According to the NHLBI, one in four Americans—more than seventy million people in the United States—had cardiovascular disease. (See Table 5.2.) The American Heart Association (AHA) reports in Heart Disease and Stroke Statistics—2005 Update (http://www.americanheart.org/downloadable/heart/1105390918119HDSStats2005Update.pdf) that almost twenty-six hundred Americans die of cardiovascular disease each day—an average of one death every thirty-four seconds.
Heart Attack and Angina Pectoris
A heart attack, or myocardial infarction (MI), occurs when the blood supply from a coronary artery to the heart muscle (the myocardium) is cut off abruptly. This happens when one of the coronary arteries that supply blood to the heart is obstructed (blocked). When the blood supply is eliminated, the heart's muscle cells are deprived of oxygen and die. Disability or death can result, depending on how much of the heart muscle has been damaged.
Angina pectoris is not a disease; it is a symptom and the name for chest pain or pressure that occurs when poor blood flow through a partially occluded (blocked) artery to the heart sharply and temporarily reduces its supply of oxygen. When the blood flow is restored, the pain subsides. A common condition, angina is often a warning of the risk of heart attack. Its dull, constricting pain typically occurs when an individual is physically active or excited but subsides when activity ceases. In men, angina usually occurs after the age of fifty, whereas women tend to develop angina later in life. According to the AHA, in 2003 an estimated 13.2 million people in the United States suffered from angina. According to the Framingham Heart Study—a landmark study of heart disease in the residents of Framingham, Massachusetts, over the course of a half-century (http://www.nhlbi.nih.gov/about/framingham/)—about 350,000 new cases of angina occur annually.
WARNING SIGNALS OF A HEART ATTACK
The AHA names several warning signs of a heart attack:
- An uncomfortable pressure, squeezing, fullness, or pain in the center of the chest behind the breastbone
- Pain that spreads to the shoulders, neck, or arms
- Chest discomfort accompanied by sweating, nausea, shortness of breath, or a feeling of weakness
IMMEDIATE CARE IS CRUCIAL
Immediate medical care dramatically improves the odds of surviving a heart attack. Treatments are most effective if given within an hour of when the attack begins. According to the AHA, intensive emergency care in the first twelve hours after a
TABLE 5.1 Ten leading causes of death and their death rates, 2002
| TABLE 5.1 | ||
|---|---|---|
| Ten leading causes of death and their death rates, 2002 | ||
| Cause of death | Deaths per 100.000 population | Years of potential life lost (millions)c |
| aIncludes 177.4 deaths per 100,000 population from coronary heart disease (CHD). | ||
| bChronic obstructive pulmonary disease (COPD) and allied conditions (including asthma). | ||
| cBased on the average remaining years of life up to age 75 years. | ||
| SOURCE: "Ten Leading Causes of Death: Death Rates, U.S., 2002," in "Disease Statistics," NHLBI Factbook, Fiscal Year 2004, National Institutes of Health, National Heart, Lung, and Blood Institute, 2005, http://www.nhlbi.nih.gov/about/04factpdfa4.pdf (accessed December 29, 2005) | ||
| 1=Hearta | 70.3 | 3.3 |
| 2=Cancer | 193.2 | 4.3 |
| 3=Cerebovascular | 56.4 | 0.5 |
| 4=Chronic obstructive pulmonary diseaseb | 43.3 | 0.5 |
| 5=Accidents | 37 | 2.9 |
| 6=Diabetes | 25.4 | 0.5 |
| 7=Influenza and pneumonia | 22.8 | 0.2 |
| 8=Alzheimer's disease | 20.4 | <0.1 |
| 9=Nephritis | 14.2 | 0.2 |
| 10=Septicemia | 11.7 | 0.2 |
| TABLE 5.2 | |
|---|---|
| Prevalence of common cardiovascular, lung, and blood diseases, 2002 | |
| Disease | Number |
| *Systolic blood pressure >140 mm Hg, diastolic blood pressure >90 mm Hg, on antihypertensive medication, or told twice of having hypertension. | |
| Note: Some persons are included in more than one diagnostic group, and persons with more than one form of anemia are counted more than once. | |
| SOURCE: "Prevalence of Common Cardiovascular, Lung, and Blood Diseases, U.S., 2002," in NHLBI Factbook, Fiscal Year 2004, National Institutes of Health, National Heart, Lung, and Blood Institute, 2005, http://www.nhlbi.nih.gov/about/04factpdfa4.pdf (accessed December 29, 2005) | |
| Total cardiovascular diseases | 70,100,000 |
| Hypertension* | 65,000,000 |
| Coronary heart disease | 13,000,000 |
| Congestive heart failure | 4,900,000 |
| Stroke | 5,400,000 |
| Congenital heart disease | 1,000,000 |
| Asthma | 20,600,000 |
| Chronic obstructive pulmonary disease | 10,800,000 |
| Chronic bronchitis only (age 25+) | 8,200,000 |
| Emphysema only (age 25+) | 1,700,000 |
| Chronic bronchitis and emphysema (age 25+) | 900,000 |
| Anemias (all forms) | 3,500,000 |
heart attack improves the patient's chance of survival and recovery. Researchers believe that patients who suffer heart attacks benefit from early intensive treatment—such as improved monitoring of their conditions and aggressive use of pharmacologic (drug) therapy, including appropriate reperfusion therapies—"clot-busting" medications—initiated with as little delay as possible. There are a variety of drugs that dissolve clots, but tissue plasminogen activator (tPA), which was approved by the Food and Drug Administration (FDA) in 1996, is currently used most often.
Treatments for Heart Disease
Once it is clear that a person is having a heart attack, immediate treatment usually includes administering drugs to help open the blocked artery, which restores blood flow to the heart and prevents clots from forming again. If the patient gets to an emergency room quickly, "reperfusion" might be done. In addition to administration of drugs to promote reperfusion, patients with heart disease also may undergo other procedures including:
- Balloon angioplasty or percutaneous transluminal coronary angioplasty (PTCA) to widen narrowed arteries with an inflated balloon
- Placement of wire mesh tubes, called stents, into arteries after angioplasty to prevent later collapse or restenosis (renarrowing)
- Coronary artery bypass graft surgery (CABG) to improve blood supply to parts of the heart muscle that have decreased blood flow
Once emergency care and immediate treatment is completed, most communities have cardiac rehabilitation programs to help people recover from a heart attack and reduce the chances of having another one.
Bypass Surgery
CABG, commonly known as "bypass surgery," can improve blood flow to the heart, relieve chest pains, and help the heart pump more efficiently. Generally, a segment of a large healthy vein, usually taken from the patient's leg, is spliced between the aorta (the main vessel carrying blood from the left side of the heart to all the arteries of the body and limbs) and the blocked coronary arteries. The coronary bypass operation thus supplies blood to the area of the heart that had a deficient blood supply. During the operation the patient is placed on a heart-lung machine that takes over the function of the heart and lungs while the surgery is proceeding. Usually, patients recovering from CABG surgery spend two or three days in the intensive care unit and several days to one week in the hospital following the surgery. The AHA reports in Heart Disease and Stroke Statistics—2005 Update that in 2002 about 515,000 coronary artery bypass surgeries were performed on 306,000 patients in the United States.
The AHA also reports that from 1979 to 2002 the total number of cardiovascular operations and procedures increased by 470%, in part because of the development of new procedures. For example, heart surgeons have developed a procedure called "minimally invasive direct coronary bypass" surgery. In this procedure the surgeon makes one or more small incisions (about three inches long) in the chest wall and works directly on the clogged artery while the heart is beating. Some surgeons use fiberoptic techniques similar to those used in gallbladder and other procedures. Anesthesiologists slow the heartbeat with drugs such as calcium channel blockers and beta-blockers to allow surgeons more control. Another technique actually stops the heartbeat and uses a modified heart-lung machine connected to a large artery in the groin while the surgeon operates through small incisions using a video camera and long-handled instruments.
Research studies have found that minimally invasive procedures have delivered the anticipated benefits including shorter recovery times, less time spent in the hospital, and the possibility of combining the new procedure with angioplasty or other procedures. As of 2006, however, no long-term follow-up data are available to substantiate the enduring benefits of these procedures. The long-term utility and success of the procedures will depend on post-procedure quality of life and survival rates for patients (John D. Puskas et al, "Clinical Outcomes, Angiographic Patency, and Resource Utilization in 200 Consecutive Off-Pump Coronary Bypass Patients," Annals of Thoracic Surgery, vol. 71, May 2001).
