to 24Rosamond11Atherosclerosis Risk in Communities StudyAny MI hospitalization1987–1994Men: 4.1%/y ↓BM: 2% ↑WM: 5.1% ↓Women: 9.8%/y ↓BW: 3.1% ↓WW: 12.1% ↓Goldberg27Worcester Heart Attack StudyIncident MI hospitalization1975–197817.812.0a17.0a31.01981–198414.913.0a19.0a32.01986–198817.010.0a16.0a29.01990–199113.213.0a19.0a31.01993–199511.711.0a17.0a―Ergin28National Health and Nutrition Examination Survey I EFSIncident CHD1971–1982Total: 23.4; WM: 27.2; WW: 15.3; BM: 39.2; BW: 26.51982–1992Total: 16.6; WM: 19.0; WW: 14.2; BM: 10.8; BW: 16.6Peterson29National Registry of Myocardial InfarctionAny MI hospitalization1990–200610.4 to 6.3Any STEMI11.5 to 8.0Any NSTEMI7.1 to 5.2Wellenius30Medicare beneficiariesAny MI hospitalization1984–2003WM: 22.7 to 10.1WM: 25.2 to 14.3WM: 40.3 to 28.7WW: 23.1 to 10.3WW: 25.2 to 14.4WW: 39.3 to 28.8BM: 18.6 to 11.2BM: 20.9 to 15.5BM: 37.2 to 34.8BW: 20.0 to 11.2BW: 21.6 to 15.1BW: 38.5 to 33.8Parikh31Framingham Heart Study, Framingham Heart Study OffspringIncident MI1960–1969 to 1990–199973.0 ↓65.0 ↓64.0 ↓Incident MI‐ECG62.0 ↓58.0 ↓64.0 ↓Incident MI‐marker78.0 ↓69.0 ↓55.0 ↓Floyd32Worcester Heart Attack StudyIncident MI hospitalization1975–200519.5 to 9.5Fang20National Hospital Discharge SurveyAny MI hospitalization1979–1981 to 2003–200517.8 to 8Yeh33Kaiser Permanente Northern CaliforniaIncident MI hospitalization1999–200810.5 to 7.8Incident NSTEMI hospitalization10.0 to 7.6Roger34Olmsted County, MNIncident MI hospitalization1987–2006−4.3%/yMcManus35Worcester Heart Attack StudyAny STEMI hospitalization199711.113.210.6a19999.913.014.0a200113.515.815.4a20038.410.08.3a20059.711.48.4aAny NSTEMI hospitalization199712.916.023.1a199913.117.027.6a200110.916.526.1a20038.913.725.6a20059.514.018.7aNguyen36Worcester Heart Attack StudyAny MI hospitalization1986–1988 to 2003–2005 Men, <65 years: 7.1 to 2.2 Women, <65 years: 9.6 to 5.3 Men, age 65 to 74 years: 14.3 to 8.2 Women, age 65 to 74 years: 19.6 to 11.5 Men ≥75 years: 30.2 to 13.3 Women ≥75 years: 29.6 to 12.6 Coles37Worcester Heart Attack StudyIncident MI2001–200711.1 to 7.9a17.1 to 12.7a25.6 to 18.6aRosamond38Atherosclerosis Risk in Communities StudyIncident MI hospitalizations1987–2008Men: 3.4%/y ↓, WM: 3.5%/y ↓, BM: 3.4% ↓, Women: 2.9% ↓, WW: 3.0%/y ↓, BW: 2.6% ↓BM indicates black men; BW, black women; CHD, coronary heart disease; ECG, electrocardiogram; NSTEMI, non‐ST‐segment myocardial infarction; STEMI, ST‐segment elevation myocardial infarction; WM, white men; WW, white women.aPost‐discharge.Numerous publications have documented improvements in the in‐hospital or short‐term case‐fatality rate.7, 11, 18, 20, 23, 24, 25, 26, 28, 29, 30, 31, 32, 33, 34, 38, 39 The first indications that CHD case‐fatality rates had improved emerged during the 1960s.7 Since then, case‐fatality rates have generally improved steadily. Fewer data are available concerning the long‐term survival of people who develop CHD. In Rochester, MN, the 5‐year mortality rate from 1965–1969 to 1970–1975 decreased from 40.0% to 34.0%.7 An early report from the Worcester Heart Attack Study failed to observe improved post‐discharge long‐term survival in patients