SAMUEL TCHWENKO, MD, MPH Epidemiologist, Heart Disease & Stroke Prevention Branch Chronic Disease & Injury Section; Division of Public Health NC Department of Health & Human Services JUSTUS WARREN TASK FORCE MEETING DECEMBER 05, 2012 1
INTRODUCTION MORTALITY MORBIDITY ECONOMIC IMPACT RISK FACTORS DISPARITIES CONCLUSION 2
I00-I78 I00-I09, I11, I13, I20-I51 Hypertensive Essential Renal (primary) Disease Hypertension (I12) (I10) Other peripheral vascular diseases (I73) Rheumatic fever with heart involvement (I01) Secondary Rheumatic chorea (I02) Acute pericarditis (I30) Rheumatic mitral valve diseases (I05) Hypertension Pulmonary embolism (I26) Rheumatic aortic valve diseases (I06) Pulmonary valve disorders (I37) (I15) Rheumatic tricuspid valve diseases (I07) Endocarditis, valve unspecified (I38) I60-I69 Multiple valve diseases (I08) Acute myocarditis (I40) Other rheumatic heart diseases (I09) Cardiomyopathy (I42) Subarachnoid haemorrhage (I60) Hypertensive heart disease (I11) Atrio-ventricular and left Intra-cerebral haemorrhage (I61) Hypertensive heart and renal disease (I13) bundle-branch block (I44) Other non-traumatic intracranial haemorrhage (I62) Other pulmonary heart diseases (I27) Other conduction disorders (I45) Cerebral infarction (I63) Other diseases of pulmonary vessels (I28) Cardiac arrest (I46) Stroke, not specified as haemorrage of infarction (I64) Other diseases of pericardium (I31) Paroxysmal tachycardia (I47) Other cerebrovascular diseases (I67) Acute and sub-acute endocarditis (I33) Atrial fibrillation and flutter (I48) Non-rheumatic mitral valve disorders (I34) Other cardiac arrhythmias (I49) Non-rheumatic aortic valve disorders (I35) Complications and ill-defined descriptions Non-rheumatic tricuspid valve disorders (I36) of heart disease (I51) I20-I25 Angina pectoris (I20) Acute myocardial infarction (I21) Subsequent myocardial infarction (I22) Other acute ischaemic heart diseases (I24) Chronic ischaemic heart disease (I25) Q20-Q28 Cardiac chambers and connections (Q20) Cardiac septa (Q21) Pulmonary and tricuspid valves (Q22) Aortic and mitral valves (Q23) Other congenital malformations of heart (Q24) I50 Heart failure(i50) Atherosclerosis (I70) Diseases of the capillaries (I78) Other aneurysm (I72) Other disorders of arteries Arterial and arterioles embolism (I77) and thrombosis (I74) 3
CVD and Leading Causes of Death, N.C., 2010 Cancer 18,013 23% Heart Disease 17,090 22% Stroke 4,281 5% Other CVD 1,861 2% All other causes 30,107 38% Other Unintentional Injuries* 2,762 4% Chronic Lower Respiratory Disease 4,490 6% *Unintentional injuries other than motor-vehicles injuries. Data Source: North Carolina Division of Public Health, State Center for Health Statistics. Leading Causes of Death in North Carolina, 2010. SCHS Online Database, 2011. http://www.schs.state.nc.us/schs/data/lcd/lcd.cfm. 4
Percent Percentage of Deaths Caused by CVD, N.C., 1980-2010 50 40 30 20 10 0 47.8 (n=23,150) 36.3 (n=17,579) 40.7 38.6 32.4 30.0 35.9 27.4 9.8 7.8 8.1 7.9 (n=4,760) (n =23,294) (n=18,520) (n=4,446) (n=25,552) (n=19,838) (n=5,329) (n=25,726) (n=19,649) (n=5,692) 29.6 1980* 1990** 1996** 2000** 2010*** Total CVD Stroke Heart Disease (n=23,232) 21.7 (n=17,090) 5.4 (n=4,281) 1996=Establishment of Justus-Warren Task Force *Total CVD estimate is the sum of deaths from diseases of the heart, hypertension, cerebrovascular diseases, and atherosclerosis. **Total CVD estimate is the sum of deaths from diseases of the heart, cerebrovascular diseases, and atherosclerosis. ***Total CVD Deaths includes deaths from ICD-10 codes I00-I99 Data Source: North Carolina Division of Public Health, State Center for Health Statistics. Leading Causes of Death in North Carolina. SCHS Online Database, 2011. http://www.schs.state.nc.us/schs/data/lcd/lcd.cfm.