Catheter-based Interventions
Some patients qualify for much simpler procedures called "catheter-based interventions" because the procedures are performed via a thin tube inserted into an artery, rather than operating on the coronary artery by cutting through the chest wall. One such catheter-based intervention, performed under a local anesthetic, is PTCA (percutaneous transluminal coronary angioplasty), also called balloon angioplasty. A physician punctures an artery in the patient's groin and threads a balloon-tipped catheter into the artery. The tip of the catheter is slowly advanced up through the arterial system and positioned in the coronary artery at the point of the blockage or stenosis (narrowing). The small, sausage-shaped balloon on the end of the catheter then is inflated, flattening the fatty plaque and widening the artery. The balloon sometimes is inflated and deflated several times to clear the artery.
PTCA has several obvious advantages over bypass surgery. First, it is performed under a local rather than a general anesthetic and does not involve opening the chest or using a heart-lung machine. It is less expensive, and the patient is usually out of the hospital and recovering in a few days. Still, PTCA is not always completely effective, and nearly one-third of patients who have had PTCA eventually require bypass surgery or another PTCA because the initial procedure is unsuccessful or the blockage recurs.
According to the AHA in Heart Disease and Stroke Statistics—2005 Update, about 657,000 PTCA procedures were performed in the United States in 2002. Of these procedures, 66% were performed on men and about half were performed on people older than age sixty-five. From 1987 to 2002 the number of PTCA procedures performed increased 324 percent. The American College of Cardiology estimates that about one million angioplasties were performed in 2005.
As technology advances, catheter-based interventions using devices such as fiber optics and laser methods may replace angioplasty as the treatments of choice. Some physicians also are using a tiny cutting blade attached to the end of a fiber-optic tube to remove accumulated plaque, although this method has not yet been proven to be more effective than balloon angioplasty.
Physicians also are placing wire mesh tubes, called stents, into arteries after angioplasty to prevent later collapse or restenosis (renarrowing). However, even with stents, arteries renarrow in about 25% of patients. Physicians at the 2004 American College of Cardiology annual meeting reported greater success using drug-coated stents, which slowly release medication to prevent vessels from reclogging after procedures to open them. The cardiologists deemed them vastly superior to metal ones that were standard just a few years prior.
Benefits appear to last for years, and even big blockages in small vessels can be fixed using these stents. Some researchers suggest that the devices work so well that when an older stent clogs, it is considered preferable to put a new drug-coated one inside it than to treat the problem with radiation as has been done in the past (Marilynn Marchione, "Drug-Coated Stent Devices Making Strides in Heart Care," Associated Press/washingtonpost.com, March 7, 2005, http://www.washingtonpost.com/wp-dyn/articles/A12390-2005Mar6.html).
HEART TRANSPLANTS
Dr. Christiaan Barnard of South Africa performed the first successful heart transplant in December of 1967; that feat was repeated one month later in the United States by Dr. Norman Shumway at Stanford University Hospital in California. According to the United Network for Organ Sharing (UNOS) on their Organ Procurement and Transplantation Network (http://www.optn.org/latestData/rptData.asp), 2,127 heart transplants were performed in the United States during 2005. The percentage of Hispanic/Latino patients receiving heart transplants has grown from 4.7% in 1994 to nearly 8% in 2005, which is a reflection of the changing population of America. Those ages thirty-five to sixty-four years still receive most of the donated hearts (68%). Women make up 27% of heart transplant recipients, which is an increase of 3% from a decade ago.
The longest recorded survival of a heart transplant patient is about twenty-two years, and as of 2003 five-year survival was about 72%. According to UNOS, 2,999 patients were awaiting heart transplants in May 2006.
Risk Factors for Heart Disease
Various risk factors exist for heart disease; although some cannot be changed, others can be modified.
UNCHANGEABLE RISK FACTORS
Four risk factors for heart disease that cannot be altered are heredity, race, gender, and increasing age. People whose parents had or have cardiovascular diseases are more likely to develop them. Race is also a significant factor—African-Americans, for instance, are twice as likely as whites to have high blood pressure, which increases the risk for heart disease. Men have a greater risk of heart attack than do women—whereas heart attacks are the leading cause of death among men older than the age of forty, heart disease is not a major cause of death among women until they reach the age of sixty. Heart attacks also are more likely to occur as a person ages. More than half of the Americans who experience heart attacks are age sixty-five or older. Of those who die from their attacks, the vast majority are older than age sixty-five.
CHANGEABLE RISK FACTORS
Cigarette smoking doubles the risk of heart attack. A smoker who suffers a heart attack is more likely to die from it and more likely to die suddenly than a nonsmoker. Once people stop smoking, however, regardless of the length of time or the amount they have smoked, the risk of heart disease decreases significantly. The prevalence of cigarette smoking declined dramatically from 1965 to 1997 and then slowly decreased from 24.7% in 1997 to 20.9% in 2004. (See Figure 5.1 and Figure 5.2.) Although smoking among high school students increased during the early 1990s, teen smoking also declined from 1997 to 2003. (See Figure 5.1.) Still, despite the decline in smoking, the American Lung Association reported in 2006 (http://www.lungusa.org/site/apps/s/content.asp?c=dvLUK9O0E&b=34706&ct=66713) that approximately 438,000 Americans die each year of smoking-related illnesses, and most of these deaths are from cardiovascular causes. Worldwide, about five million people die prematurely each year from smoking.
High blood pressure, which usually has no symptoms or warning signs, is called the "silent killer." High blood pressure means that it is more difficult for blood to pump through the arteries, which increases the heart's workload, causing it to weaken and enlarge over time. Generally, blood pressure increases with age. Men have a higher incidence of high blood pressure than women do until about age fifty-five, when the risks become equal for both sexes. High blood pressure is a major problem for older women—more than 50% of women older than age sixty-five have this risk factor. (See Table 5.3.) In the majority of cases, high blood pressure can be controlled through diet, exercise, and medication.
High blood cholesterol levels increase the risk of coronary heart disease. Reduction of dietary fat, especially artery-clogging saturated fat, can reduce blood
FIGURE 5.1 Cigarette smoking among men, women, high school students, and mothers during pregnancy, 1965–2003
Lack of physical exercise is also a risk factor for heart disease. Figure 5.3 shows that only about one-third of adults age eighteen and older engaged in regular leisure-time physical activity. Nonpoor adults were more likely (37%) than near poor (23%) or poor adults (25%) to report regular physical activity and about one-half of poor and near poor adults were inactive compared with less than one-third of nonpoor adults. For men and women, the percentage of adults that engages in regular leisure-time physical activity decreased with advancing age. Among adults of all ages—particularly among younger adults (ages eighteen to twenty-four) and older adults (age seventy-five and older)—women were less
FIGURE 5.2 Prevalence of current smoking among adults aged 18 years and over, 1997–2005
Some research also links the risk of heart disease with stress levels, behavioral habits, and socioeconomic level. Many studies have indicated that the risk of death from heart disease is considerably greater for less-educated people than for more-educated people. There may be several reasons for this. For instance, people who are better educated usually have higher incomes, better access to health care, and greater knowledge of prevention techniques.
CONTRIBUTING FACTORS
Diabetes, or elevated blood glucose, affects cholesterol and triglyceride levels. The disease can sharply increase the risk of heart attack, especially when blood glucose is uncontrolled or poorly controlled. About 65% of deaths among people with diabetes result from heart disease and stroke, according to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK; http://diabetes.niddk.nih.gov/dm/pubs/statistics/index.htm). Adults with diabetes have heart disease death rates that are two to four times higher than adults without diabetes.
Obesity is also a factor contributing to heart disease. Research has shown that the location of body fat may affect the risk of suffering a heart attack significantly. Men with a waist measurement that exceeds their hip measurement ("pot bellies," or excessive abdominal fat) and women whose waistline measurement is more than 80% of their hip dimension (apple-shaped) are at greater risk. Although obesity is directly associated with increased risk for cardiovascular disease, being overweight to any degree strains the heart.
The prevalence of obesity among adults age twenty and older in the United States has increased from 19.4% in 1997 to 25.6% in 2005. (See Figure 5.5.) Although the prevalence of overweight and obesity has increased in both males and females in all racial and ethnic groups, non-Hispanic white women were less likely to be obese than Hispanic and non-Hispanic African-American women; obesity was highest among non-Hispanic African-American women (35.8%). (See Figure 5.6.)
Prevalence of Heart Disease and Mortality Vary
In 2003 about 685,000 people in the United States died from heart disease, the leading cause of death in America. (See Table 5.4.) In 2002 the age-adjusted death rate for heart disease was 59% lower than the rate in 1950. Table 5.5 shows that in 2002 the age-adjusted death rate for heart disease was highest among African-American males (371 per one hundred thousand) and white males (294.1 per one hundred thousand), and lowest among Asian/Pacific Islander females (108.1 per one hundred thousand) and American Indian/Alaska Native females (123.6 per one hundred thousand). The death rate for white females from heart disease was 192.1 per one hundred thousand, whereas African-American females had a heart disease death rate of 263.2 per one hundred thousand.
