Coronary Heart Disease
Map 2.1 Progress Towards Coronary Heart Disease Mortality Objective Northampton Gates Currituck Camden Pasquotank Halifax Hertford Perquimans Nash Bertie Chowan Edgecombe Martin Washington Tyrrell Dare Wilson Johnston Greene Pitt Beaufort Hyde Harnett Wayne Lenoir Craven Hoke Cumberland Sampson Duplin Jones Pamlico Scotland Onslow Carteret Robeson Bladen Pender Columbus New Hanover Reduction Necessary to Meet Objective Brunswick meets objective 0.1% to 10.0% 10.1% to 20.0% 20.1% or more HP 2010 Objective for Coronary Heart Disease Mortality: Reduce coronary heart disease deaths to no more than 166.0 per 100,000 population Coronary Heart Disease ICD-9 Codes: 402, 410-414, 429.2 Based on Five-Year Average, Age-Adjusted Rates Standardized to US 2000 SM Coronary Heart Disease 2 Data Source: NC State Center for Health Statistics
CORONARY HEART DISEASE Coronary heart disease (CHD) is responsible for one in every five deaths in the United States (US), and it is also the leading cause of premature, permanent disability. Of all the diseases of the heart, CHD is the most common, most costly, and most preventable. The total annual costs of CHD in the US has recently been estimated to be $118 billion. CHD results from atherosclerosis of the coronary arteries. Atherosclerosis occurs when cholesterol deposits develop in the arteries of the heart and other areas of the body. As the deposits grow, the coronary arteries become stiff and narrow, and blood flow to the muscles of the heart decreases. The primary manifestations of CHD are chest pain and heart attack. CHD also leads to other forms of heart disease such as congestive heart failure. In 1998, CHD accounted for 64% of the heart disease deaths in North Carolina (NC). Factors that contribute to the development of atherosclerosis and CHD include high levels of cholesterol and fat in the blood, tobacco use, physical inactivity, obesity, hypertension, diabetes, and stress. Substantial progress has been made in reducing deaths attributable to CHD. Between 1987 and 1996, national CHD mortality rates fell 22%, almost meeting the Healthy People 2000 goal of a 26% reduction. Factors that may have contributed to the decline include: a reduction in the prevalence of smoking, decreased fat and cholesterol intake, improvements in blood pressure and cholesterol levels, increased physical activity, more expedient and effective treatment of heart attacks, and advances in the diagnosis and management of coronary heart disease. Despite these achievements, there has been little progress towards reducing gender and racial disparities in heart disease mortality. Males in the US have an age-adjusted mortality rate that is 62% greater than the rate for females. While the death rates for non-white and white males in the US are fairly equal, non-white females in the US die at a rate 13% higher than white females. Within eastern North Carolina (ENC), gender and racial disparities are even larger. Men in ENC die at a rate 74% higher than females, and the death rate for non-whites exceeds the rate for whites by 12%. The goal of closing racial and gender gaps in CHD mortality clearly represent a major public health challenge for the coming decade. Further reductions in mortality will also be necessary in order to reach the objective for CHD mortality set forth in Healthy People 2010. Currently, none of the counties in the region meet the goal for CHD mortality; 32 counties will have to reduce their current CHD death rates by more than 20%, and eight counties will have to reduce their rates by 10 to 20% (see Map 2.1). HP 2010 OBJECTIVE FOR CORONARY HEART DISEASE MORTALITY Objective: Reduce coronary heart disease deaths to no more than 166.0 per 100,000 population Baseline: 208.0 coronary heart disease deaths per 100,000 population in 1998 Currently, none of the counties in the region meet the objective for coronary heart disease mortality. Coronary Heart Disease 3