who sustained an MI in 1975, 1978, or 1981.40 A subsequent analysis of data from this study again failed to find improvements in 1‐, 2‐, and 5‐year survival rates for patients who were discharged during 1975–1978, 1981–1984, 1986–1988, and 1990–1991.27 More recently, 1‐year survival for patients discharged with an ST‐segment elevation MI (STEMI) during 2003 and 2005 and for patients discharged with non‐ST‐segment MI (NSTEMI) during 2005 improved,35 and 1‐ and 2‐year mortality rates from 2001 to 2006 decreased from 17.1% to 12.7% and 25.6% to 18.6%, respectively.37 In the Minnesota Heart Survey, 3‐year mortality after hospitalization for MI decreased from 21% in 1985 to 18% in 1990 among men and from 29% to 24% among women.18 Among Medicare beneficiaries, 1‐year mortality after a MI decreased from 40.2% in 1984 to 34.5% in 2003.30 In the Framingham Study, 1‐ and 5‐year mortality among adults who had an MI decreased by 65% and 64%, respectively, during the period from 1960 to 1999.31PrevalenceBroadly speaking, prevalence represents the net sum of input (incidence) and outflow (mortality). Thus, information about trends in CHD prevalence may shed light on the incidence of CHD. Information about the prevalence of CHD comes from national surveys, cohort studies, and regional surveillance systems. National surveys like the National Health and Nutrition Examination Survey (NHANES), National Health Interview Survey (NHIS), and Behavioral Risk Factor Surveillance System (BRFSS) use questionnaires to collect data to estimate the prevalence of CHD. Because these systems rely on self‐reported information, such information is particularly susceptible to various biases.Several analyses of NHANES data have been undertaken. Among NHANES participants aged 40 to 74 years, estimates of the prevalence of self‐reported MI were 6.3% during 1971–1975, 5.6% during 1976–1980, and 5.7% during 1988–1994.41 Among adults aged 35 to 54 years who participated in NHANES, the prevalence of self‐reported MI was 2.5% during 1988–1994 and 2.2% during 1999–2004 among men and 0.7% during 1988–1994 and 1.0% during 1999–2004 among women.42 Analysis of NHANES data by the National Heart, Lung, and Blood Institute showed that the prevalence of self‐reported MI has declined from 1971–1975 to 2005–2008 most clearly among whites and among men.6To examine the recent trend in CHD prevalence, we used NHANES data of adults aged ≥20 years from 1999 to 2012 (Table 3).43 CHD was defined as ever having been told by a doctor or other health professional that the participant had CHD, angina pectoris, or a heart attack. The unadjusted prevalence showed little change during the 10‐year period. After adjustment for age, the prevalence of CHD increased from 6.3% during 1999–2000 to 6.9% during 2003–2004 and then decreased to 5.2% during 2009–2012, and the overall trend showed a decrease (P for linear trend=0.001). Furthermore, decreases in the age‐adjusted prevalence of self‐reported CHD were noted for men, women, whites, African Americans, adults who had not completed high school or with education beyond high school, adults without diagnosed diabetes, and adults