According to the CDC, if all forms of major heart disease were eliminated, average life expectancy would increase by almost seven years. The AHA reports in Heart Disease and Stroke Statisics—2006 Update (http://www.americanheart.org/downloadable/heart/1136308648540Statupdate2006.pdf) that between 1993 and 2003 the death rates from heart disease declined 22.1%. The death rates in 2003 from cardiovascular disease were 359.1 per one hundred thousand for white males and 256.2 per one hundred thousand for white females. That same year the death rates from heart disease were 479.6 for African-American males and 354.8 for African-American females; these numbers are much higher than the cardiovascular disease death rate for the total population in 2003—for every one hundred thousand TABLE 5.3 High blood pressure, by sex, age, race and Hispanic origin, and poverty status, 1988–94 and 1999–2002
| TABLE 5.3 | ||||
|---|---|---|---|---|
| High blood pressure, by sex, age, race and Hispanic origin, and poverty status, 1988–94 and 1999–2002 | ||||
| [Data are based on physicla examinations of a sample of the civilian noninstitutionalized population] | ||||
| Sex, age, and race and Hispanic origina, and poverty status | Elevated blood pressure or taking antihypertensive medicationb,c | Elevated blood pressureb | ||
| 1998–94 | 1999–2002 | 1988–94 | 1999–2002 | |
| 20-74 years, age adjustedd | Percent of population | |||
| Both sexese,f | 21.7 | 25.6 | 15.4 | 16.4 |
| Male | 23.4 | 25.2 | 18.2 | 16.3 |
| Femalee | 20.0 | 25.7 | 12.6 | 16.1 |
| Not Hispanic or Latino: | ||||
| White only, male | 22.6 | 24.0 | 17.3 | 14.8 |
| White only, femalee | 18.4 | 23.3 | 11.2 | 14.1 |
| Black or African American only, male | 34.3 | 36.9 | 27.9 | 25.6 |
| Black or African American only, femalee | 35.0 | 39.5 | 23.5 | 25.7 |
| Mexican male | 23.4 | 22.6 | 19.1 | 18.2 |
| Mexican femalee | 21.0 | 23.4 | 16.5 | 17.2 |
| Poverty status:g | ||||
| Poor | 27.5 | 29.0 | 19.0 | 19.3 |
| Near poor | 22.6 | 29.3 | 15.8 | 19.5 |
| Nonpoor | 20.4 | 24.1 | 14.6 | 14.9 |
| 20 years and over, age adjustedd | ||||
| Both sexese,f | 25.5 | 30.0 | 18.5 | 19.9 |
| Male | 26.4 | 28.8 | 20.6 | 19.1 |
| Femalee | 24.4 | 30.6 | 16.4 | 20.2 |
| Not Hispanic or Latino: | ||||
| White only, male | 25.6 | 27.6 | 19.7 | 17.6 |
| White only, femalee | 23.0 | 28.5 | 15.1 | 18.5 |
| Black or African American only, male | 37.5 | 40.6 | 30.3 | 28.2 |
| Black or African American only, femalee | 38.3 | 43.5 | 26.4 | 28.9 |
| Mexican male | 26.9 | 26.8 | 22.2 | 21.5 |
| Mexican femalee | 25.0 | 27.9 | 20.4 | 21.2 |
| Poverty status:g | ||||
| Poor | 31.7 | 33.9 | 22.5 | 23.3 |
| Near poor | 26.6 | 33.5 | 19.3 | 23.0 |
| Nonpoor | 23.9 | 28.2 | 17.5 | 18.2 |
| 20 years and over, crude | ||||
| Both sexese,f | 24.1 | 30.2 | 17.6 | 19.9 |
| Male | 23.8 | 27.6 | 18.7 | 18.2 |
| Femalee | 24.4 | 32.7 | 16.5 | 21.6 |
| Not Hispanic or Latino: | ||||
| White only, male | 24.3 | 28.3 | 18.7 | 17.8 |
| White only, femalee | 24.6 | 32.9 | 16.4 | 21.6 |
| Black or African American only, male | 31.1 | 35.9 | 25.5 | 25.2 |
| Black or African American only, femalee | 32.5 | 42.1 | 22.2 | 27.3 |
| Mexican male | 16.4 | 16.5 | 13.9 | 14.1 |
| Mexican femalee | 15.9 | 18.8 | 12.7 | 13.8 |
| Poverty status:g | ||||
| Poor | 25.7 | 30.3 | 18.7 | 21.1 |
| Near poor | 26.7 | 34.8 | 19.8 | 24.1 |
| Nonpoor | 22.2 | 28.2 | 16.2 | 17.8 |
| Male | ||||
| 20-34 years | 7.1 | 8.1h | 6.6 | 7.3h |
| 35-44 years | 17.1 | 17.1 | 15.2 | 12.1 |
| 45-54 years | 29.2 | 31.0 | 21.9 | 20.4 |
| 55-64 years | 40.6 | 45.0 | 28.4 | 24.8 |
| 65-74 years | 54.4 | 59.6 | 39.9 | 34.9 |
| 75 years and over | 60.4 | 69.0 | 49.7 | 50.6 |
people in the United States in 2003, about 309 people died from heart disease.
Based on the Framingham Heart Study, the AHA reported that in people younger than age seventy-five, more cardiovascular disease results from coronary heart disease (acute and chronic ischemic heart disease, angina, and MI) in men, whereas women suffer more from congestive heart failure (when the heart's pumping action is impaired to the degree that it is less than adequate). Although heart attacks are most prevalent among older people, they also occur in younger people; in 2001 about 25% of deaths in the forty-five- to sixty-four-year-old age group was from heart disease. Nevertheless, about four of five people who die of heart attacks are older than age sixty-five.
Women and Heart Disease
Until the early 1990s, almost all research on heart disease was carried out on middle-aged men. However,
TABLE 5.3 High blood pressure, by sex, age, race and Hispanic origin, and poverty status, 1988–94 and 1999–2002 [CONTINUED]
| TABLE 5.3 | ||||
|---|---|---|---|---|
| High blood pressure, by sex, age, race and Hispanic origin, and poverty status, 1988–94 and 1999–2002 [CONTINUED] | ||||
| [Date are based on physical examinations of a sample of the civilian noninstitutionalized population] | ||||
| Sex, age, and race and Hispanic origina, and poverty status | Elevated blood pressure or taking antihypertensive medicationb,c | Elevated blood pressureb | ||
| 1988–94 | 1999–2002 | 1988–94 | 1999–2002 | |
| aPersons of Mexican origin may be of any race. Starting with data year 1999 race-specific estimates are tabulated according to 1997 Standards for Federal Data on Race and Ethnicity and are not strictly comparable with estimates for earlier years. The two non-Hispanic race categories shown in the table conform to 1997 standards. The 1999–2002 race-specific estimates are for persons who reported only one racial group. Prior to data year 1999, data were tabulated according to 1977 standards. Estimates for single race categories prior to 1999 included persons who reported one race or, if they reported more than one race, identified one race as best representing their race. | ||||
| bElevated blood pressure is defined as having systolic pressure of at least 140 mmHg or diastolic pressure of at least 90 mmHg. Those with elevated blood pressure may be taking prescribed medicine for high blood pressure. | ||||
| cRespondents were asked, "Are you now taking prescribed medicine for your high blood pressure?" | ||||
| dAge adjusted to the 2000 standard population using five age groups. Age-adjusted estimates may differ from other age-adjusted estimates based on the same data and presented elsewhere if different age groups are used in the adjustment procedure. | ||||
| eExcludes pregnant women. | ||||
| fIncludes persons of all races and Hispanic origins, not just those shown separately. | ||||
| gPoor persons are defined as below the poverty threshold. Near poor persons have incomes of 100 percent to less than 200 percent of the poverty threshold. Nonpoor persons have incomes of 200 percent or greater than the poverty threshold. Persons with unknown poverty status are excluded. | ||||
| hEstimates are considered unreliable. | ||||
| Notes: Percents are based on the average of blood pressure measurements taken. In 1999–2002, 78 percent of participants had 3 blood pressure readings. Data have been revised and differ from the previous edition of Health, United States. Estimates for persons 20 years and over are used for setting and tracking Healthy People 2010 objectives. | ||||
| SOURCE: "Table 69. Hypertension (Elevated Blood Pressure) among Persons 20 Years of Age and over, according to Sex, Age, Race and Hispanic Origin, and Poverty Status: United States, 1988–94 and 1999–2002," in Health, United States, 2005, Centers for Disease Control and Prevention, National Center for Health Statistics, November 2005, http://www.cdc.gov/nchs/data/hus/hus05.pdf (accessed December 8, 2005) | ||||
| Femalee | ||||
| 20-34 years | 2.9 | 2.7h | 2.4h | 1.4h |
| 35-44 years | 11.2 | 15.1 | 6.4 | 8.5 |
| 45-54 years | 23.9 | 31.8 | 13.7 | 19.1 |
| 55-64 years | 42.6 | 53.9 | 27.0 | 31.9 |
| 65-74 years | 56.2 | 72.2 | 38.2 | 53.0 |
| 75 years and over | 73.6 | 83.1 | 59.9 | 64.4 |
heart disease affects women, too. When a woman enters menopause, she begins to lose the protection provided by the hormones that appear to reduce the risk of heart disease. As a result, the rates of coronary heart disease are two to three times higher among postmenopausal women than among premenopausal women, according to the AHA. One in three women older than age sixty-five suffers from some form of cardiovascular disease.