Crude Mortality Rates for Coronary Heart Disease, 1994-1998: The higher five-year average, crude CHD mortality rate for ENC as compared to all other North Carolina counties (ONC) indicates a 5% greater disease burden in ENC (see Table 2.1). The four counties in the region with the highest five-year average crude CHD mortality rates are Hyde (395.1), Columbus (326.4), Beaufort (323.8), and Bladen (320.1). Map 2.2 shows county level crude mortality rates across the region. Age-Adjusted Mortality Rates for Coronary Heart Disease, 1994-1998: After adjustment for variation in age, the five-year average CHD mortality rate for ENC is 17% higher than the rate for ONC. Hyde County has the highest five-year average, age-adjusted CHD mortality rate in the region with 321.0 deaths per 100,000 population, a rate that is 1.5 times higher than the rate for ONC. Other counties in the region with high age-adjusted rates include Scotland (316.4), Columbus (310.2), and Robeson (297.4). Geographically, age-adjusted death rates for CHD follow a pattern similar to the crude rates for heart disease, with high mortality concentrated around the Pamlico Sound and in the southwestern border of the region. There is also a band of high mortality running from Halifax County south to Onslow County (see Map 2.2). Trends in Coronary Heart Disease Mortality, 1979-1998: National CHD death rates have declined steadily over the last 20 years, as Figure 2.1 demonstrates. ENC has followed this pattern, with a 34% reduction since the early 1980 s. Yet, the regional age-adjusted death rate still exceeds those for ONC and the US. None of the counties in the region currently meet the objective for CHD mortality that has been set forth in Healthy People 2010. Achieving the Healthy People 2010 objective will be a serious challenge for most counties in the east, as 32 of the 41 (78%) counties will have to reduce their current rate by 20% or more over the next 10 years (see Map 2.1). Disparities in Coronary Heart Disease Mortality, 1979-1998: The second major challenge for the region will be to reduce disparities in CHD mortality (see Map 2.3). As the Figure 2.1 demonstrates, the regional death rates for white males exceeded that of non-whites prior the mid-1980 s. This trend changed during the early 1990 s when death rates begin to fall dramatically for white males but only modestly for non-white males. The pattern of CHD mortality for females is similar to that for men, but the reversal in racial disparities occurred earlier for women than men. The greater declines in white mortality relative to non-whites resulted in the growing racial disparities that are depicted in Figure 2.2. Currently, non-white males die of CHD at a rate that is 10% higher than that for white males, and the CHD death rate for non-white females is 17% higher than the rate for white females. However, there are 17 ENC counties where white males have higher death rates than non-white males, and 11 ENC counties with greater morality among white females than non-white females (see Table 2.1). Geographic variation in age-adjusted mortality rates by race and gender are shown in Map 2.3. Another troubling trend apparent in the figures is that disparities in NC have been growing in recent years while those for the nation have stabilized. As compared to the rest of the state, the mortality gap for the eastern region is smaller, due mainly to the high death rates for whites in the east. In addition to racial disparities in CHD death rates, there is also a major gender gap. Males in the east currently die at a rate that is 70% higher than the female rate, although the decline in the male death rate over the last 20 years has narrowed the gap slightly. Coronary Heart Disease 4
