Georgia epidemiology report, Vol. 21, no. 12 (Dec. 2005)

December 2005

volume 21 number 12

Cardiovascular Disease in Georgia: 2005 Update

Introduction Cardiovascular disease (CVD) is the leading cause of death in Georgia, and was responsible for 23,295 (35% of all) deaths during 2003. This article is a summary of the Georgia 2005 Cardiovascular Disease Report (1); it presents an overview of the mortality, morbidity, risk factors, and prevention of CVD.
Methods Vital Records death certificates were analyzed for underlying causes due to death by CVD, coded 390-448 by ICD-9 (1980 to 1998) and I00-I78 by ICD-10 (1999 to present). Mortality rates were calculated using the direct method from the 2000 standard population and estimated GA and United States (US) population from the US Bureau of Census data.

Table 1. Cardiovascular disease deaths in Georgia, 2003

Causes___________ Cardiovascular Disease Total
Heart Disease Ischemic Heart Disease Hypertensive Heart Disease Other Heart Disease
Stroke Hypertension Atherosclerosis Other

# Deaths 2003 23,295
17,180 9,579
855 6,746 4,285
894 305 631

Hospitalization data from non-federal, acute care hospitals in Georgia were provided by the Georgia Hospital Association and restricted to Georgia residents. ICD-9-CM codes were used to identify principal diagnoses of CVD during hospitalization.
Data on behaviors, health history, and health knowledge among adults were obtained from the Georgia Behavioral Risk Factor Surveillance System, a random-digit dial telephone survey conducted annually in a sample of persons aged 18 years and older. The sample is weighted so that it represents the total adult population of the state.
Further details on methodology are available in the report, Cardiovascular Disease in Georgia, 2005 (1).

Age-adjusted death rate per 100,000 population

Figure 1. Cardiovascular disease death rates in Georgia and the United States, 1980-2003
600
GA
500
US
400
300
200
100
0
79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04
NOTE. The dotted line indicates a change in coding system for cause of death. ICD-9 codes were used for 1980-1998 deaths; ICD-10 codes were used for 1999-2003 deaths.

Results CVD Mortality and Morbidity Cardiovascular disease includes all diseases of the heart and blood vessels (Table 1). CVD is the nation's leading killer of both men and women across all racial and ethnic groups, accounting for approximately 900,000 deaths annually nationwide (2,3). Cardiovascular disease is also the leading cause of death of Georgians, accounting for 23,295 (or 35% of all) deaths during 2003 (Figure 1).
Cardiovascular disease death rates have declined both in Georgia and the U.S. during the past 23 years (Figure 1). The

causes of the decline are debated but presumably are related to the decline in cigarette smoking during the 1980s, a population-wide reduction in blood cholesterol, and improvements in medical care. From 1980 through 2003, the CVD death rate in Georgia declined by an average of 2.4% per year (Figure 1). Throughout this time period; however, Georgia's CVD death rate was consistently above the U.S. rate. Among the 50 states during 2002, Georgia had the tenth highest CVD death rate. CVD death rates in Georgia differ by sex and race. The age-adjusted death rate from CVD were 1.4 times higher for males (411 per 100,000) than for females (292 per 100,000) during 2003. The age-adjusted

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Table 2. Premature* cardiovascular disease deaths by race and sex, Georgia, 2003
Total CVD Premature* deaths (No.) CVD deaths
(No. (%))

Black males White males Black females White females

2,823 8,132 3,392 8,806

*Premature death is death <65 years of age

1,336 (47%) 2,248 (28%)
935 (28%) 1,065 (12%)

Figure 2. Prevalence of CVD risk factors among

Percentage

90 80 70 60 50 40 30 23 20 10 0
Current smoker

adults, Georgia, 2003
77
58

33

25

28

8

Obese

Not meeting <5 Friuts and Ever high

recommended Vegetables per cholesterol (1)

physical

day

activity

Ever hypertension
(2)

Diabetes

(1) Of persons who had their blood cholesterol level checked, the percentage told that they have high cholesterol (2) The percentage of Georgians who reported having been told they had high blood pressure

death rate from CVD was 1.4 times higher for blacks (426 per 100,000) than for whites (325 per 100,000) during 2003. The reasons for higher rates among blacks are not well understood, but they may be due to a higher percentage of blacks with high blood pressure, or a higher percentage living in poverty with associated factors of poor diet or decreased access to health care.
As stated above, males have a higher risk than females for dying from CVD. However, 11,038 males and 12,257 females in Georgia died from CVD during 2003. Since men experience CVD at a higher rate earlier in life, many people consider heart disease a "man's disease." However CVD is the leading killer of women in Georgia, current health promotion campaigns and programs aim to promote and educate women and health professionals about the risks and severity of CVD among women.
Since CVD is associated with risk factors that are adopted early in life by many Georgians, CVD is responsible for a significant number of premature deaths. Of Georgians who died from CVD during 2003, 24% were younger than 65 years of age. A greater percentage of blacks than whites die from CVD at ages less than 65 years (Table 2). Almost one half (47%) of black men who died of CVD during 2003 were less than 65 years, whereas only 28% of white men who died of CVD were less than 65 years.
Georgia also has a large financial burden from CVD. In 2003, CVD caused 142,000 hospitalizations and resulted in

