Decline in Cardiovascular Mortality: Possible Causes and Implications.

If the control of infectious diseases was the public health success story of the first half of the 20th century, then the decline in mortality from coronary heart disease and stroke has been the success story of the century's past 4 decades. The early phase of this decline in coronary heart disease and stroke was unexpected and controversial when first reported in the mid-1970s, having followed 60 years of gradual increase as the US population aged. However, in 1978, the participants in a conference convened by the National Heart, Lung, and Blood Institute concluded that a significant recent downtick in coronary heart disease and stroke mortality rates had definitely occurred, at least in the US Since 1978, a sharp decline in mortality rates from coronary heart disease and stroke has become unmistakable throughout the industrialized world, with age-adjusted mortality rates having declined to about one third of their 1960s baseline by 2000. Models have shown that this remarkable decline has been fueled by rapid progress in both prevention and treatment, including precipitous declines in cigarette smoking, improvements in hypertension treatment and control, widespread use of statins to lower circulating cholesterol levels, and the development and timely use of thrombolysis and stents in acute coronary syndrome to limit or prevent infarction. However, despite the huge growth in knowledge and advances in prevention and treatment, there remain many questions about this decline. In fact, there is evidence that the rate of decline may have abated and may even be showing early signs of reversal in some population groups. The National Heart, Lung, and Blood Institute, through a request for information, is soliciting input that could inform a follow-up conference on or near the 40th anniversary of the original landmark conference to further explore these trends in cardiovascular mortality in the context of what has come before and what may lie ahead.

Redistribution of heart failure as the cause of death: the Atherosclerosis Risk in Communities Study.

BACKGROUND: Heart failure is sometimes incorrectly listed as the underlying cause of death (UCD) on death certificates, thus compromising the accuracy and comparability of mortality statistics. Statistical redistribution of the UCD has been used to examine the effect of misclassification of the UCD attributed to heart failure, but sex- and race-specific redistribution of deaths on coronary heart disease (CHD) mortality in the United States has not been examined. METHODS: We used coarsened exact matching to infer the UCD of vital records with heart failure as the UCD from 1999 to 2010 for decedents 55 years old and older from states encompassing regions under surveillance by the Atherosclerosis Risk in Communities (ARIC) Study (Maryland, Minnesota, Mississippi, and North Carolina). Records with heart failure as the UCD were matched on decedent characteristics (five-year age groups, sex, race, education, year of death, and state) to records with heart failure listed among the multiple causes of death. Each heart failure death was then redistributed to plausible UCDs proportional to the frequency among matched records. RESULTS: After redistribution the proportion of deaths increased for CHD, chronic obstructive pulmonary disease, diabetes, hypertensive heart disease, and cardiomyopathy, P < 0.001. The percent increase in CHD mortality after redistribution was the highest in Mississippi (12%) and lowest in Maryland (1.6%), with variations by year, race, and sex. Redistribution proportions for CHD were similar to CHD death classification by a panel of expert reviewers in the ARIC study. CONCLUSIONS: Redistribution of ill-defined UCD would improve the accuracy and comparability of mortality statistics used to allocate public health resources and monitor mortality trends.

Individual education, area income, and mortality and recurrence of myocardial infarction in a Medicare cohort: the National Longitudinal Mortality Study.

BACKGROUND: The Medicare program provides universal access to hospital care for the elderly; however, mortality disparities may still persist in this population. The association of individual education and area income with survival and recurrence post Myocardial Infarction (MI) was assessed in a national sample. METHODS: Individual level education from the National Longitudinal Mortality Study was linked to Medicare and National Death Index records over the period of 1991-2001 to test the association of individual education and zip code tabulation area median income with survival and recurrence post-MI. Survival was partitioned into 3 periods: in-hospital, discharge to 1 year, and 1 year to 5 years and recurrence was partitioned into two periods: 28 day to 1 year, and 1 year to 5 years. RESULTS: First MIs were found in 8,043 women and 7,929 men. In women and men 66-79 years of age, less than a high school education compared with a college degree or more was associated with 1-5 year mortality in both women (HRR 1.61, 95% confidence interval 1.03-2.50) and men (HRR 1.37, 1.06-1.76). Education was also associated with 1-5 year recurrence in men (HRR 1.68, 1.18-2.41, < High School compared with college degree or more), but not women. Across the spectrum of survival and recurrence periods median zip code level income was inconsistently associated with outcomes. Associations were limited to discharge-1 year survival (RR lowest versus highest quintile 1.31, 95% confidence interval 1.03-1.67) and 28 day-1 year recurrence (RR lowest versus highest quintile 1.72, 95% confidence interval 1.14-2.57) in older men. CONCLUSIONS: Despite the Medicare entitlement program, disparities related to individual socioeconomic status remain. Additional research is needed to elucidate the barriers and mechanisms to eliminating health disparities among the elderly.