Age-Adjusted Death Rate Major Cardiovascular Disease Death Rates, NC vs. US 1979-2009 600 500 400 300 200 100 North Carolina United States 0 '79 '81 '83 '85 '87 '89 '91 '93 '95 '97 '99 '01 '03 '05 '07 '09 Year Major Cardiovascular Disease: 1999-2009: ICD-10 codes I00-I78; 1979-1998: ICD-9 codes 390-434, 436-448 multiplied by comparability ratio of 0.9981. Rates per 100,000 population, age-adjusted to the 2000 U.S. standard population. Data Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File, 1979-1998 and 1999-2009. CDC WONDER Online Database, 2011. http://wonder.cdc.gov/mortsql.html.
Age-Adjusted Death Rate 450 400 350 300 250 200 150 100 Heart Disease Death Rates, NC vs. US, 1979-2009 50 North Carolina 0 '79 '81 '83 '85 '87 '89 '91 '93 '95 '97 '99 '01 '03 '05 '07 '09 Year United States Heart Disease: 1999-2009: ICD-10 codes I00-I09, I11, I13, I20-I51; 1979-1998: ICD-9 codes 390-398, 402, 404, 410-429 multiplied by comparability ratio of 0.9858. Rates per 100,000 population, age-adjusted to the 2000 U.S. standard population. Data Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File, 1979-1998 and 1999-2009. CDC WONDER Online Database, 2011. http://wonder.cdc.gov/mortsql.html.
Age-Adjusted Death Rate Stroke Death Rates, NC vs. US, 1979-2009 140 120 100 80 60 40 20 North Carolina United States 0 '79 '81 '83 '85 '87 '89 '91 '93 '95 '97 '99 '01 '03 '05 '07 '09 Year Stroke: 1999-2009: ICD-10 codes I60-I69; 1979-1998: ICD-9 codes 430-434, 436-438 multiplied by comparability ratio of 1.0588. Rates per 100,000 population, age-adjusted to the 2000 U.S. standard population. Data Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File, 1979-1998 and 1999-2009. CDC WONDER Online Database, 2011. http://wonder.cdc.gov/mortsql.html.
Age-adjusted Death Rate Coronary Heart Disease Death Rates, 1979-2008 350 300 250 200 150 100 50 0 North Carolina United States '79 '81 '83 '85 '87 '89 '91 '93 '95 '97 '99 '01 '03 '05 '07 Year Coronary Heart Disease: 1999-2008: ICD-10 codes I20-I25; 1979-1998: ICD-9 codes 410-414, 429.2 multiplied by comparability ratio of 0.9990. Rates per 100,000 population, age-adjusted to the 2000 U.S. standard population. Data Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File, 1979-1998 and 1999-2008. CDC WONDER Online Database, 2011. http://wonder.cdc.gov/mortsql.html.
Contribution of prevention to decline in CVD mortality About 44% of the reduction in national coronary heart disease mortality that occurred between 1980 and 2000, is attributed to changes in risk factors (Ford et al. 2007). Positive contributions: reduction in total cholesterol, systolic blood pressure, smoking and physical inactivity Negative contributions: Increase in diabetes and obesity 47% attributed to treatment 10
Percent Premature Major Cardiovascular Disease Deaths, NC vs. US 1979-2009 30 28 26 24 22 20 18 16 14 12 North Carolina United States 10 '79 '81 '83 '85 '87 '89 '91 '93 '95 '97 '99 '01 '03 '05 '07 '09 Year Premature= Less than 65 years of age. Major Cardiovascular Disease: 1999-2008: ICD-10 codes I00-I78; 1979-1998: ICD-9 codes 390-434, 436-448. Data Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File, 1979-1998 and 1999-2009. CDC WONDER Online Database, 2011. http://wonder.cdc.gov/mortsql.html.