In fact, starting at age seventy-five, the prevalence of cardiovascular disease is higher among women than among men of the same age group, the AHA reports. Of women who have heart attacks, 38% die within the first year, compared with 25% of men. In part because women have heart attacks at older ages than men do, they are more likely to die from one within a few weeks of its occurrence. The occurrence of a second heart attack during the six years following the initial attack is 35% for women; within six years 11% will have a stroke, 6% will experience sudden cardiac death, and 46% will have disabling heart failure. Among African-American women thirty-five to seventy-four years of age, the death rate from coronary heart disease is about 70% higher than it is for white women.
Women are more seriously affected by heart disease than men are because women have smaller arteries, they frequently wait longer to get care, and they are generally older (typically by ten years) when heart disease strikes. Another reason could be that women's early symptoms of heart disease often differ from those of the "classic" heart attack. According to a study entitled "Women's Early Warning Symptoms of AMI" published in the November 2003 issue of Circulation: Journal of the American Heart Association, symptoms that often occur in women before a heart attack are (in order of frequency): unusual fatigue, sleep disturbance, shortness of breath, indigestion, and anxiety. Symptoms that may occur during a heart attack are comparable to the symptoms men experience: shortness of breath, weakness, unusual fatigue, cold sweat, and dizziness.
Women also undergo fewer cardiac procedures than do men. There also has been research demonstrating that anticlotting drugs, originally formulated for men, do not offer women comparable benefits. Finally, women may underestimate their vulnerability to heart disease. According to the AHA, surveys reveal that women fear breast cancer more than cardiovascular disease, even though more women die as a result of cardiovascular disease (one in 2.5 deaths) than from breast cancer (one in thirty deaths).
Rates of Treatment of Heart Disease Have Increased But Still Need Improvement
The January 2006 issue of Circulation (L. Kristen Newby et al, "Long-Term Adherence to Evidence-Based
FIGURE 5.3 Leisure-time physical activity among adults 18 years of age and over, by poverty status, 2003
Secondary Prevention Therapies in Coronary Artery Disease") reported that between 1995 and 2002 the percent of patients with coronary artery disease that was prescribed and used pharmacological agents that have proven survival benefits, such as daily aspirin, increased each year. Nonetheless, the report found that many patients are still not using these drugs on a consistent basis. For example, just 71% of patients used aspirin consistently. The researchers lamented this low rate of the use of aspirin and other effective therapies to improve survival, observing, "For a drug that is well-understood, inexpensive, easily available and fairly well-tolerated, we should see rates in the upper 90%." An editorial in the same issue of the journal (Sidney C. Smith, Jr., "Evidence-Based Medicine: Making the Grade—Miles to Go before We Sleep") noted that while progress has been made "most patients still do not receive the comprehensive medical therapies that can dramatically improve cardiovascular outcomes. If we are to recognize the true potential of these therapies, we must … provide the
FIGURE 5.4 Percentage of adults aged 18 years and over who engaged in regular leisure-time physical activity, by age group and sex, January-June 2005
necessary focus and resources to see that remaining gaps in therapy are eliminated for all sociodemographic groups."
Stroke
Stroke (cerebrovascular disease) is a cardiovascular disease that affects the blood vessels of the central nervous system. When an artery supplying oxygen and nutrients to the brain bursts or becomes clogged with a blood clot, a part of the brain does not receive the oxygen it needs. Without the necessary oxygen, the affected nerve cells die within moments. The parts of the body controlled by these nerve cells also become
FIGURE 5.5 Prevalence of obesity among adults aged 20 years and over, 1997–2005
Stroke affects people in different ways. The extent of the resulting damage or loss depends on the type of stroke and the area of the brain that has been damaged. Physicians often can identify the location of a stroke in the brain from the symptoms and deficits observed during a neurologic examination, even before an imaging study (computed tomography or magnetic resonance imaging) confirms the region of the brain affected. The senses, speech, the ability to understand speech, behavioral patterns, thought, and memory are affected most frequently. The most common effect is for one side of the body to become paralyzed or severely weakened. A loss of sensation or vision as the result of the stroke can result in a loss of awareness of the affected parts, so many stroke victims may forget or "neglect" the parts of the body that are weakened or paralyzed. Falls, bumping into objects, or dressing only one side of the body tend to result from this sudden lack of awareness.
INCIDENCE OF STROKE DEATHS IS DECLINING
Stroke is the third-leading cause of death in America, following heart disease and cancer. (See Table 5.4.) The CDC reports that each year about five hundred thousand people suffer a new stroke and two hundred thousand have a recurrent stroke. An estimated 157,689 Americans died
FIGURE 5.6 Age-adjusted prevalence of obesity among adults aged 20 years and over, by sex and race/ethnicity, January-June 2005
The AHA reports that from the early 1970s to the early 1990s, the estimated number of noninstitutionalized stroke survivors increased from 1.5 million to 2.4 million. Nonetheless, stroke accounted for about one of every fifteen deaths in the United States in 2003 and was the underlying or contributing cause of death for about 273,000 persons. Because women live longer than men, more women die of stroke each year. In 2003 women accounted for 61% of U.S. stroke deaths, the AHA also reported (http://www.americanheart.org/presenter.jhtml?identifier=3037185).
The death rate for stroke declined substantially between 1950 and 2002. (See Figure 5.7.) The decrease in the number of stroke victims occurred at about the same rate for both sexes and for both African-Americans and whites. Nevertheless, as shown in Table 5.6, in 2002 the age-adjusted death rate for stroke was substantially higher among African-Americans (76.3 per one hundred thousand) than among whites (54.2 per one hundred thousand), American Indian or Alaska Natives (37.5 per
TABLE 5.4 Leading causes of death, 2003
| TABLE 5.4 | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| Leading causes of death, 2003 | |||||||||
| [Death rates on an annual basis per 100,000 population: age-adjusted rates per 100,000 U.S. stand population.] | |||||||||
| Ranka | Cause of death | Number | Percent of total deaths | 2003 crude death rate | Age-adejusted death rate | ||||
| 2003 | Percent change | Ratio | |||||||
| 2002 to 2003 | Male to female | Blck to white | Hispanic to non-Hispanic white | ||||||
| aRank based on number of deaths. | |||||||||
| bCategory not applicable. | |||||||||
| SOURCE: Donna L. Hoyert et al., "Table 2. Percentage of Total Deaths, Death Rates, Age-Adjusted Death Rates for 2003, Percentage Change in Age-Adjusted Death Rates from 2002 to 2003 and Ratio of Age-Adjusted Death Rates by Race and Sex for the 15 Leading Causes of Death for the Total Population in 2003: United States," in Deaths: Final Data for 2003, Health E-Stats, Centers for Disease Control and Prevention, National Center for Health Statistics, January 19, 2006, http://www.cdc.gov/nchs/data/hestat/finaldeaths03_tables.pdf (accessed January 24, 2006) | |||||||||
| All causes | 2,448,288 | 100.0 | 841.9 | 832.7 | ™1.5 | 1.4 | 1.3 | 0.8 | |
| 1 | Diseases of heart | 685,089 | 28.0 | 235.6 | 232.3 | ™3.5 | 1.5 | 1.3 | 0.8 |
| 2 | Malignant neoplasms | 556,902 | 22.7 | 191.5 | 190.1 | ™1.8 | 1.5 | 1.2 | 0.7 |
| 3 | Cerbrovascular | 157,689 | 6.4 | 54.2 | 53.5 | ™4.8 | 1.0 | 1.5 | 0.8 |
| 4 | Chronic lower respiratory diseases | 126,382 | 5.2 | 43.5 | 43.3 | ™0.5 | 1.4 | 0.7 | 0.4 |
| 5 | Accidents (unintentional injuries) | 109,277 | 4.5 | 37.6 | 37.3 | 1.1 | 2.2 | 1.0 | 0.8 |
| 6 | Diabetes mellitus | 74,219 | 3.0 | 25.5 | 25.3 | ™0.4 | 1.3 | 2.1 | 1.6 |
| 7 | Influenza and pneumonia | 65,163 | 2.7 | 22.4 | 22.0 | ™2.7 | 1.4 | 1.1 | 0.8 |
| 8 | Alzheimer's disease | 63,457 | 2.6 | 21.8 | 21.4 | 5.9 | 0.8 | 0.8 | 0.6 |
| 9 | Nephritis, nephrotic syndrome and nephrosis | 42,453 | 1.7 | 14.6 | 14.4 | 1.4 | 1.4 | 2.3 | 1.0 |
| 10 | Septicemia | 34,069 | 1.4 | 11.7 | 11.6 | ™0.9 | 1.2 | 2.3 | 0.8 |
| 11 | Intentional self-harm (suicide) | 31,484 | 1.3 | 10.8 | 10.8 | ™0.9 | 4.3 | 0.4 | 0.4 |
| 12 | Chronic liver disease and cirrhosis | 27,503 | 1.1 | 9.5 | 9.3 | ™1.1 | 2.2 | 0.9 | 1.6 |
| 13 | Essential (primary) hypertension and hypertensive renal disease | 21,940 | 0.9 | 7.5 | 7.4 | 5.7 | 1.0 | 2.8 | 1.0 |
| 14 | Parkinson's disease | 17,997 | 0.7 | 6.2 | 6.2 | 5.1 | 2.2 | 0.4 | 0.5 |
| 15 | Assault (homicide) | 17,732 | 0.7 | 6.1 | 6.0 | ™1.6 | 3.6 | 5.7 | 2.9 |
| All other causes (residual) | 416,932 | 17.0 | 143.4 | b | b | b | b | b | |
one hundred thousand), Asian or Pacific Islanders (47.7 per one hundred thousand), and Hispanic or Latinos (41.3 per one hundred thousand).