Cardiovascular epidemiology in a changing world--challenges to investigators and the National Heart, Lung, and Blood Institute.

Over the past 60 years, revolutionary discoveries made by epidemiologists have contributed to marked declines in cardiovascular disease morbidity and mortality. Now, in an era of increasingly constrained resources, researchers in cardiovascular epidemiology face a number of challenges that call for novel, paradigm-shifting approaches. In this paper, the authors pose to the community 4 critical questions: 1) How can we avoid wasting resources on studies that provide little incremental knowledge? 2) How can we assure that we direct our resources as economically as possible towards innovative science? 3) How can we be nimble, responding quickly to new opportunities? 4) How can we identify prospectively the most meritorious research questions? Senior program staff at the National Heart, Lung, and Blood Institute invite the epidemiology community to join them in an ongoing Web-based blog conversation so that together we might develop novel approaches that will facilitate the next generation of high-impact discoveries.

Lifestyle factors and risk for new-onset diabetes: a population-based cohort study.

BACKGROUND: Epidemiologic data on the combined influence of several lifestyle factors on diabetes risk are rare, particularly among older adults. OBJECTIVE: To examine how combinations of lifestyle risk factors relate to the 11-year risk for incident diabetes. DESIGN: Population-based prospective cohort study. SETTING: National Institutes of Health (NIH)-AARP Diet and Health Study. PARTICIPANTS: 114,996 men and 92,483 women, aged 50 to 71 years in 1995 to 1996, without evidence of heart disease, cancer, or diabetes. MEASUREMENTS: A comprehensive survey of demographic characteristics and lifestyle factors, including dietary intake, body weight and height, physical activity, smoking, and alcohol consumption at baseline (1995 to 1996). Low-risk groups were formed by dichotomizing each lifestyle factor. Incident self-reported, physician-diagnosed diabetes was identified with a follow-up survey in 2004 to 2006. RESULTS: 11,031 men (9.6%) and 6969 women (7.5%) developed new-onset diabetes. For each additional lifestyle factor in the low-risk group, the odds for diabetes were 31% lower (odds ratio [OR], 0.69 [95% CI, 0.68 to 0.71]) among men and 39% lower (OR, 0.61 [CI, 0.60 to 0.63]) among women. Men and women whose diet score, physical activity level, smoking status, and alcohol use were all in the low-risk group had ORs for diabetes of 0.61 (CI, 0.56 to 0.66) and 0.43 (CI, 0.34 to 0.55), respectively. When absence of overweight or obesity was added, the respective ORs were 0.28 (CI, 0.23 to 0.34) and 0.16 (CI, 0.10 to 0.24) for men and women. Results did not differ by family history of diabetes or level of adiposity. LIMITATION: The study was observational, with potential for residual confounding. CONCLUSION: Lifestyle factors, when considered in combination, are associated with a substantial reduction in risk for diabetes. PRIMARY FUNDING SOURCE: The NIH-AARP Diet and Health Study was supported by the Intramural Research Program of the NIH.

Trends in serum lipids among US youths aged 6 to 19 years, 1988-2010.