MORBIDITY Over 650,000 adult North Carolinians (about 9.2% of the adult population) have a history of either heart attack, angina or stroke Cardiovascular disease is the leading cause of hospitalization in North Carolina 162,329 CVD hospital discharges (about 16.7% of all discharges) in 2010 30,000 stroke 108,000 heart disease 39,000 heart attacks Heart disease and Stroke are among the top ten leading causes of disability in noninstitutionalized US adults. 12
Age-Adjusted Discharge Rate CVD Hospital Discharge Rates, N.C., 1995-2010 3,000 2,500 2,000 1,500 1,000 500 Total Males Females 0 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 Year Total Cardiovascular Disease, excluding congenital malformations: ICD-9-CM Codes 390-459; Principal diagnosis only. Discharge rates per 100,000 population, age-adjusted to the U.S. 2000 standard population. Data Source: North Carolina Division of Public Health, State Center for Health Statistics. North Carolina Inpatient Hospital Discharges, 1995-2010. Produced by: State Center for Health Statistics, 06/08/2012.
Total Hospital Charges in 2011 Dollars Cardiovascular Disease Hospital Charges, N.C., 1995-2010 $6,000,000,000 $5,000,000,000 $4,000,000,000 Total Males Females $3,000,000,000 $2,000,000,000 $1,000,000,000 $0 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 Total Cardiovascular Disease, excluding congenital malformations: ICD-9-CM codes 390-459; Principal diagnosis only. Data Source: North Carolina Division of Public Health, State Center for Health Statistics. North Carolina Inpatient Hospital Discharges, 1995-2010. Produced by: State Center for Health Statistics, 06/08/2012. Charges adjusted to 2011 dollars using the Bureau of Labor Statistics Consumer Price Index tables for Medical Care for years 1995-2012, U.S. city average, not seasonally adjusted. Year
Charges per Stay in 2011 Dollars Cardiovascular Disease: Average Hospital Charges per Stay, N.C., 1995-2010 $45,000 $40,000 $35,000 $30,000 $25,000 $20,000 $15,000 $10,000 $5,000 $0 Total Males Females '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 Year Total Cardiovascular Disease, excluding congenital malformations: ICD-9-CM codes 390-459; Principal diagnosis only. Data Source: North Carolina Division of Public Health, State Center for Health Statistics. North Carolina Inpatient Hospital Discharges, 1995-2010. Produced by: State Center for Health Statistics, 06/08/2012. Charges adjusted to 2011 dollars using the Bureau of Labor Statistics Consumer Price Index tables for Medical Care for years 1995-2012, U.S. city average, not seasonally adjusted.
Medicaid Cost in U.S. Dollars Annual Medicaid Costs for Selected CVD Sub-Categories, N.C., 2011 $700,000,000 $648,317,030 $600,000,000 $500,000,000 $400,000,000 $300,000,000 $200,000,000 $100,000,000 $231,402,818 $177,403,772 $189,045,580 $75,022,000 $70,995,836 $0 Total CVD Heart Disease Stroke Hypertension CHF CHD ICD-10: I00- I99, Q20-Q28 ICD-10: I00-I09, I11, I13, I20-I51 ICD-10: I60-I69 ICD-10: I10-I15 ICD-10: I50 ICD-10: I20-I25 CHD: Coronary Heart Disease. CHF: Congestive Heart Failure. Source: North Carolina Division of Public Health, State Center for Health Statistics. North Carolina Annual Medicaid Cost due to CVD, 2011. Produced by: State Center for Health Statistics, 09/19/2012.