Table 2.1 Coronary Heart Disease Mortality in Eastern North Carolina, 1994-1998 Totals Rates Non-White Males County Deaths Crude Adjusted Deaths Rate Deaths Rate Deaths Rate Deaths Rate Beaufort 701 323.8 280.9 84 343.9 104 230.4 243 380.0 270 224.0 Bertie 259 254.0 234.7 85 417.7 67 191.6 60 265.3 47 133.0 Bladen 481 320.1 283.8 90 377.8 83 226.6 168 414.2 140 199.1 Brunswick 742 235.9 223.2 66 360.1 51 182.0 374 266.6 251 171.8 Camden 59 187.3 188.3 6 230.2 8 200.1 20 207.7 25 167.1 Carteret 748 256.8 242.9 21 413.5 23 191.7 393 327.2 311 181.8 Chowan 183 258.9 194.3 26 266.9 31 164.4 62 225.7 64 158.4 Columbus 843 326.4 310.2 136 462.4 148 307.2 304 425.5 255 205.1 Craven 830 190.7 224.8 107 318.2 114 197.9 335 289.0 274 164.7 Cumberland 1,935 131.7 241.8 303 319.2 316 205.5 741 326.0 575 177.1 Currituck 148 182.6 192.6 13 413.0 7 121.1 73 219.8 55 145.8 Dare 218 164.3 196.5 4 301.8 6 209.4 103 214.6 105 172.7 Duplin 566 260.6 247.2 91 357.4 63 143.6 220 361.2 192 184.7 Edgecombe 706 252.8 265.6 175 402.8 170 205.1 183 373.4 178 181.4 Gates 128 259.7 252.1 26 334.7 18 165.4 51 388.9 33 171.8 Greene 172 199.9 197.2 32 272.5 28 152.5 70 325.6 42 113.3 Halifax 876 310.6 288.8 206 417.8 191 238.2 248 401.6 231 197.6 Harnett 792 200.0 225.1 92 379.2 95 241.2 309 269.2 296 162.3 Hertford 280 253.1 223.5 71 318.3 62 159.9 70 319.8 77 163.8 Hoke 188 133.7 184.8 42 234.1 47 154.9 61 265.6 38 115.3 Hyde 104 395.1 321.0 17 442.7 13 203.1 40 457.5 34 248.2 Johnston 1,170 235.8 254.9 93 337.3 82 182.9 538 345.8 457 190.7 Jones 112 243.4 232.1 18 289.6 18 157.2 43 354.5 33 169.0 Lenoir 838 284.0 269.4 164 458.3 150 205.7 250 348.3 274 207.5 Martin 316 245.5 225.3 81 389.8 51 147.6 86 301.1 98 167.3 Nash 960 223.9 239.6 129 323.0 135 215.1 377 338.0 319 164.5 New Hanover 1,370 191.8 201.2 131 306.4 157 210.5 544 249.8 538 149.8 Northampton 310 298.6 237.5 95 376.3 78 197.2 76 265.3 61 146.3 Onslow 783 105.7 259.0 63 339.2 51 149.4 358 325.5 311 215.1 Pamlico 154 258.2 192.1 28 423.9 18 158.2 58 250.8 50 126.7 Pasquotank 418 245.9 235.3 66 327.2 72 203.3 145 326.3 135 165.6 Pender 379 210.7 203.5 60 390.1 73 205.3 135 229.6 111 140.3 Perquimans 156 289.6 213.2 28 382.0 17 133.5 61 256.4 50 159.6 Pitt 965 160.8 214.5 150 291.9 157 176.3 341 296.0 317 158.5 Robeson 1,351 241.7 297.4 354 388.1 371 250.6 320 421.1 306 210.5 Sampson 643 249.0 226.4 89 262.4 106 200.3 242 318.1 206 162.4 Scotland 469 268.9 316.4 80 451.7 101 286.3 137 391.5 151 243.0 Tyrrell 57 307.3 245.0 3 104.6 9 168.0 27 427.5 18 197.9 Washington 214 317.0 294.0 37 382.8 40 261.3 73 382.7 64 205.4 Wayne 1,138 203.4 255.6 157 298.0 209 238.3 404 332.1 368 193.1 Wilson 892 261.0 269.3 142 395.3 149 219.1 289 327.4 312 212.2 ENC 29 13,291 220.6 243.6 2,125 353.7 2,059 197.6 4,759 321.7 4,348 180.0 ENC 41 23,654 212.4 243.5 3,661 350.4 3,689 208.0 8,632 318.1 7,672 177.7 ONC 51,464 202.5 208.3 3,981 312.0 4,041 191.9 22,832 275.4 20,610 151.5 PNC 36,953 188.9 209.4 3,526 309.3 3,602 192.2 15,503 276.1 14,322 152.4 WNC 14,511 248.2 206.3 455 333.5 439 190.1 7,329 276.1 6,288 150.0 NC 75,118 205.5 218.3 7,642 329.3 7,730 199.2 31,464 285.6 28,282 157.8 US, 1996 570,826 215.1 224.4 32,338 281.4 32,887 196.1 255,336 287.5 250,265 173.8 Coronary Heart Disease ICD-9 Codes: 402, 410-414,429.2 Age-Adjusted Rates Standardized to US 2000 SM Total Number of Deaths and Rates for Five-Year Period, except US Race-Gender Specific Age-Adjusted Death Rates Non-White Females White Males White Females NC Data Source: NC State Center for Health Statistics US Data Source: National Center for Health Statistics Coronary Heart Disease 5
Map 2.2 Crude and Age-Adjusted Coronary Heart Disease Mortality Rates: North Carolina and Eastern North Carolina, 1994-1998 Crude Rate Per 100,000 Population 105.7-221.1 221.2-260.6 260.7-395.1 Age-Adjusted Rate Per 100,000 Population under 166.0 166.0-249.0 249.1-332.0 over 332.0 Coronary Heart Disease ICD-9 Codes: 402, 410-414, 429.2 Five-Year Average, Age-Adjusted Rates Standardized to US 2000 SM Coronary Heart Disease 6 Data Source: NC State Center for Health Statistics