CONTEXT: For more than 20 years, primary prevention of coronary heart disease has included strategies intended to improve overall serum lipid concentrations among youths. OBJECTIVE: To examine trends in lipid concentrations among youths from 1988-1994 through 2007-2010. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional analysis of serum lipid concentrations among 16,116 youths aged 6 to 19 years who participated in the nationally representative National Health and Nutrition Examination Survey during 3 time periods: 1988-1994, 1999-2002, and 2007-2010. MAIN OUTCOME MEASURES: Among all youths, mean serum total cholesterol (TC), non-high-density lipoprotein cholesterol (non-HDL-C), high-density lipoprotein cholesterol (HDL-C); and among adolescents only, low-density lipoprotein cholesterol (LDL-C) and geometric mean triglyceride levels. Trends in adverse lipid concentrations are reported for TC levels of 200 mg/dL and greater, non-HDL-C levels of 145 mg/dL and greater, HDL-C levels of less than 40 mg/dL, LDL-C levels of 130 mg/dL and greater, and triglyceride levels of 130 mg/dL and greater. RESULTS: Among youths aged 6 to 19 years between 1988-1994 and 2007-2010, there was a decrease in mean TC (from 165 mg/dL [95% CI, 164-167] to 160 mg/dL [95% CI, 158-161]; P < .001) and a decrease in the prevalence of elevated TC (from 11.3% [95% CI, 9.8%-12.7%] to 8.1% [95% CI, 6.7%-9.5%]; P = .002). Mean HDL-C significantly increased between 1988-1994 and 2007-2010, but the prevalence of low HDL-C did not change. Mean non-HDL-C and prevalence of elevated non-HDL-C both significantly decreased over the study period. In 2007-2010, 22% (95% CI, 20.3%-23.6%) of youths had either a low HDL-C level or high non-HDL-C, which was lower than the 27.2% (95% CI, 24.6%-29.7%) in 1988-1994 (P = .001). Among adolescents (aged 12-19 years) between 1988-1994 and 2007-2010, there was a decrease in mean LDL-C (from 95 mg/dL [95% CI, 92-98] to 90 mg/dL [95% CI, 88-91]; P = .003) and a decrease in geometric mean triglycerides (from 82 mg/dL [95% CI, 78-86] to 73 mg/dL [95% CI, 70-76]; P < .001). Prevalence of elevated LDL-C and triglycerides between 1988-1994 and 2007-2010 also significantly decreased. CONCLUSIONS: Between 1988-1994 and 2007-2010, a favorable trend in serum lipid concentrations was observed among youths in the United States but almost 1 in 10 had elevated TC in 2007-2010.

Prevalence of major cardiovascular risk factors and cardiovascular diseases among Hispanic/Latino individuals of diverse backgrounds in the United States.

CONTEXT: Major cardiovascular diseases (CVDs) are leading causes of mortality among US Hispanic and Latino individuals. Comprehensive data are limited regarding the prevalence of CVD risk factors in this population and relations of these traits to socioeconomic status (SES) and acculturation. OBJECTIVES: To describe prevalence of major CVD risk factors and CVD (coronary heart disease [CHD] and stroke) among US Hispanic/Latino individuals of different backgrounds, examine relationships of SES and acculturation with CVD risk profiles and CVD, and assess cross-sectional associations of CVD risk factors with CVD. DESIGN, SETTING, AND PARTICIPANTS: Multicenter, prospective, population-based Hispanic Community Health Study/Study of Latinos including individuals of Cuban (n = 2201), Dominican (n = 1400), Mexican (n = 6232), Puerto Rican (n = 2590), Central American (n = 1634), and South American backgrounds (n = 1022) aged 18 to 74 years. Analyses involved 15,079 participants with complete data enrolled between March 2008 and June 2011. MAIN OUTCOME MEASURES: Adverse CVD risk factors defined using national guidelines for hypercholesterolemia, hypertension, obesity, diabetes, and smoking. Prevalence of CHD and stroke were ascertained from self-reported data. RESULTS: Age-standardized prevalence of CVD risk factors varied by Hispanic/Latino background; obesity and current smoking rates were highest among Puerto Rican participants (for men, 40.9% and 34.7%; for women, 51.4% and 31.7%, respectively); hypercholesterolemia prevalence was highest among Central American men (54.9%) and Puerto Rican women (41.0%). Large proportions of participants (80% of men, 71% of women) had at least 1 risk factor. Age- and sex-adjusted prevalence of 3 or more risk factors was highest in Puerto Rican participants (25.0%) and significantly higher (P < .001) among participants with less education (16.1%), those who were US-born (18.5%), those who had lived in the United States 10 years or longer (15.7%), and those who preferred English (17.9%). Overall, self-reported CHD and stroke prevalence were low (4.2% and 2.0% in men; 2.4% and 1.2% in women, respectively). In multivariate-adjusted models, hypertension and smoking were directly associated with CHD in both sexes as were hypercholesterolemia and obesity in women and diabetes in men (odds ratios [ORs], 1.5-2.2). For stroke, associations were positive with hypertension in both sexes, diabetes in men, and smoking in women (ORs, 1.7-2.6). CONCLUSION: Among US Hispanic/Latino adults of diverse backgrounds, a sizeable proportion of men and women had adverse major risk factors; prevalence of adverse CVD risk profiles was higher among participants with Puerto Rican background, lower SES, and higher levels of acculturation.