with a body mass index <30 kg/m2.Table 3. Unadjusted and Age‐Adjusted Prevalence (%, SE) of Self‐Reported CHD Among Adults Aged ≥20 Years, National Health and Nutrition Examination Survey 1999–20121999–20002001–20022003–20042005–20062007–20082009–20102011–2012P Linear TrendUnadjusted resultsTotal5.8 (0.4)5.9 (0.5)6.8 (0.8)6.1 (0.5)5.6 (0.3)5.5 (0.4)5.4 (0.4)0.165Age, y20 to 441.0 (0.3)1.0 (0.2)0.7 (0.3)1.1 (0.3)0.8 (0.2)1.0 (0.3)1.0 (0.3)0.99645 to 544.9 (0.9)3.7 (0.8)4.3 (0.8)4.2 (0.6)3.7 (0.6)4.0 (0.6)2.9 (0.8)0.15455 to 6413.2 (1.5)11.4 (2.5)11.9 (1.9)8.9 (1.6)8.2 (1.1)9.2 (1.0)7.0 (0.8)0.00165+18.3 (1.3)21.6 (1.9)23.9 (2.2)20.4 (1.2)19.2 (1.4)16.3 (1.0)17.9 (1.1)0.022GenderMen7.3 (0.8)6.8 (0.7)7.8 (1.0)7.1 (0.6)7.0 (0.5)7.3 (0.6)6.5 (0.6)0.529Women4.5 (0.5)5.0 (0.6)5.8 (0.7)5.1 (0.6)4.3 (0.3)3.9 (0.4)4.4 (0.4)0.105Race or ethnicityWhites6.7 (0.4)6.7 (0.6)7.7 (0.8)6.9 (0.6)6.1 (0.5)6.4 (0.5)6.2 (0.6)0.177African Americans4.0 (0.6)5.8 (0.9)4.7 (0.6)5.9 (0.7)4.4 (0.7)4.7 (0.7)4.4 (0.4)0.668Mexican Americans2.6 (0.3)2.6 (0.5)2.8 (0.6)3.1 (0.4)3.1 (0.4)3.7 (0.7)2.6 (0.8)0.414Other4.3 (0.5)2.8 (0.7)5.4 (1.9)2.3 (0.7)5.4 (0.8)3.1 (0.6)4.1 (0.6)0.991Education<High school8.2 (0.6)10.3 (1.0)10.8 (1.9)10.6 (1.1)8.4 (0.5)8.3 (1.0)8.0 (0.9)0.144High school graduate or equivalent7.0 (0.7)6.0 (0.8)7.1 (1.2)6.4 (1.1)6.2 (0.7)7.1 (0.8)7.0 (1.3)0.806>High school4.0 (0.5)4.2 (0.4)5.3 (0.5)4.6 (0.4)4.3 (0.3)4.1 (0.4)4.2 (0.5)0.733Diagnosed diabetesYes21.4 (3.2)19.2 (3.0)21.4 (3.0)21.0 (1.8)20.0 (1.7)17.6 (1.9)19.3 (1.9)0.425No4.7 (0.4)4.9 (0.4)5.4 (0.5)4.7 (0.4)4.1 (0.3)4.3 (0.3)3.8 (0.4)0.014BMI, kg/m2<253.9 (0.3)3.3 (0.5)5.5 (0.8)3.4 (0.5)4.1 (0.4)3.5 (0.6)3.5 (0.6)0.36825 to <306.7 (0.7)5.7 (0.8)7.2 (0.8)7.1 (0.7)5.3 (0.5)4.9 (0.5)5.2 (0.7)0.034≥307.2 (0.7)8.0 (1.0)8.0 (0.9)7.2 (0.6)7.0 (0.8)8.0 (0.6)7.3 (0.5)0.873Age‐adjusted resultsTotal6.3 (0.4)6.4 (0.5)6.9 (0.6)6.1 (0.3)5.5 (0.3)5.3 (0.3)5.2 (0.3)0.001GenderMen8.4 (0.9)7.9 (0.7)8.4 (0.9)7.7 (0.5)7.4 (0.5)7.4 (0.4)6.6 (0.5)0.043Women4.6 (0.5)5.2 (0.5)5.6 (0.7)4.9 (0.6)4.0 (0.3)3.7 (0.4)4.0 (0.3)0.003Race or ethnicityWhites6.6 (0.4)6.5 (0.6)7.0 (0.7)6.2 (0.4)5.4 (0.4)5.5 (0.4)5.2 (0.4)0.001African Americans5.4 (0.9)7.5 (0.9)5.6 (0.7)7.1 (0.7)4.9 (0.7)4.9 (0.5)4.8 (0.4)0.037Mexican Americans4.6 (0.5)5.5 (0.7)5.4 (0.5)4.4 (0.4)5.2 (0.6)5.6 (0.7)4.8 (1.4)0.908Other5.5 (0.9)4.3 (0.8)7.3 (2.5)2.9 (0.8)6.1 (0.7)4.2 (0.8)4.9 (0.7)0.481Education<High school7.3 (0.7)9.1 (1.0)8.8 (1.3)9.1 (0.9)7.4 (0.6)7.0 (0.8)6.3 (0.7)0.040High school graduate or equivalent7.2 (0.7)6.3 (0.9)6.8 (1.0)5.6 (0.6)5.7 (0.5)6.5 (0.8)6.1 (1.2)0.404>High school5.5 (0.7)5.4 (0.4)6.5 (0.5)5.5 (0.4)4.8 (0.3)4.3 (0.3)4.5 (0.4)0.008Diagnosed diabetesYes14.3 (2.8)13.6 (3.1)13.1 (2.0)12.0 (1.3)12.2 (1.4)9.6 (1.2)11.6 (1.6)0.150No5.6 (0.4)5.7 (0.4)6.0 (0.5)5.2 (0.4)4.5 (0.3)4.6 (0.3)4.1 (0.3)<0.001BMI, kg/m2<255.1 (0.4)4.5 (0.6)6.3 (0.8)3.7 (0.5)4.6 (0.4)3.9 (0.5)3.6 (0.4)0.00325 to <306.8 (0.7)5.9 (0.7)6.5 (0.7)6.7 (0.5)4.9 (0.4)4.5 (0.4)4.8 (0.5)0.002≥307.1 (0.8)8.7 (0.9)8.2 (0.9)7.1 (0.4)6.7 (0.8)7.3 (0.5)6.8 (0.4)0.151Based on data from the NHIS from 1980 to 1989, the age‐adjusted prevalence of