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Heart disease has been the leading cause of death in the United States for the past 80 years1 and is a major cause of disability. Heart disease also results in substantial health-care expenditures; for example, coronary heart disease is projected to cost an estimated $151.6 billion in direct and indirect costs in 2007.2 Although some self-reported national data are available,3 state-specific prevalence data for heart disease have not been reported previously. In addition, although racial/ethnic, geographic, and sex differences in death rates for heart disease have been documented,4,5 less information has been available regarding the prevalence of persons living with heart disease. To estimate the prevalence of myocardial infarction (MI) and angina/coronary heart disease (CHD) in each of the 50 states, the District of Columbia (DC), Puerto Rico, and the U.S. Virgin Islands (USVI), CDC analyzed self-reported data from the 2005 Behavioral Risk Factor Surveillance System (BRFSS).* This report summarizes the results of that analysis and provides the first state-based prevalence estimates of these heart diseases. The results indicated that substantial geographic, racial / ethnic, educational, and sex disparities existed in the prevalence of MI and angina/CHD. To lower the incidence of heart disease and meet the overall Healthy People 2010 goal to eliminate health disparities, public health programs should target disproportionately affected populations.
BRFSS is a state-based, random-digit–dialed telephone survey of the noninstitutionalized, U.S. civilian population aged ≥18 years and is administered by state health departments in collaboration with CDC. In 2005, the median response rate among states, based on Council of American Survey and Research Organizations (CASRO) guidelines, was 51.1% (range: 34.6%-67.4%). This rate accounts for both the efficiency of the telephone sampling method used and participation rates among eligible respondents who were contacted. A total of 356,112 respondents from all 50 states, DC, Puerto Rico, and USVI participated in the survey. State (including DC) and territory sample sizes ranged from 2,422 (USVI) to 23,302 (Washington).
Survey respondents answered questions indicating whether a doctor or other health professional had ever told them that they had experienced a “heart attack, also called a myocardial infarction” or “angina or coronary heart disease.” Differences in prevalence were assessed by age, race/ethnicity, sex, education, and state or territory of residence. Data were weighted to reflect each state and territory's population aged ≥18 years, and results were age adjusted to the 2000 U.S. adult standard population. Race/ethnicity identification was provided by respondents; persons who identified themselves as multiracial were included in a separate category.
In 2005, a total of 4.0% (95% confidence interval [CI] = 3.9-4.1) of respondents reported a history of MI, and 4.4% (CI = 4.3-4.5) reported a history of angina/CHD. A total of 6.5% (CI = 6.3-6.6) of respondents reported a history of one or more of these conditions (MI, angina/CHD, or both). Men had a significantly higher prevalence of MI history than women (5.5%, CI = 5.3-5.7, versus 2.9%, CI = 2.8-3.0), angina/CHD (5.5%, CI = 5.3-5.8, versus 3.4%, CI = 3.3-3.6), and one or more of these conditions (8.2%, CI = 8.0-8.5, versus 5.0%, CI = 4.9-5.2). The prevalences of history of MI, angina / CHD, and one or more of these conditions increased among successive age groups and decreased with higher education. Of persons with less than a high school diploma, 9.8% (CI = 9.3-10.4) reported a history of one or more of the conditions, nearly twice the proportion among college graduates (5.0%, CI = 4.7-5.2). American Indians/Alaska Natives and multiracial persons had substantially higher prevalences of a history of MI, angina / CHD, and one or more of these conditions than did non-Hispanic whites. The prevalences of all of these conditions among whites and blacks were similar.
The prevalence of respondents with a history of MI ranged from 2.1% (CI = 1.5-2.9) in USVI to 6.1% (CI = 5.4-6.9) in West Virginia. Puerto Rico (8.5%) and West Virginia (7.3%) had the highest prevalence of angina/CHD history; Colorado (2.8%) and USVI (2.2%) had the lowest prevalence. The prevalence of any condition (MI, angina/CHD, or both) ranged from 3.5% (CI = 2.7-4.5) in USVI to 10.4% (CI = 9.4-11.4) in West Virginia. States and territories with the highest prevalence of a history of any of the conditions had approximately twice the prevalence of those with the lowest prevalence.
