Heart disease is the leading cause of death for both men and women in the United States. During 2002, nearly 700,000 individuals in the US died of heart disease.1 Of these deaths, approximately 500,000 are the result of ischemic coronary heart disease, with 47% of these individuals dying before emergency services or transport to a hospital could occur. Fifty-one percent of those dying of heart disease are women.2, 3 Heart disease is the leading cause of death for most American ethnic groups, including whites, African Americans, Hispanics, American Indians, and Alaskan Natives. Discouragingly, heart disease death rates are 30% higher in African Americans compared with whites.2 The projected cost for the immense burden of heart disease in the US during 2006 was between $143 and $258 billion, including health care services, medications, and lost productivity.4, 5
Risk factors for the development of atherosclerotic disease are unfortunately widespread in the US population. Indeed, between 1999 and 2000, approximately 30% of individuals aged 20 years or older had diagnosed hypertension or were taking antihypertensive medication, 17% had high blood cholesterol, 6.5% were diabetic, 30.5% were obese, and more than 21% smoked cigarettes. Moreover, more than 37% reported no leisure-time physical activity.2 In 2003, approximately 37% of American adults reported having 2 or more of these risk factors for cardiovascular disease. Ninety percent of patients with ischemic coronary artery disease have at least one atherosclerotic risk factor.6
With these grim statistics in mind, the report of King et al in this issue of The American Journal of Medicine is very disturbing.7 Despite vigorous efforts on the part of national and local health authorities and organizations such as the American Heart Association, the incidence of atherosclerotic arterial disease risk factors has actually increased in recent years. King et al compared 5 major atherosclerotic risk factors present in a large cross-sectional population sample of US residents studied in the National Health and Nutrition Examination Survey during the years 1988-1994 to results from the National Health and Nutrition Examination Survey data from the years 2001-2006 for adults aged 40-74 years.
During the 2 6-year periods studied, obesity in this US population sample increased by 8%; recommended levels of physical exercise decreased by 10%, and dietary fruit and vegetable intake decreased by 16%. Smoking rates remained essentially unchanged, while moderate alcohol use increased by 11%. Adherence to all 5 of the lifestyle measures just enumerated fell from 15% during 1988-1994 to 8% during 2001-2006.
During the time period 1979-1998, the yearly decrease in hospital mortality rates for ischemic coronary heart disease was 5.3%. However, the decrease in out-of-hospital sudden death rates was substantially less than that for in-hospital coronary heart disease mortality. Because 49% of these sudden cardiac deaths were unexpected, the burden of these unhappy events on the US population remains high.8, 9 This statistic is particularly unsettling because for many of these sudden death victims, their demise was the first indication of the presence of coronary heart disease.10
Unexpected sudden death was highest in African Americans compared with other US ethnic groups. This also is reflected in the population samples studied by King et al, in which adherence to the 5 healthy lifestyles listed above was lower in minorities.7 One particularly disturbing finding from the study was that individuals with a history of hypertension, diabetes mellitus, or cardiovascular disease were no more likely to adhere to a healthy lifestyle than were people without these conditions.
In an effort to stem the tide of unexpected sudden cardiac deaths and mortality in general from ischemic heart disease, a number of authorities have suggested earlier and more aggressive primary coronary heart disease preventive measures. Evidence of early and often far advanced coronary atherosclerosis in young individuals supports the concept that prevention of ischemic cardiac disease deaths must focus on the prevention of coronary atherosclerosis. It was initially a surprise to investigators when advanced coronary artery disease was demonstrated in the majority of US servicemen dying of war trauma during the Korean War.9 Equally surprising was the fact that coronary atherosclerosis is often present in young children who are found to have coronary risk factors.11, 12, 13 In light of these latter statistics, it is particularly disturbing that healthy lifestyle choices are declining rather than improving in the US population. This does not augur well for the future. It is likely that if the deteriorating trends in lifestyle choices observed by King et al continue into the future, decreases in coronary heart disease mortality observed over the last 40 years will begin to reverse. The time is now long overdue to start aggressive preventive cardiovascular disease programs in our schools, our homes, and our worksites. I hope the new administration in Washington, DC is listening!!
As always, I'd be interested in hearing your comments on this important topic. Feel free to post a comment on our blog, http://amjmed.blogspot.com, regarding this editorial or other Journal content.
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