The two blood thinners heparin and warfarin are often used to reduce the chance of blood clot and recurrent strokes, although these drugs pose some risk of bleeding problems. Clinical trials have shown that the drugs are safe if their use is closely monitored. Another drug, tissue plasminogen activator (tPA), is a "clot-busting drug" approved specifically for fighting strokes. tPA, which became available in 1996, must be administered within three hours after the onset of a stroke. The drug works to stop the swift advance of damage caused by clots shutting off blood flow to the brain, which accounts for four-fifths of strokes. Early detection and immediate treatment is vital for tPA treatment to be optimally effective. Regular, low doses of aspirin also have proved effective in preventing stroke.
REHABILITATION FOR STROKE SURVIVORS
Stroke is a leading cause of serious long-term disability. The AHA asserts that stroke accounts for more than half of all patients hospitalized for acute brain diseases. According to Kate Hardie et al in "Ten-Year Risk of First Recurrent Stroke and Disability after First-Ever Stroke in the Perth Community Stroke Study" (Stroke, vol. 35, no. 3, February 5, 2005), the risk of first recurrent stroke is six times greater than the risk of first-ever stroke in the general population of the same age and sex, almost one half of survivors remain disabled, and one seventh require institutional care.
Many survivors lose mental and physical abilities and need expensive, lengthy, and intensive rehabilitation to regain their independence. In some cases independence is not achievable. Stroke can affect virtually all senses and perception, and patients who have had a stroke may find even familiar surroundings incomprehensible. They may be unable to recognize or understand well-known objects or people. The simplest activities become difficult, and depression is a common problem because patients who have had a stroke may feel overwhelmed and develop a sense of despair.
According to the National Institute of Neurological Disorders and Stroke, the duration of recovery depends on the severity of the stroke. Between one-half and two-thirds of stroke survivors regain the ability to function independently, while 15% to 30% suffer permanent disability and 20% require institutional care.
In the Framingham Heart Study of cardiovascular disease, 31% of stroke survivors needed help taking care TABLE 5.5 Death rates for diseases of the heart, by sex, race, Hispanic origin, and age, 1950–2002
| TABLE 5.5 | ||||||||
|---|---|---|---|---|---|---|---|---|
| Death rates for diseases of the heart, by sex, race, Hispanic origin, and age, 1950–2002 | ||||||||
| [Deta are based on death certificates] | ||||||||
| Sex, race, Hispanic origin, and age | 1950a | 1960a | 1970 | 1980 | 1990 | 2000 | 2001 | 2002 |
| All persons | Deaths per 100,000 resident population | |||||||
| All ages, age adjustedb | 586.8 | 559.0 | 492.7 | 412.1 | 321.8 | 257.6 | 247.8 | 240.8 |
| All ages, crude | 355.5 | 369.0 | 362.0 | 336.0 | 289.5 | 252.6 | 245.8 | 241.7 |
| Under 1 year | 3.5 | 6.6 | 13.1 | 22.8 | 20.1 | 13.0 | 11.9 | 12.4 |
| 1-4years | 1.3 | 1.3 | 1.7 | 2.6 | 1.9 | 1.2 | 1.5 | 1.1 |
| 5-14 years | 2.1 | 1.3 | 0.8 | 0.9 | 0.9 | 0.7 | 0.7 | 0.6 |
| 15-24 years | 6.8 | 4.0 | 3.0 | 2.9 | 2.5 | 2.6 | 2.5 | 2.5 |
| 25-34 years | 19.4 | 15.6 | 11.4 | 8.3 | 7.6 | 7.4 | 8.0 | 7.9 |
| 35-44 years | 86.4 | 74.6 | 66.7 | 44.6 | 31.4 | 29.2 | 29.6 | 30.5 |
| 45-54 years | 308.6 | 271.8 | 238.4 | 180.2 | 120.5 | 94.2 | 92.9 | 93.7 |
| 55-64 years | 808.1 | 737.9 | 652.3 | 494.1 | 367.3 | 261.2 | 246.9 | 241.5 |
| 65-74 years | 1,839.8 | 1,740.5 | 1,558.2 | 1,218.6 | 894.3 | 665.6 | 635.1 | 615.9 |
| 75-84 years | 4,310.1 | 4,089.4 | 3,683.8 | 2,993.1 | 2,295.7 | 1,780.3 | 1,725.7 | 1,667.2 |
| 85 years and over | 9,150.6 | 9,317.8 | 7,891.3 | 7,777.1 | 6.739.9 | 5,926.1 | 5,664.2 | 5,446.8 |
| Male | ||||||||
| All ages, age adjustedb | 697.0 | 687.6 | 634.0 | 538.9 | 412.4 | 320.0 | 305.4 | 297.4 |
| All ages, crude | 423.4 | 439.5 | 422.5 | 368.6 | 297.6 | 249.8 | 242.5 | 240.7 |
| Under 1 year | 4.0 | 7.8 | 15.1 | 25.5 | 21.9 | 13.3 | 11.8 | 12.9 |
| 1-4 years | 1.4 | 1.4 | 1.9 | 2.8 | 1.9 | 1.4 | 1.5 | 1.1 |
| 5-14 years | 2.0 | 1.4 | 0.9 | 1.0 | 0.9 | 0.8 | 0.7 | 0.7 |
| 15-24 years | 6.8 | 4.2 | 3.7 | 3.7 | 3.1 | 3.2 | 3.2 | 3.3 |
| 25-34 years | 22.9 | 20.1 | 15.2 | 11.4 | 10.3 | 9.6 | 10.3 | 10.5 |
| 35-44 years | 118.4 | 112.7 | 103.2 | 68.7 | 48.1 | 41.4 | 41.7 | 43.1 |
| 45-54 years | 440.5 | 420.4 | 376.4 | 282.6 | 183.0 | 140.2 | 136.6 | 138.4 |
| 55-64 years | 1,104.5 | 1,066.9 | 987.2 | 746.8 | 537.3 | 371.7 | 349.8 | 343.4 |
| 65-74 years | 2,292.3 | 2,291.3 | 2,170.3 | 1,728.0 | 1,250.0 | 898.3 | 851.3 | 827.1 |
| 75-84 years | 4,825.0 | 4,742.4 | 4,534.8 | 3,834.3 | 2,968.2 | 2,248.1 | 2,177.3 | 2,110.1 |
| 85 years and over | 9,659.8 | 9,788.9 | 8,426.2 | 8,752.7 | 7,418.4 | 6,430.0 | 6,040.5 | 5,823.5 |
| Female | ||||||||
| All ages, age adjustedb | 484.7 | 447.0 | 381.6 | 320.8 | 257.0 | 210.9 | 203.9 | 197.2 |
| All ages, crude | 288.4 | 300.6 | 304.5 | 305.1 | 281.8 | 255.3 | 249.0 | 242.7 |
| Under 1 year | 2.9 | 5.4 | 10.9 | 20.0 | 18.3 | 12.5 | 12.0 | 11.8 |
| 1-4 years | 1.2 | 1.1 | 1.6 | 2.5 | 1.9 | 1.0 | 1.4 | 1.0 |
| 5-14 years | 2.2 | 1.2 | 0.8 | 0.9 | 0.8 | 0.5 | 0.7 | 0.6 |
| 15-24 years | 6.7 | 3.7 | 2.3 | 2.1 | 1.8 | 2.1 | 1.8 | 1.7 |
| 25-34 years | 16.2 | 11.3 | 7.7 | 5.3 | 5.0 | 5.2 | 5.6 | 5.2 |
| 35-44 years | 55.1 | 38.2 | 32.2 | 21.4 | 15.1 | 17.2 | 17.6 | 18.0 |
| 45-54 years | 177.2 | 127.5 | 109.9 | 84.5 | 61.0 | 49.8 | 50.7 | 50.6 |