257,979 166,700 36,538 104,566 27,771 38,808 Annual Cost per Beneficiary Number of Beneficiaries Annual Medicaid Costs per Beneficiary for Selected CVD Sub-Categories, N.C., 2011 $5,000.00 Annual Cost per Beneficiary Number of Beneficiaries $4,571.32 300,000 $4,000.00 250,000 200,000 $3,000.00 $2,624.36 $2,701.45 $2,000.00 $1,943.07 $2,212.98 150,000 $1,134.05 100,000 $1,000.00 50,000 $0.00 Total CVD Hypertension CHD Heart Disease CHF Stroke ICD-10: I00-I99, Q20-Q28 ICD-10: I10-I15 ICD-10: I20-I25 ICD-10: I00-I09, I11, I13, I20-I51 CHD: Coronary Heart Disease. CHF: Congestive Heart Failure. Source: North Carolina Division of Public Health, State Center for Health Statistics. North Carolina Annual Medicaid Cost due to CVD, 2011. Produced by: State Center for Health Statistics, 09/19/2012. ICD-10: I50 ICD-10: I60-I69 0
RISK FACTORS Nine risk factors account for more than 90% of the risk of initial heart attacks and strokes (INTERHEART & INTERSTROKE studies): 1. Hypertension 2. Current smoking 3. Obesity (abdominal) 4. Unhealthy diet 5. Physical inactivity 6. Diabetes 7. Alcohol intake 8. Psychosocial factors (psychological stress, financial stress, major adverse life events, locus of control, depression) 9. Abnormal lipids (e.g. cholesterol) 18
RISK FACTORS High blood pressure Primary or contributing cause for 45% of all CVD deaths If completely eliminated from the population, there will be 34.6% fewer cases of stroke and 17.9% fewer cases of myocardial infarction Responsible for about 45% of all strokes occurring in hypertensive individuals High cholesterol and other lipid abnormalities Stronger risk factor for heart attacks compared to strokes 19
Percent 70 65 60 55 50 45 40 35 30 25 20 Prevalence of Modifiable Risk Factors: Overweight & Obesity, N.C. 2000-2010 Total Overweight Obese '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 Year Total Obese Overweight Data Source: North Carolina Division of Public Health, State Center for Health Statistics. North Carolina Behavioral Risk Factor Surveillance System, 2012. Extracted by: Heart Disease and Stroke Branch: 10/11/2012.
Percent Prevalence of Modifiable Risk Factors: Smoking and Physical Inactivity, N.C. 2001-2010 30 25 Smoking 20 15 Physical Inactivity 10 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 Year Smoking Physical Inactivity Data Source: North Carolina Division of Public Health, State Center for Health Statistics. North Carolina Behavioral Risk Factor Surveillance System, 2012. Extracted by: Heart Disease and Stroke Branch: 10/11/2012.
Percent Prevalence of Modifiable Risk Factors: High Cholesterol, Hypertension, Diabetes, and Recommended Fruits and Vegetables Consumption, N.C. 2000-2010 40 35 30 25 20 15 10 High Cholesterol Diabetes Hypertension Recommended Fruits and Vegetables Consumption* 5 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 Year High Cholesterol Hypertension Diabetes Fruits & Vegetables *Consumed five or more servings of fruits or vegetables per day Data Source: North Carolina Division of Public Health, State Center for Health Statistics. North Carolina Behavioral Risk Factor Surveillance System, 2012. Extracted by: Heart Disease and Stroke Branch: 10/11/2012.
DISPARITIES/NON-MODIFIABLE RISK FACTORS Race/Ethnicity: African Americans bear a greater burden of CVD Gender: Men are more like to get a heart attack at an earlier age (<55 years) than women Age: Risk of CVD increases with age irrespective of the presence of potentially modifiable risk factors Socio-Economic Status (Education, income): The poor and less educated bear a greater burden of CVD Geographical location: The eastern part of the state has a greater burden of CVD (especially stroke) 23
Age-Adjusted Death Rate 500 Major Cardiovascular Disease Death Rates by Race/Ethnicity, N.C., 1999-2009 450 400 350 300 250 200 150 100 50 '99 '01 '03 '05 '07 '09 Year Non Hispanic African American Non Hispanic Whites Hispanics American Indian or Alaska Native Asian or Pacific Islander Overall Major Cardiovascular Disease: 1999-2009: ICD-10 codes I00-I78. Rates per 100,000 population, age-adjusted to the 2000 U.S. standard population. Data Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File, 1999-2009. CDC WONDER Online Database, 2011. http://wonder.cdc.gov/mortsql.html
7.2 10.4 15.0 13.8 13.2 24.5 21.7 23.5 26.9 16.6 34.9 35.4 34.2 32.4 32.5 30.4 30.9 Percent 40.0 38.8 38.4 62.6 73.6 70.3 73.8 90 80 CVD Modifiable Risk Factors by Race and Ethnicity, N.C., 2011 White Black American Indian Hispanic 70 60 50 40 30 20 10 0 Overweight & High Cholesterol Hypertension Physical Inactivity* Current Smoker Diabetes Obese Adults=18+ *Physical Inactivity=Respondent answered No to During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise? Data Source: North Carolina Division of Public Health, State Center for Health Statistics. North Carolina Behavioral Risk Factor Surveillance System, 2012. Extracted by: Heart Disease and Stroke Branch: 10/16/2012.