self‐reported CHD among US adults aged 45 to 84 years varied between 2.2% and 2.6% with no clear trend.44 Recent data from the BRFSS showed that the prevalence of self‐reported CHD declined from 6.7% in 2006 to 6.0% in 2010 in adult populations aged ≥18 years.45 Declines were noted in all age groups, men and women, all education groups, and among whites and Hispanics but not among blacks, Asians or Native Hawaiians/Other Pacific Islanders, and American Indians or Alaska Natives.In several NHANES, electrocardiograms (ECGs) were administered to adults aged 40 to 74 years. However, recent NHANES have not included this component. The percentages of adults with possible or probable ECG‐defined MI were 3.6% during 1971–1975, 3.4% during 1976–1980, and 2.4% during 1988–1994.41Among successive groups of Framingham Study participants who were aged 55 to 64 years in 1953, 1963, and 1973, the prevalence of CHD among men increased from 10.2% in 1953 to 15.9% in 1973 (P=0.003) and that among women from 5.5% in 1953 to 6.9% in 1973 (P=0.250).46 CHD was defined as MI, coronary insufficiency, angina pectoris, and sudden and non‐sudden death from CHD.Period prevalence of MI (hospitalization for MI or an out‐of‐hospital death due to MI) in the Pee Dee area of South Carolina decreased from 642 per 100 000 population in 1978 to 469 per 100 000 population in 1985.26 This overall trend reflected a significant decrease among white men, nonsignificant decreases among black men and women, and a nonsignificant increase among white women.A series of autopsy studies from Olmsted County, Minnesota provide an interesting perspective on the trend in the prevalence of CHD. Among adults aged >30 years, the prevalence of “significant coronary disease” increased from 23% during 1950–1954 to 51% during 1975–1979 and the prevalence of a MI scar ranged between 36% and 41%.47 A subsequent autopsy study showed that the prevalence of atherosclerosis declined among adults aged 20 to 59 years (1979–1983: 38%; 1984–1989: 36%; 1990–1994: 27%; P for trend=0.02) but not adults aged ≥60 years (1979–1983: 61%; 1984–1989: 70%; 1990–1994: 59%; P for trend=0.44) from 1979 to 1994.48 A more recent autopsy study among residents aged 16 to 64 years from 1981 to 2004 showed declines in the prevalence of any coronary artery disease and mean grade.49Risk FactorsImpressive changes in major risk factors for CHD have occurred since the 1960s when national data about many of these risk factors first became available. The per capita cigarette consumption in the United States increased tremendously from 1900 into the 1960s. Subsequent to the first Surgeon General's Report in 1964, cigarette consumption started to decline and has reached levels last seen during the 1930s.50 In concert, the prevalence of smoking has decreased precipitously from 42.4% in 1965 to 19.3% in 2010.51 Furthermore, the exposure to second‐hand tobacco smoke has also declined.52Concentrations of total cholesterol, non‐high‐density lipoprotein cholesterol, and low‐density lipoprotein cholesterol have decreased. Among adults aged 20 to 74 years, mean concentrations of total cholesterol were 222 