| 55-64 years | 510.0 | 429.4 | 351.6 | 272.1 | 215.7 | 159.3 | 151.8 | 147.2 |
| 65-74 years | 1,419.3 | 1,261.3 | 1,082.7 | 828.6 | 616.8 | 474.0 | 455.9 | 440.1 |
| 75-84 years | 3,872.0 | 3,528.7 | 3,120.8 | 2,497.0 | 1,893.8 | 1,475.1 | 1,428.9 | 1,389.7 |
| 85 years and over | 8,796.1 | 9,016.8 | 7,591.8 | 7,350.5 | 6,478.1 | 5,720.9 | 5,506.8 | 5,283.3 |
| White malec | ||||||||
| All ages, age adjustedb | 700.2 | 694.5 | 640.2 | 539.6 | 409.2 | 316.7 | 301.8 | 294.1 |
| All ages, crude | 433.0 | 454.6 | 438.3 | 384.0 | 312.7 | 265.8 | 257.8 | 256.0 |
| 45-54 years | 423.6 | 413.2 | 365.7 | 269.8 | 170.6 | 130.7 | 127.0 | 128.6 |
| 55-64 years | 1,081.7 | 1,056.0 | 979.3 | 730.6 | 516.7 | 351.8 | 330.8 | 324.0 |
| 65-74 years | 2,308.3 | 2,297.0 | 2,177.2 | 1,729.7 | 1,230.5 | 877.8 | 829.1 | 807.8 |
| 75-84 years | 4,907.3 | 4,839.9 | 4,617.6 | 3,883.2 | 2,983.4 | 2,247.0 | 2,175.8 | 2,112.0 |
| 85 years and over | 9,950.5 | 10,135.8 | 8,818.0 | 8,958.0 | 7,558.7 | 6,560.8 | 6,157.2 | 5,939.8 |
| Black or African American malec | ||||||||
| All ages, age adjustedb | 639.4 | 615.2 | 607.3 | 561.4 | 485.4 | 392.5 | 384.5 | 371.0 |
| All ages, crude | 346.2 | 330.6 | 330.2 | 301.0 | 256.8 | 211.1 | 209.0 | 206.3 |
| 45-54 years | 622.5 | 514.0 | 512.8 | 433.4 | 328.9 | 247.2 | 242.6 | 246.0 |
| 55-64 years | 1,433.1 | 1,236.8 | 1,135.4 | 987.2 | 824.0 | 631.2 | 602.2 | 605.3 |
| 65-74 years | 2,139.1 | 2,281.4 | 2,237.8 | 1,847.2 | 1,632.9 | 1,268.8 | 1,245.8 | 1,192.7 |
| 75-84 yearsd | 4,106.1 | 3,533.6 | 3,783.4 | 3,578.8 | 3,107.1 | 2,597.6 | 2,569.3 | 2,449.6 |
| 85 years and over | — | 6,037.9 | 5,367.6 | 6,819.5 | 6,479.6 | 5,633.5 | 5,459.9 | 5,125.7 |
of themselves, 20% required help walking, and 71% had some type of impaired vocational ability when examined seven years after the occurrence of their strokes. Sixteen percent needed to be institutionalized.
Spontaneous recovery in the initial thirty days after a stroke probably accounts for the highest levels of regained functional ability. Rehabilitation to reduce dependency and improve physical ability, however, is TABLE 5.5 Death rates for diseases of the heart, by sex, race, Hispanic origin, and age, 1950–2002 [CONTINUED]
| TABLE 5.5 | ||||||||
|---|---|---|---|---|---|---|---|---|
| Death rates for diseases of the heart, by sex, race, Hispanic origin, and age, 1950–2002 [CONTINUED] | ||||||||
| [Data are based on death certificates] | ||||||||
| Sex, race, Hispanic origin, and age | 1950a | 1960a | 1970 | 1980 | 1990 | 2000 | 2001 | 2002 |
| American Indian or Alaska Native malec | Deaths per 100,000 resident population | |||||||
| All ages, age adjustedb | — | — | — | 320.5 | 264.1 | 222.2 | 200.7 | 201.2 |
| All ages, crude | — | — | — | 130.6 | 108.0 | 90.1 | 89.1 | 92.0 |
| 45-54 years | — | — | — | 238.1 | 173.8 | 108.5 | 109.1 | 104.2 |
| 55-64 years | — | — | — | 496.3 | 411.0 | 285.0 | 301.1 | 273.2 |
| 65-74 years | — | — | — | 1,009.4 | 839.1 | 748.2 | 682.1 | 638.4 |
| 75-84 years | — | — | — | 2,062.2 | 1,788.8 | 1,655.7 | 1,384.5 | 1,422.7 |
| 85 years and over | — | — | — | 4,413.7 | 3,860.3 | 3,318.3 | 2,895.7 | 3,162.4 |
| Asian or Pacific Islander malec | ||||||||
| All ages, age adjustedb | — | — | — | 286.9 | 220.7 | 185.5 | 169.8 | 169.8 |
| All ages, crude | — | — | — | 119.8 | 88.7 | 90.6 | 87.3 | 89.4 |
| 45-54 years | — | — | — | 112.0 | 70.4 | 61.1 | 60.1 | 60.6 |
| 55-64 years | — | — | — | 306.7 | 226.1 | 182.6 | 162.0 | 154.2 |
| 65-74 years | — | — | — | 852.4 | 623.5 | 482.5 | 439.1 | 422.4 |
| 75-84 years | — | — | — | 2,010.9 | 1,642.2 | 1,354.7 | 1,273.8 | 1,252.4 |
| 85 years and over | — | — | — | 5,923.0 | 4,617.8 | 4,154.2 | 3,688.1 | 3,841.3 |
| Hispanic or Latino malec,e | ||||||||
| All ages, age adjustedb | — | — | — | — | 270.0 | 238.2 | 232.6 | 219.8 |
| All ages, crude | — | — | — | — | 91.0 | 74.7 | 74.6 | 74.0 |
| 45-54 years | — | — | — | — | 116.4 | 84.3 | 82.9 | 80.5 |
| 55-64 years | — | — | — | — | 363.0 | 264.8 | 242.2 | 256.0 |
| 65-74 years | — | — | — | — | 829.9 | 684.8 | 683.7 | 657.7 |
| 75-84 years | — | — | — | — | 1,971.3 | 1,733.2 | 1,702.7 | 1,599.5 |
| 85 years and over | — | — | — | — | 4,711.9 | 4,897.5 | 4,784.3 | 4,301.8 |
| White, not Hispanic or Latino malee | ||||||||
| All ages, age adjustedb | — | — | — | — | 413.6 | 319.9 | 304.8 | 297.7 |
| All ages, crude | — | — | — | — | 336.5 | 297.5 | 289.5 | 289.2 |
| 45-54 years | — | — | — | — | 172.8 | 134.3 | 130.7 | 133.1 |
| 55-64 years | — | — | — | — | 521.3 | 356.3 | 335.8 | 327.6 |
| 65-74 years | — | — | — | — | 1,243.4 | 885.1 | 834.7 | 813.5 |
| 75-84 years | — | — | — | — | 3,007.7 | 2,261.9 | 2,190.4 | 2,129.9 |
| 85 years and over | — | — | — | — | 7,663.4 | 6,606.6 | 6,195.4 | 5,994.1 |
| White femalec | ||||||||
| All ages, age adjustedb | 478.0 | 441.7 | 376.7 | 315.9 | 250.9 | 205.6 | 198.7 | 192.1 |
| All ages, crude | 289.4 | 306.5 | 313.8 | 319.2 | 298.4 | 274.5 | 267.7 | 261.0 |
| 45-54 years | 141.9 | 103.4 | 91.4 | 71.2 | 50.2 | 40.9 | 41.5 | 41.7 |
| 55-64 years | 460.2 | 383.0 | 317.7 | 248.1 | 192.4 | 141.3 | 134.3 | 130.6 |
| 65-74 years | 1,400.9 | 1,229.8 | 1,044.0 | 796.7 | 583.6 | 445.2 | 429.0 | 414.7 |
| 75-84 years | 3,925.2 | 3,629.7 | 3,143.5 | 2,493.6 | 1,874.3 | 1,452.4 | 1,407.9 | 1,368.2 |
| 85 years and over | 9,084.7 | 9,280.8 | 7,839.9 | 7,501.6 | 6,563.4 | 5,801.4 | 5,582.5 | 5,350.6 |
| Black or African American femalec | ||||||||
| All ages, age adjustedb | 536.9 | 488.9 | 435.6 | 378.6 | 327.5 | 277.6 | 269.8 | 263.2 |
| All ages, crude | 287.6 | 268.5 | 261.0 | 249.7 | 237.0 | 212.6 | 208.6 | 205.0 |
| 45-54 years | 525.3 | 360.7 | 290.9 | 202.4 | 155.3 | 125.0 | 125.9 | 124.9 |