Map 2.3 Race-Gender Specific, Age-Adjusted Coronary Heart Disease Mortality Rates: North Carolina and Eastern North Carolina, 1994-1998 White Males White Females Per 100,000 Population under 166.0 166.0-249.0 249.1-332.0 over 332.0 Non-White Males Non-White Females Coronary Heart Disease ICD-9 Codes: 402, 410-414,429.2 Five-Year Average, Age-Adjusted Rates Standardized to US 2000 SM Data Source: NC State Center for Health Statistics Coronary Heart Disease 7
Figure 2.1 Age-Adjusted Coronary Heart Disease Mortality Rates by Gender: Regional and National Trends, 1979-1998 Males Age-Adjusted Mortality Rates per 100,000 Population 700 600 500 400 300 200 100 0 ENC Non-White Males ENC White Males ONC Males US Males HP 2010 Objective 1981 1986 1991 1996 2010 Females Age-Adjusted Mortality Rates per 100,000 Population 700 600 500 400 300 200 100 0 ENC Non-White Females ENC White Females ONC Females US Females HP 2010 Objective 1981 1986 1991 1996 2010 Coronary Heart Disease ICD-9 Codes: 402, 410-414, 429.2 Five-Year Average, Age-Adjusted Rates Standardized to US 2000 SM US Rates for Middle Year of Five Year Periods NC Data Source: NC State Center for Health Statistics US Data Source: National Center for Health Statistics Coronary Heart Disease 8
Figure 2.2 Racial Disparities in Age-Adjusted Coronary Heart Disease Mortality Rates by Gender: Regional and National Trends, 1979-1998 1.40 Males Non-White to White Rate Ratios 1.20 Rate Ratios 1.00 0.80 1981 1986 1991 1996 ENC 0.85 0.92 1.06 1.10 ONC 0.94 1.01 1.09 1.13 US 0.87 0.92 0.99 0.98 1.40 Females Non-White to White Rate Ratios 1.20 Rate Ratios 1.00 0.80 1981 1986 1991 1996 ENC 0.94 1.06 1.10 1.17 ONC 1.14 1.13 1.19 1.27 US 1.02 1.08 1.13 1.13 Coronary Heart Disease ICD-9 Codes: 402, 410-414, 429.2 Based on Five-Year Average, Age-Adjusted Rates Standardized to US 2000 SM US Rates for Middle Year of Five Year Periods NC Data Source: NC State Center for Health Statistics US Data Source: National Center for Health Statistics Coronary Heart Disease 9
SOURCES OF INFORMATION ABOUT CORONARY HEART DISEASE American Heart Association (1999). 2000 Heart and Stroke Statistical Update. Dallas, TX: American Heart Association. Centers for Disease Control and Prevention (1999). Achievements in public health, 1900-1999: Decline in deaths from heart disease and stroke-- United States, 1900-1999. Morbidity and Mortality Weekly Report, 48 (30): 649-656. Governor s Task Force for Healthy Carolinians (2000). Healthy Carolinians 2010: North Carolina s Plan for Health and Safety. Raleigh, NC: Department of Health and Human Services. Huston, S. L., Yemisi, A., and Lengerich, E. J. (1997). The Burden of Cardiovascular Disease in North Carolina: Mortality, Costs, and Risk Factor Data. Raleigh, NC: North Carolina Division of Community Health. National Center for Health Statistics (1999). Health, United States, 1999. With Health and Aging Chartbook. Hyattsville, MD: National Center for Health Statistics. National Center for Health Statistics (1999). Healthy People 2000 Review, 1998-1999. Hyattsville, MD: Public Health Service. United States Department of Health and Human Services (2000). Healthy People 2010. 2nd ed. With Understanding and Improving Health and Objectives for Health Improvement. 2 vols. Washington, DC: U. S. Government Printing Office. American Heart Association (http://www.americanheart.org) Centers for Disease Control and Prevention (http://www.cdc.gov) Healthy People 2010 (http://web.health.gov/healthypeople) National Center for Health Statistics (http://www.cdc.gov/nchs) National Heart, Lung, and Blood Institute (http://www.nhlbi.nih.gov) North Carolina Heart Disease and Stroke Prevention Task Force (http://startwithyourheart.com) North Carolina State Center for Health Statistics (http://www.schs.state.nc.us/schs) Coronary Heart Disease 10
Appendix B ICD-9 Codes for Coronary Heart Disease 402: Hypertensive heart disease 410: Acute myocardial infarction 411: Other acute and subacute forms of ischemic heart disease 412: Old myocardial infarction 413: Angina pectoris 414: Other forms of chronic ischemic heart disease 429.2: Cardiovascular disease, unspecified Coronary Heart Disease 11