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Innovation in clinical specialities: cardiovascular disease
Cardiovascular risk factor trends
and options for reducing future
coronary heart disease mortality in
the United States of America
ARTICLE BY SIMON CAPEWELL
Division of Public Health, University of Liverpool, England
EARL S FORD
Division of Adult and Community Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
JANET B CROFT
Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
JULIA A CRITCHLEY
Institute of Health and Society, Newcastle University, England
KURT J GREENLUND
Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
DARWIN R LABARTHE
Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
One of the objectives of the Healthy People 2010 initiative in the United States of America (USA) is achievement of a 20% reduction
in age-adjusted coronary heart disease (CHD) mortality rates. We examined the potential for changes in cardiovascular risk factors
to achieve that target using a previously validated, comprehensive CHD mortality model. This model integrates information on
trends in all the major cardiovascular risk factors, stratified by age and sex. The potential reductions in CHD mortality within the
projected population of the USA aged 25 to 84 years in 2010 (198 million) from base year 2000 were calculated for three
contrasting scenarios. In the first scenario, if age-adjusted CHD mortality rates observed in 2000 remained unchanged, some 388
470 CHD deaths would occur in 2010. Continuation of recent risk factor trends should result in approximately 19 000 fewer coronary
deaths (some 51 000 fewer deaths attributable to improvements in total cholesterol and men’s blood pressure, decreased smoking
and increased physical activity, minus approximately 32 000 additional deaths attributable to adverse trends in obesity, diabetes
and women’s blood pressure). In the second scenario, success in reaching all the Healthy People 2010 risk factor targets would
achieve approximately 188 000 fewer deaths. In the third, additional reductions in risk factors to the levels already seen in the lowrisk
stratum could potentially prevent approximately 372 000 deaths. Achievement of the Healthy People 2010 targets could almost
halve predicted CHD deaths. Additional reductions in major risk factors could prevent or postpone substantially more CHD deaths.
Coronary heart disease (CHD) accounted for over 450 000
deaths in the United States of America (USA) in 2004. 1,2
The burden of CHD is enormous, affecting more than 13
million people and generating direct health-care costs exceeding
US$ 150 billion annually. 1,2 Since the late 1970s, age-adjusted
CHD mortality rates have been halved in most industrialized
countries including the USA. However, between 1990 and 2000
this decrease diminished, with clear flattening in younger age
groups. 1,2 Many adults in the USA still demonstrate high levels of
risk for cardiovascular disease. Total cholesterol levels exceed 200
mg/dl among more than 100 million adults, approximately 70
million have or are being treated for high blood pressure (a systolic
blood pressure ≥140 mmHg or diastolic blood pressure ≥90
mmHg) and over 50 million people still smoke. 2–4
The Healthy People 2010 (HP2010) initiative promoted by the
government of the USA contains targets for heart disease and
stroke that explicitly address risk factor prevention, detection and
management, along with prevention of recurrent events. HP2010
objectives include a 20% reduction in age-adjusted CHD mortality
rates (from 203 per 100 000 population in 1998 to 162 per 100
000 in 2010).3 They also include specific targets for reducing
cholesterol (to 199 mg/dl), smoking (to 12%), hypertension (to
16%), diabetes (to 6%), obesity (to 15%) and inactivity (to 20%). 3
Inactivity was measured in the Behavioral Risk Factor Surveillance
System of the United States Centers for Disease Control and
Prevention as the proportion of adults engaging in no physical
activity.5 If those targets are achieved, what reduction in CHD
mortality might actually result?
Large meta-analyses and cohort studies have consistently
demonstrated substantial reductions in CHD deaths related to
decreases in each of the major cardiovascular risk factors among
individuals covered by the studies. 6–8 However, it is difficult to
attribute a decline in the mortality rate for an entire population
either to specific risk factor changes or to more effective medical
interventions because favourable trends in both often have
occurred simultaneously. 9,10 Furthermore, risk factor improvements
such as lower blood pressure or cholesterol may be achieved
through medications, lifestyle changes or a combination. 1,2,8–10
68 Hospital and Healthcare Innovation Book 2009/2010