| 55-64 years | 1,210.2 | 952.3 | 710.5 | 530.1 | 442.0 | 332.8 | 323.1 | 312.3 |
| 65-74 years | 1,659.4 | 1,680.5 | 1,553.2 | 1,210.3 | 1,017.5 | 815.2 | 768.0 | 734.0 |
| 75-84 yearsd | 3,499.3 | 2,926.9 | 2,964.1 | 2,707.2 | 2,250.9 | 1,913.1 | 1,849.6 | 1,821.9 |
| 85 years and over | — | 5,650.0 | 5,003.8 | 5,796.5 | 5,766.1 | 5,298.7 | 5,207.3 | 5,111.2 |
| American Indian or Alaska Native femalec | ||||||||
| All ages, age adjustedb | — | — | — | 175.4 | 153.1 | 143.6 | 127.0 | 123.6 |
| All ages, crude | — | — | — | 80.3 | 77.5 | 71.9 | 68.2 | 68.5 |
| 45-54 years | — | — | — | 65.2 | 62.0 | 40.2 | 42.7 | 29.7 |
| 55-64 years | — | — | — | 193.5 | 197.0 | 149.4 | 126.5 | 124.3 |
| 65-74 years | — | — | — | 577.2 | 492.8 | 391.8 | 384.2 | 365.8 |
| 75-84 years | — | — | — | 1,364.3 | 1,050.3 | 1,044.1 | 934.3 | 1,002.5 |
| 85 years and over | — | — | — | 2,893.3 | 2,868.7 | 3,146.3 | 2,510.3 | 2,372.5 |
also vital. The patient's attitude, the skills of the rehabilitation team, and support and understanding from the patient's family all affect the quality of recovery.
NATIONAL COSTS OF STROKE
The costs of stroke are high in terms of emotional distress, lost wages, and medical care expenditures. The AHA estimated that the costs of stroke were nearly $58 billion in 2006, including the costs
TABLE 5.5 Death rates for diseases of the heart, by sex, race, Hispanic origin, and age, 1950–2002 [CONTINUED]
| TABLE 5.5 | ||||||||
|---|---|---|---|---|---|---|---|---|
| Death rates for diseases of the heart, by sex, race, Hispanic origin, and age, 1950–2002 [CONTINUED] | ||||||||
| [Data are based on death certificates] | ||||||||
| Sex, race, Hispanic origin, and age | 1950a | 1960a | 1970 | 1980 | 1990 | 2000 | 2001 | 2002 |
| aIncludes deaths of persons who were not residents of the 50 states and the District of Columbia. | ||||||||
| bAge-adjusted rates are calculated using the year 2000 standard population. | ||||||||
| cThe race groups, white, black, Asian or Pacific Islander, and American Indian or Alaska Native, include persons of Hispanic and non-Hispanic origin. Persons of Hispanic origin may be of any race. Death rates for the American Indian or Alaska Native and Asian or Pacific Islander populations are known to be underestimated. | ||||||||
| dIn 1950 rate is for the age group 75 years and over. | ||||||||
| ePrior to 1997, excludes data from states lacking an Hispanic-origin item on the death certificate. | ||||||||
| Notes: "—"=Data not available. Age groups were selected to minimize the presentation of unstable age-specific death rates based on small numbers of deaths and for consistency among comparison groups. | ||||||||
| SOURCE: "Table 36. Death Rates for Diseases of Heart, according to Sex, Race, Hispanic Origin, and Age: United States, 1950–2002," in Health, United States, 2005, Centers for Disease Control and Prevention, National Center for Health Statistics, November 2005, http://www.cdc.gov/nchs/data/hus/hus05.pdf (accessed December 8, 2005) | ||||||||
| Asian or Pacific Islander femalec | Deaths per 100,000 resident population | |||||||
| All ages, age adjustedb | — | — | — | 132.3 | 149.2 | 115.7 | 112.9 | 108.1 |
| All ages, crude | — | — | — | 57.0 | 62.0 | 65.0 | 67.9 | 67.4 |
| 45-54 years | — | — | — | 28.6 | 17.5 | 15.9 | 18.4 | 16.4 |
| 55-64 years | — | — | — | 92.9 | 99.0 | 68.8 | 62.8 | 61.8 |
| 65-74 years | — | — | — | 313.3 | 323.9 | 229.6 | 241.7 | 239.9 |
| 75-84 years | — | — | — | 1,053.2 | 1,130.9 | 866.2 | 848.7 | 796.9 |
| 85 years and over | — | — | — | 3,211.0 | 4,161.2 | 3,367.2 | 3,186.3 | 3,067.4 |
| Hispanic or Latino femalec,e | ||||||||
| All ages, age adjustedb | — | — | — | — | 177.2 | 163.7 | 161.0 | 149.7 |
| All ages, crude | — | — | — | — | 79.4 | 71.5 | 71.8 | 69.7 |
| 45-54 years | — | — | — | — | 43.5 | 28.2 | 27.9 | 30.2 |
| 55-64 years | — | — | — | — | 153.2 | 111.2 | 107.2 | 105.7 |
| 65-74 years | — | — | — | — | 460.4 | 366.3 | 363.1 | 346.4 |
| 75-84 years | — | — | — | — | 1,259.7 | 1,169.4 | 1,155.7 | 1,090.8 |
| 85 years and over | — | — | — | — | 4,440.3 | 4,605.8 | 4,521.1 | 4,032.8 |
| White, not Hispanic or Latino femalee | ||||||||
| All ages, age adjustedb | — | — | — | — | 252.6 | 206.8 | 200.0 | 193.7 |
| All ages, crude | — | — | — | — | 320.0 | 304.9 | 298.4 | 292.3 |
| 45-54 years | — | — | — | — | 50.2 | 41.9 | 42.7 | 42.6 |
| 55-64 years | — | — | — | — | 193.6 | 142.9 | 136.0 | 132.0 |
| 65-74 years | — | — | — | — | 584.7 | 448.5 | 431.8 | 417.4 |
| 75-84 years | — | — | — | — | 1,890.2 | 1,458.9 | 1,414.7 | 1,377.2 |
| 85 years and over | — | — | — | — | 6,615.2 | 5,822.7 | 5,601.6 | 5,384.5 |
of hospitalization, nursing home service, doctors' and nurses' services, medications, and lost productivity. Most of these costs were associated with health care facilities that provide long-term rehabilitation or residential care (Robert Adams et al, "American Heart Association/American Stroke Association Scientific Statement," May 2006).
High Blood Pressure
Blood pressure is a combination of two forces: the heart pumping blood into the arteries and the resistance of small arteries called arterioles to the flow of blood. The greater the resistance, the greater the pressure needed by the heart to keep the blood moving. The walls of the arterioles are elastic enough to allow for the expansion and contraction caused by the constantly changing rate of blood flow, thus allowing for a steady blood pressure in normal bodies. If the arterioles stay contracted or lose their elasticity as a result of atherosclerosis (commonly known as "hardening of the arteries"), the resistance to blood flow increases and blood pressure rises.