JR Neyer, KJ Greenlund, PhD, CH Denny, PhD, NL Keenan, PhD, DR Labarthe, MD, PhD, JB Croft, PhD, Div for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, CDC.
This report describes the first state-based prevalence estimates of MI and angina/CHD. The overall prevalence estimates in this report are comparable to previously published self-reported data on a national level.3 Substantial disparities by sex, race/ethnicity, and education were observed in the prevalence of these heart conditions in the United States in 2005. The results also suggest variation among states, with an approximately twofold difference between states with the highest and lowest prevalences. Many of the states with the highest prevalence were clustered in the lower Mississippi and Ohio River valleys, areas that have been documented previously as having high proportions of residents with heart-disease risk factors6 and high heart-disease mortality.4,5
One important explanation for the geographic variation in heart-disease prevalence is variation in the proportion of the population with heart-disease risk factors.6 A previous analysis suggested that up to 60% of the variation in state heart-disease mortality is a result of differences in the prevalence of cardiovascular risk factors among states,7 which has been attributed to differences in cultural norms, lack of economic opportunity, poverty, and social isolation.4 Additional studies that include small-area analyses, in-depth interviews, and more precise race/ethnicity prevalence estimates, quality-of-care assessments, and health outcomes might further define these differences and lead to effective interventions.
The findings in this report are subject to at least four limitations. First, BRFSS data are based on self-reported information and are subject to recall bias. Second, BRFSS does not include persons living in nursing homes, prisons, military bases, or other institutions, populations whose inclusion might alter heart-disease prevalence estimates for the entire population. Third, BRFSS is limited to households with landline telephones and does not include persons without telephones or who use cellular telephones exclusively. Finally, although the BRFSS response rate was low, BRFSS data are considered valid and reliable when compared with data from other surveys.8
CDC has formed local, state, national, and international partnerships to control risk factors, reduce heart disease, and attain the national health objectives described in Healthy People 2010. For example, CDC has partnered with nearly 80 other organizations to form the National Forum for Heart Disease and Stroke Prevention. The forum is pursuing a comprehensive agenda for achieving national goals for preventing heart disease and stroke.9 In addition, the CDC State Heart Disease and Stroke Prevention Program funds health departments in 32 states and DC to support heart-disease prevention through education, strategies to change physical and social environments to decrease risk for heart disease, and elimination of racial/ethnic disparities in heart-disease risk. CDC also funds 15 WISEWOMAN projects that provide low-income, underinsured, and uninsured women aged 40-64 years with lifestyle interventions, referral services, and screening for chronic-disease risk factors to prevent cardiovascular disease; approximately 12,000 women have received services through WISEWOMAN in the past 4 years.†
This report indicates that the prevalence of certain heart diseases varies between men and women, among various levels of education achievement, among racial/ethnic groups, and among states and territories. These data can help health planners (e.g., policy makers and public health officials) better target resources and can aid the development of more tailored prevention programs for groups with disproportionately high heart-disease prevalence. The importance of preventing and controlling risk factors such as high blood pressure, high blood cholesterol, diabetes, tobacco use, physical inactivity, and obesity to reduce the risk of heart disease is well-established.10 Measures should include prevention of risk factors, early detection and control of risk factors, and reduction of risk in persons who have already received a diagnosis of heart disease. Persons with known heart disease should have regular clinical follow-up and consultations to reduce their heart-disease risk factors.10 In addition, community- and state-level policies are needed to promote healthy lifestyles, help reduce tobacco exposure, ensure access to healthy foods, establish school and worksite heart-health education programs, and result in an environment that is safe for and conducive to physical activity.‡
The findings in this report are based on data provided by BRFSS state coordinators.
REFERENCES: 10 available
*Information regarding BRFSS data and methods is available at http://www.cdc.gov/brfss/technical_infodata/surveydata/2005.htm.
†Additional information regarding the WISEWOMAN program is available at http://www.cdc.gov/wisewoman.
‡American Heart Association Guide for Improving Cardiovascular Health at the Community Level: A Statement for Public Health Practitioners, Healthcare Providers, and Health Policy Makers. Available at http://circ.ahajournals.org/cgi/reprint/107/4/645.
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