mg/dL during 1960–1962, 216 mg/dL during 1971–1975, 215 mg/dL during 1976–1980, 204 mg/dL during 1988–1994, and 203 mg/dL during 1999–2002.53 Among adults aged ≥20 years, mean concentrations of total cholesterol were 206 mg/dL during 1988–1994, 203 mg/dL during 1999–2002, and 196 mg/dL during 2007–2010; mean concentrations of high‐density lipoprotein cholesterol were 50.7 mg/dL during 1988–1994, 51.3 mg/dL during 1999–2002, and 52.5 mg/dL during 2007–2010; mean concentrations of non‐high‐density lipoprotein cholesterol were 155 mg/dL during 1988–1994, 152 mg/dL during 1999–2002, and 144 mg/dL during 2007–2010; and mean concentrations of low‐density lipoprotein cholesterol were 129 mg/dL during 1988–1994, 123 mg/dL during 1999–2002, and 116 mg/dL during 2007–2010.54 In addition, control of hypercholesterolemia has also improved.55The trend in hypertension has been more complicated.56, 57, 58 Among adults aged 18 to 74 years, the age‐adjusted prevalence of hypertension was 29.7% during 1960–1962, 36.3% during 1971–1974, 31.8% during 1976–1980.56 Among adults aged ≥20 years, the age‐adjusted prevalence of hypertension was 29.6% during 1999–2000, 29.0% during 2001–2002, 30.7% during 2003–2004, 29.9% during 2005–2006, 30.6% during 2007–2008, and 29.5% during 2009–2010.58 Both publications used a similar definition of hypertension (systolic blood pressure ≥140 mm Hg, diastolic blood pressure ≥90 mm Hg, or use of antihypertensive medication). Thus, the prevalence of hypertension has shown little change since 1988–1994. However, control of hypertension is improving.57, 58, 59 Of adults with hypertension, 33.2% were controlled during 1999–2002 compared with 45.8% during 2005–2008.59National data sets provide few insights about the long‐term changes in physical activity. Analyses of data from the NHIS show that 14.3% of adults aged ≥18 years in 1998, 15.0% in 2000, 19.1% in 2009, and 20.7% in 2010 met the 2008 Physical Activity Guidelines for Americans (both aerobic activity [≥150 minutes/week of moderate‐intensity, 75 minutes/week of vigorous‐intensity aerobic physical activity, or an equivalent combination of moderate‐and vigorous‐intensity aerobic activity] and muscle‐ strengthening activities [≥2 days/week of muscle‐strengthening activities involving all major muscle groups of moderate or high intensity]).60 This apparent increase in leisure‐time physical activity may have been counterbalanced by unfavorable trends in energy expenditure at work and sedentary behavior. From 1960–1962 to 2003–2006, estimated mean daily energy expenditure at work among men and women declined by more than 100 calories.61 Sedentary behavior as exemplified by screen time (the amount of time that people spend watching television and videos, playing video games, or using a computer) has increased nationally.62Weight and height have been measured in national surveys in the United States since 1960–1962. Among adults aged 20 to 74 years, the prevalence of obesity (body mass index ≥30 kg/m2) was 13.4% during 1960–1962, 14.5% during 1971–1974, 15.0% during 1976–1980, 23.3% during 1988–1994, and 30.9% during 1999–2000.63 Among adults