Blood pressure is measured in millimeters (mm) of mercury (Hg) by an instrument known as a sphygmomanometer. The sphygmomanometer produces two values: the systolic pressure (a measurement of the maximum pressure of the blood flow when the heart contracts or beats) and the diastolic pressure (the minimum pressure of the blood flow between beats). A typical "normal" range of values may vary, but the more resistance there is to blood flow, the higher the reading. High blood pressure (hypertension) for adults is defined as a systolic pressure equal to or greater than 140 mm Hg and/or a diastolic pressure equal to or greater than 90 mm Hg. In the United States nearly one in three adults has high blood pressure. "Prehypertension" is defined as systolic pressure of 120-139 mm Hg or diastolic pressure of 80-89 mm Hg. About two-thirds of individuals age forty-five to sixty-four and 80% of those age sixty-five to seventy-four have prehypertension ("Prehypertension Accounts for a Substantial Number of Hospitalizations, Nursing Home Admissions, and Premature Deaths," Agency for Healthcare Quality, April 2005).
FIGURE 5.7 Death rates for leading causes of death for all ages, 1950–2002
Elevated blood pressure causes the heart to work harder than normal and places the arteries under a strain that might contribute to a heart attack, stroke, or atherosclerosis. When the heart works too hard, it can become enlarged and eventually will be unable to function at maximum pumping capacity.
PREVALENCE OF HYPERTENSION
As many as one in five Americans, including children as young as age six, have high blood pressure, according to the AHA. The cause of hypertension is unknown in 90% to 95% of cases; this is called essential hypertension. The remaining cases are termed secondary hypertension because they result from an identified condition, such as an abnormality in the kidneys, adrenal gland, or aorta.
The AHA reports that African-Americans, Puerto Ricans, Cuban Americans, and Mexican Americans are more likely to suffer from hypertension than whites. Table 5.3 shows data about high blood pressure among people twenty years of age and older by race, poverty status, and Hispanic origin. In the period 1999–2002 hypertension was more prevalent among the poor (19.3%) and near poor (19.5%) than among the nonpoor (14.9%). Both African-American males and African-American females have a higher incidence of high blood pressure than white or Mexican American males and females.
The AHA reports that in 2003 hypertension was either the primary cause of death or contributed to the death of about 277,000 Americans. From 1993 to 2003 the age-adjusted death rate from hypertension increased by nearly 30%, and the actual number of deaths rose 56.1%. As many as 30% of all deaths among African-American men with hypertension and 20% of all deaths among African-American women with hypertension can be attributed to high blood pressure (Heart Disease and Stroke Statisics—2006 Update).
TREATMENT
In almost all cases, hypertension is treatable. A variety of medications, including diuretics, which rid the body of excess fluid and salt, can lower blood pressure.
Diet and lifestyle changes are also essential to control hypertension. Some people with only mildly elevated blood pressure need only to reduce or eliminate salt in their diets. Blood pressure in overweight or obese people often declines when they lose weight. Heavy drinkers often see improved blood pressure when they abstain from alcohol or drink less. Some people find exercise, stress management techniques, and relaxation therapy helpful. When people are aware of the problem and follow prescribed treatments, high blood pressure can be controlled and need not be fatal. Patients, however, often stop taking high blood pressure medication once their hypertension is controlled. This poses a serious danger; it is essential that patients continue to take the medication even if they feel perfectly well.
CANCER
Cancer is a large group of diseases characterized by the uncontrolled growth and spread of abnormal cells. These cells may grow into masses of tissue called tumors. Tumors made up of cells that are not cancerous are called benign tumors. The tumors consisting of cancer cells are called malignant tumors. The dangerous aspect of cancer is that cancer cells invade and destroy normal tissue.
The spread of cancer cells occurs either by local growth of the tumor or by some of the cells becoming detached and traveling through the blood and lymph systems to start additional tumors in other parts of the body. Metastasis (the spread of cancer cells) may be confined to a region of the body, but left untreated (and often despite treatment), the cancer cells can spread throughout the entire body, causing death. The rapid, invasive, and destructive nature of cancer makes it, arguably, the most TABLE 5.6 Age-adjusted death rates for selected causes of death, by sex, race, and Hispanic origin, selected years 1950–2002
| TABLE 5.6 | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| Age-adjusted death rates for selected causes of death, by sex, race, and Hispanic origin, selected years 1950–2002 | |||||||||
| [Data are based on death certificates] | |||||||||
| Sex, race, Hispanic origin, and cause of death | 1950a | 1960a | 1970 | 1980 | 1990 | 1995 | 2000 | 2001 | 2002 |
| All persons | Age-adjusted death rate per 100,000 populationb | ||||||||
| All causes | 1,446.0 | 1,339.2 | 1,222.6 | 1,039.1 | 938.7 | 909.8 | 869.0 | 854.5 | 845.3 |
| Diseases of heart | 586.8 | 559.0 | 492.7 | 412.1 | 321.8 | 293.4 | 257.6 | 247.8 | 240.8 |
| Ischemic heart disease | — | — | — | 345.2 | 249.6 | 219.7 | 186.8 | 177.8 | 170.8 |
| Cerebrovascular diseases | 180.7 | 177.9 | 147.7 | 96.2 | 65.3 | 63.1 | 60.9 | 57.9 | 56.2 |
| Malignant neoplasms | 193.9 | 193.9 | 198.6 | 207.9 | 216.0 | 209.9 | 199.6 | 196.0 | 193.5 |
| Trachea, bronchus, and lung | 15.0 | 24.1 | 37.1 | 49.9 | 59.3 | 58.4 | 56.1 | 55.3 | 54.9 |
| Colon, rectum, and anus | — | 30.3 | 28.9 | 27.4 | 24.5 | 22.5 | 20.8 | 20.1 | 19.7 |
| Prostatec | 28.6 | 28.7 | 28.8 | 32.8 | 38.4 | 37.0 | 30.4 | 29.1 | 27.9 |
| Breastd | 31.9 | 31.7 | 32.1 | 31.9 | 33.3 | 30.5 | 26.8 | 26.0 | 25.6 |
| Chronic lower respiratory diseases | — | — | — | 28.3 | 37.2 | 40.1 | 44.2 | 43.7 | 43.5 |
| Influenza and pneumonia | 48.1 | 53.7 | 41.7 | 31.4 | 36.8 | 33.4 | 23.7 | 22.0 | 22.6 |
| Chronic liver disease and cirrhosis | 11.3 | 13.3 | 17.8 | 15.1 | 11.1 | 9.9 | 9.5 | 9.5 | 9.4 |
| Diabetes mellitus | 23.1 | 22.5 | 24.3 | 18.1 | 20.7 | 23.2 | 25.0 | 25.3 | 25.4 |
| Human immunodeficiency virus (HIV) disease | — | — | — | — | 10.2 | 16.2 | 5.2 | 5.0 | 4.9 |
| Unintentional injuries | 78.0 | 62.3 | 60.1 | 46.4 | 36.3 | 34.4 | 34.9 | 35.7 | 36.9 |
| Motor vehicle-related injuries | 24.6 | 23.1 | 27.6 | 22.3 | 18.5 | 16.3 | 15.4 | 15.3 | 15.7 |
| Suicidee | 13.2 | 12.5 | 13.1 | 12.2 | 12.5 | 11.8 | 10.4 | 10.7 | 10.9 |
| Homicidee | 5.1 | 5.0 | 8.8 | 10.4 | 9.4 | 8.3 | 5.9 | 7.1 | 6.1 |
| Male | |||||||||
| All causes | 1,674.2 | 1,609.0 | 1,542.1 | 1,348.1 | 1,202.8 | 1,143.9 | 1,053.8 | 1,029.1 | 1,013.7 |
| Diseases of heart | 697.0 | 687.6 | 634.0 | 538.9 | 412.4 | 371.0 | 320.0 | 305.4 | 297.4 |
| Ischemic heart disease | — | — | — | 459.7 | 328.2 | 286.5 | 241.4 | 228.5 | 220.4 |
| Cerebrovascular diseases | 186.4 | 186.1 | 157.4 | 102.2 | 68.5 | 65.9 | 62.4 | 59.0 | 56.5 |
| Malignant neoplasms | 208.1 | 225.1 | 247.6 | 271.2 | 280.4 | 267.5 | 248.9 | 243.7 | 238.9 |
| Trachea, bronchus, and lung | 24.6 | 43.6 | 67.5 | 85.2 | 91.1 | 84.2 | 76.7 | 75.2 | 73.2 |
| Colon, rectum, and anus | — | 31.8 | 32.3 | 32.8 | 30.4 | 27.4 | 25.1 | 24.2 | 23.7 |
| Prostate | 28.6 | 28.7 | 28.8 | 32.8 | 38.4 | 37.0 | 30.4 | 29.1 | 27.9 |
| Chronic lower respiratory diseases | — | — | — | 49.9 | 55.4 | 54.8 | 55.8 | 54.0 | 53.5 |
| Influenza and pneumonia | 55.0 | 65.8 | 54.0 | 42.1 | 47.8 | 42.8 | 28.9 | ||