Cardiovascular Disease Death Rates by County of Residence, N.C., 2005-2009 Death Rate 196.7-243.7 243.8-263.9 264.0-311.8 311.9-354.4 354.5-439.6 N.C. overall: 263.9 U.S.: 255.4 Total Cardiovascular Disease, including congenital malformations: ICD-10 codes I00-I99; Q20-Q28. Rates per 100,000 population, age-adjusted to the 2000 U.S. standard population. Data Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File, 1999-2009. CDC WONDER Online Database, 2011. http://wonder.cdc.gov/mortsql.html.
Heart Disease Death Rates by County of Residence, N.C., 2006-2010 Death Rate 141.5-172.6 172.7-184.9 185.0-206.0 N.C. overall: 184.9 206.1-238.0 238.1-346.2 Heart Disease: ICD-10 codes I00-I09, I11, I13, I20-I51. Rates per 100,000 population, age-adjusted to the 2000 U.S. standard population. N.C. Data Source: North Carolina Division of Public Health, State Center for Health Statistics. Volume 2: Leading Causes of Death in North Carolina 2010, 2011. http://www.schs.state.nc.us/schs/deaths/lcd/2010/. U.S. Data Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File, 1999-2008. CDC WONDER Online Database, 2011. http://wonder.cdc.gov/mortsql.html.
Stroke Death Rates by County of Residence, N.C., 2006-2010 Death Rate 25.7-41.1 41.2-47.8 47.9-53.1 53.2-69.9 70.0-96.1 N.C. overall: 47.8 Stroke: ICD-10 codes I60-I69. Rates per 100,000 population, age-adjusted to the 2000 U.S. standard population. N.C. Data Source: North Carolina Division of Public Health, State Center for Health Statistics. Volume 2: Leading Causes of Death in North Carolina 2010, 2011. http://www.schs.state.nc.us/schs/deaths/lcd/2010/. U.S. Data Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File, 1999-2008. CDC WONDER Online Database, 2011. http://wonder.cdc.gov/mortsql.html.
Cardiovascular Disease Hospital Discharge Rates by County of Residence, N.C., 2006-2010 Hospital Discharge Rate 576.2-1121.1 1121.2-1700.0 1700.1-2060.4 2060.5-2552.2 2552.3-3124.4 N.C. overall: 1700.0 Total Cardiovascular Disease, excluding congenital malformations: ICD-9-CM codes: 390-459; Principal diagnosis only; N.C. residents only. Discharge rates per 100,000 population age-adjusted to the U.S. 2000 standard population. Data Source: North Carolina Division of Public Health, State Center for Health Statistics. North Carolina Inpatient Hospital Discharges, 2006-2010. Produced by: State Center for Health Statistics, 06/08/2012.
Heart Disease Hospital Discharge Rates by County of Residence, N.C., 2006-2010 Hospital Discharge Rate 389.5-713.7 713.8-1143.9 1144.0-1289.5 1289.6-1634.7 1634.8-2173.9 N.C. overall: 1143.9 Heart Disease: ICD-9-CM codes: 391-392.0, 393-398, 402, 404, 410-416, 420-429; Principal diagnosis only; N.C. residents only. Discharge rates per 100,000 population age-adjusted to the U.S. 2000 standard population. Data Source: North Carolina Division of Public Health, State Center for Health Statistics. North Carolina Inpatient Hospital Discharges, 2006-2010. Produced by: State Center for Health Statistics, 06/08/2012.
Stroke Hospital Discharge Rates by County of Residence, N.C., 2006-2010 Hospital Discharge Rate 106.4-169.8 169.9-265.9 266.0-298.4 298.5-385.7 385.8-550.0 N.C. overall: 298.4 Stroke: ICD-9-CM codes 430-438.; Principal diagnosis only; N.C. residents only. Discharge rates per 100,000 population age-adjusted to the U.S. 2000 standard population. Data Source: North Carolina Division of Public Health, State Center for Health Statistics. North Carolina Inpatient Hospital Discharges, 2006-2010. Produced by: State Center for Health Statistics, 06/08/2012.
CONCLUSION Major progress in curbing CVD mortality over the past 3 decades CVD still among the top killers of North Carolinians Premature deaths as a proportion of all CVD deaths on the rise Steady rise in the prevalence of several key modifiable risk factors Disparities by race/ethnicity, social class and geographic location persist Projected exponential rise in the already hefty economic burden of CVD Need for continued and renewed focus on control of risk factors 32
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