Academic journal article Bulletin of the World Health Organization

Cardiovascular Risk Factor Trends and Potential for Reducing Coronary Heart Disease Mortality in the United States of America/ Tendances Des Facteurs De Risque Cardiovasculaire et Possibilites De Reduire la Mortalite Par Cardiopathie Coronarienne Aux Etats-Unis d'Amerique/tendencias De Los Factores De Riesgo Cardiovascular Y Potencial De Reduccion De la Mortalidad Por Cardiopatia Coronaria

Academic journal article Bulletin of the World Health Organization

Cardiovascular Risk Factor Trends and Potential for Reducing Coronary Heart Disease Mortality in the United States of America/ Tendances Des Facteurs De Risque Cardiovasculaire et Possibilites De Reduire la Mortalite Par Cardiopathie Coronarienne Aux Etats-Unis d'Amerique/tendencias De Los Factores De Riesgo Cardiovascular Y Potencial De Reduccion De la Mortalidad Por Cardiopatia Coronaria

Article excerpt

Introduction

Coronary heart disease (CHD) accounted for over 450 000 deaths in the United States of America in 2004. (1,2) The burden of CHD in the United States is enormous; more than 13 million people are affected, and the costs of direct health care exceed USS 150 billion annually. (1,2)

Since the late 1970s, age-adjusted CHD mortality rates have been halved in most industrialized countries, including the United States. However, between 1990 and 2000 this decrease diminished, and in younger age groups it nearly ceased. (1,2) Many adults in the United States are still at high risk for cardiovascular disease. Total blood cholesterol levels exceed 200 mg/dl among more than 100 million adults; approximately 70 million have or are being treated for high blood pressure (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 United States 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 an overall rate of 203 per 100 000 population in 1998 to 162 per 100 000 in 2010). (3) They also include specific targets for reducing mean total blood cholesterol (to 199 mg/dl), smoking (to 12% of the population), 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 by 2010? 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 have often occurred simultaneously. (9,10) Furthermore, risk factor improvements, such as lower blood pressure or total blood cholesterol, may be achieved through medications, lifestyle changes or a combination. (1,2,8-10)

A variety of CHD policy models have been developed to estimate the relative contributions and hence the population impact of medical and public health interventions. Good models are able to integrate and simultaneously consider large amounts of data on patient numbers, treatments and population risk factor trends. (9-11) The CHD Policy Model developed in the United States was used successfully to examine risk factor trends in that country between 1980 and 1990 (9) and later demonstrated the potential advantages of a population-based approach to prevention, (12) consistent with European studies. (13-15) Capewell et al. subsequently developed and refined a CHD mortality model called IMPACT and applied it in a variety of populations. (10,16-19) Approximately 44% of the substantial CHD mortality decline in the United States between 1980 and 2000 was attributable to changes in major risk factors, and 47% to specific cardiological treatments. (10) These findings resembled those from other industrialized countries. (16,17,19,20)

Three earlier analyses suggested that further modest reductions in major risk factors could halve CHD deaths in the United Kingdom. (15,21-23) To determine if similar gains could be attained for the population of the United States or if they would be rendered unattainable by recent dramatic rises in obesity and diabetes, we used the previously calibrated IMPACT model (10) for the United States to estimate the number of CHD deaths that could be prevented or postponed in 2010, compared with the number in 2000. …

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