The Hispanic mortality advantage and ethnic misclassification on US death certificates.

OBJECTIVES: We tested the data artifact hypothesis regarding the Hispanic mortality advantage by investigating whether and to what degree this advantage is explained by Hispanic origin misclassification on US death certificates. METHODS: We used the National Longitudinal Mortality Study, which links Current Population Survey records to death certificates for 1979 through 1998, to estimate the sensitivity, specificity, and net ascertainment of Hispanic ethnicity on death certificates compared with survey classifications. Using national vital statistics mortality data, we estimated Hispanic age-specific and age-adjusted death rates, which were uncorrected and corrected for death certificate misclassification, and produced death rate ratios comparing the Hispanic with the non-Hispanic White population. RESULTS: Hispanic origin reporting on death certificates in the United States is reasonably good. The net ascertainment of Hispanic origin is just 5% higher on survey records than on death certificates. Corrected age-adjusted death rates for Hispanics are lower than those for the non-Hispanic White population by close to 20%. CONCLUSIONS: The Hispanic mortality paradox is not explained by an incongruence between ethnic classification in vital registration and population data systems.

Trends from 1987 to 2004 in sudden death due to coronary heart disease: the Atherosclerosis Risk in Communities (ARIC) study.

BACKGROUND: Few data are available on the secular changes in sudden coronary heart disease (CHD) death in US communities. METHODS: We examined trends in sudden CHD death from 1987 to 2004, using data from the Atherosclerosis Risk in Communities (ARIC) study. Sudden CHD deaths in residents of 4 communities aged 35 to 74 years were ascertained using multiple sources such as death certificates, informant and coroner interviews, and physician adjudications. Poisson regression was used to assess the trends for the 6 periods: 1987 to 1989, 1990 to 1992, 1993 to 1995, 1996 to 1998, 1999 to 2001, 2002 to 2004, after adjusting for demographic factors. RESULTS: Overall, 32.6% of CHD deaths were sudden, occurring within an hour after the onset of symptoms, 63.5% of which had no prior diagnosis of CHD. For women, the rate declined by 40% (P = .059) for sudden deaths with CHD history, 27% (P = .067) for those without CHD history, and 39% (P < .001) for nonsudden CHD deaths. The trends did not differ by community. For men, the trends differed by community for sudden deaths with and without CHD history (Ps for the interaction= .019 and .009, respectively) but not for nonsudden CHD death (P for the interaction= .10). For all communities combined, the decline in men was greatest for sudden deaths with CHD history (by 58%, P < .001), followed by nonsudden CHD deaths (by 39%, P < .001) and sudden deaths without CHD history (by 31%, P = .002). However, the proportion of CHD deaths that were sudden had remained stable over time. CONCLUSION: Although the rate of sudden CHD deaths, with and without CHD history, declined over time, the trend pattern may differ by community and gender.

Increasing cardiovascular disease burden due to diabetes mellitus: the Framingham Heart Study.

BACKGROUND: Marked reductions in cardiovascular disease (CVD) morbidity and mortality have occurred in the United States over the last 50 years. We tested the hypothesis that the relative burden of CVD attributable to diabetes mellitus (DM) has increased over the past 5 decades. METHODS AND RESULTS: Participants aged 45 to 64 years from the Framingham Heart Study, who attended examinations in an "early" time period (1952 to 1974), were compared with those who attended examinations in a later time period (1975 to 1998). The risk of CVD events (n=133 among those with and 1093 among those without DM) attributable to DM in the 2 time periods was assessed with Cox proportional hazards models; population attributable risk of DM as a CVD risk factor was calculated for each time period. The age- and sex-adjusted hazard ratio for DM as a CVD risk factor was 3.0 (95% CI, 2.3 to 3.9) in the earlier time period and 2.5 (95% CI, 1.9 to 3.2) in the later time period. The population attributable risk for DM as a CVD risk factor increased from 5.4% (95% CI, 3.8% to 6.9%) in the earlier time period to 8.7% (95% CI, 5.9% to 11.4%) in the later time period (P for attributable risk ratio=0.04), although multivariable adjustment resulted in attenuation of these findings (P=0.12); most of these observations were found among men. CONCLUSIONS: The proportion of CVD attributable to DM has increased over the past 50 years in Framingham. These findings emphasize the need for increased efforts to prevent DM and to aggressively treat and control CVD risk factors among those with DM.