aged ≥20 years, the prevalence of obesity (body mass index ≥30 kg/m2) was 30.5% during 1999–2000, 30.6% during 2001–2002, 32.2% during 2003–2004, 34.3% during 2005–2006, and 33.8% during 2007–2008, and 35.7% during 2009–2010.64, 65 Abdominal obesity has also increased since 1988–1994.66, 67In the wake of the stark rise in obesity, the prevalence of diabetes has increased substantially since 1976–1980. Using 1985 WHO criteria, the prevalence of diabetes among adults aged 40 to 74 years was 11.4% during 1976–1980 and 14.3% during 1988–1994.68 Using 2008 ADA criteria, the prevalence of diabetes was 15.3% during 1988–1994 and 17.5% during 2005–2006.69Predicted CHD RiskStarting with the Framingham Risk Score,70 multiple CHD risk equations have been developed to estimate the risk of developing incident CHD over a defined period, generally 10 years. Because these risk equations integrate the effects of key risk factors for CHD, trends in the predicted risk for CHD may correlate with trends in incident CHD. Using risk equations contained in the Adult Treatment Panel III report, little change in predicted 10‐year risk for CHD was observed from the period 1988–1994 to 1999–2002 among US adults.71 During 1988–1994, 76.5% of adults had a predicted 10‐year risk of <10%, 11.2% had a predicted 10‐year risk of 10% to 20%, and 12.3% had a predicted 10‐year risk of >20%. During 1999–2002, these percentages were 75.6%, 11.4%, and 13.0%, respectively. A subsequent analysis of national data showed that mean predicted 10‐year risk calculated using the Framingham Risk Score for CHD decreased from 10.0% during 1976–1980 to 7.9% during 1988‐1994 (P<0.001) and decreased from 7.9% during 1988–1994 to 7.4% during 1999‐2004 (P<0.001).72 The results from the latter study support the thesis of a decline in the incidence of CHD. A more recent analysis of NHANES data showed a continuing decline in predicted 10‐year risk from 1999–2000 to 2009–2010.73IncidenceBecause incident CHD can manifest itself in different clinical presentations, measuring incident CHD can be challenging. A person may experience the first signs of CHD as angina pectoris and be treated on an outpatient basis. Another person may experience an MI as the first sign of CHD and be hospitalized. Someone else may die of sudden cardiac death. Thus, providing an integrated picture of all these possible first occurrences of CHD would require a system that is able to capture the spectrum of disease expression. However, such a system does not currently exist at the national level. Because national data about incident CHD" @default.
• W1995806507 created "2016-06-24" @default.
• W1995806507 creator A5008046120 @default.
• W1995806507 creator A5056145805 @default.
• W1995806507 creator A5065857137 @default.
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• W1995806507 creator A5084957131 @default.
• W1995806507 date "2014-12-17" @default.
• W1995806507 modified "2023-09-26" @default.
• W1995806507 title "Challenges of Ascertaining National Trends in the Incidence of Coronary Heart Disease in the United States" @default.
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