$3.3 billion in hospital charges. Annual CVD medical charges have increased over time and will likely continue to increase with rising healthcare costs, advances in medical care, aging population, and escalating risk factor prevalence.
CVD Risk Factors Some CVD risk factors cannot be changed, for example, old age, male sex, and family history of heart attacks at a young age. However, several risk factors are modifiable and occur among children, teens, and adults. The modifiable risk factors for CVD include smoking, obesity, inadequate physical activity, poor diet, high blood cholesterol level, high blood pressure and diabetes. Individuals with non-modifiable risk factors should be particularly diligent in eliminating modifiable risk factors.
Among Georgia adults, about one-quarter (23%) reported that they currently smoke cigarettes, one-quarter (25%) were obese, and more than half (58%) did not meet the recommended level of physical activity. Approximately three-quarters (77%) reported that they did not consume at least five servings of fruits and vegetables per day. Of persons who had been checked, one-third (33%) were ever told that they have high cholesterol. More than onequarter (28%) reported ever having high blood pressure. The prevalence of diabetes was about one in twelve (8%) among Georgia adults (Figure 2).
Since risk factors work in combination to increase risk, it is important to consider multiple risk factors. Of the seven

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Table 3. Adults by number of modifiable risk factors*, Georgia, 2003

Number of Risk Factors

Number of Adults

Percent of Adults

0

346,000

6%

1

1,146,000

20%

2

1,620,000

29%

3

1,350,000

24%

4

722,000

13%

5

334,000

6%

6

119,000

2%

7

17,000

<1%

*Modifiable Risk Factors include being obese, not meeting recommended physical activity recommendations, current smoker, ever having high blood pressure, and ever having high cholesterol, consuming <5 daily fruits and vegetables, and diabetes

Figure 3. Age-adjusted percentage of adults reporting history of heart attack, stroke or coronary heart disease

by number of modifiable risk factors*, Georgia, 2003

80

75

Age-adjusted percentage with history of heart attack, stroke, or coronary
heart disease

70

60

50

40
32

30
22

20

11

10
2

4

5

7

0

0

1

2

3

4

5

6

7

Number of modifiable risk factors*
*Modifiable Risk Factors include being obese, not meeting recommended physical activity recommendations,
current smoker, ever having high blood pressure, and ever having high cholesterol, consuming <5 daily
fruits and vegetables, and diabetes

Table 4. Percentage of adults with selected risk factors reporting that a doctor or health professional talked with them about healthy lifestyles, Georgia,
2003

High Risk Group Lifestyle Issue

Discussed issue with health professional

Obese adults Obese adults
Obese adults

Lose weight

38%

Eat fewer high fat or high

35%

cholesterol foods

Eat more fruits and

43%

vegetables

Obese adults

Increased physical activity

48%

Adults reporting ever high Eat fewer high fat and high

48%

cholesterol

cholesterol foods

Adults consuming less than 5 Eat more fruits and

30%

fruits and vegetables per day vegetables

Adults not meeting

Be more physically active

37%

recommended level of

physical activity

major modifiable risk factors, 74% of Georgia adults have two or more. One-tenth (9%) of Georgians have 5 or more risk factors. Only 6% percent of Georgia adults live with no major behavior-related CVD risk factors (Table 3).

Modifiable risk factors and history of a CVD event are strongly associated. The higher the number of risk factors a person has, the higher the likelihood of having a CVD event.

Three-quarters (75%) of persons reporting 7 modifiable risk factors had a history of CVD, whereas only 2% of persons with no modifiable risk factors had a history of CVD (Figure 3).
Medical Risk Assessment and Advice The majority of high-risk individuals do not discuss relevant behavior modifications with medical professionals (Table 4). In high-risk populations, less than half reported receiving medical advice regarding adopting healthier lifestyles. In addition to doing a personalized risk assessment, medical professionals can also provide counseling or direct individuals to resources to assist in the modification of their risk factors.
Discussion The practical implications of these findings are clear. CVD is the leading cause of death in Georgia and is responsible for billions in health care expenditures. The rate of CVD is declining, but the rate in Georgia is higher than in the United States.
Addressing the modifiable risk factors is the best preventive measure for reducing the risk of developing CVD. Since the arteriosclerosis that causes most CVD begins at an early age, a greater effort needs to be made for all Georgians to reduce their CVD risk factors. Prevention can start at an early age in schools or homes through activities such as proper exercise and diet. It is very important for clinicians to screen their patients for CVD risk factors and then play an active role in helping to control those risk factors. This includes screening and management for hypertension, hypercholesteremia and diabetes, as well as routine discussions about the benefits of smoking cessation, increased physical activity, low-fat diets, and weight loss.
This article was written by Kevin Gregory, M.P.H., Manxia Wu, M.D., M.P.H., and Dafna Kanny, Ph.D.
References 1. Gregory, KS, Wu, M, Kanny, D. Cardiovascular
Disease in Georgia, 2005. Georgia Department of Human Resources, Division of Public Health, and the American Heart Association, Southeast Affiliate, December 2005. Publication number DPH05/094HW 2. American Heart Association. Heart and Stroke Statistics- 2005 Update. Dallas, TX: American Heart Association; 2005. 3. Hoyert DL,Kung HC, Smith BL. Deaths: Preliminary data for 2003. National Vital Statistics Reports; vol 53 no 15. Hyattsville, MD: National Center for Health Statistics, 2005.

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The Georgia Epidemiology Report Epidemiology Branch Two Peachtree St., NW Atlanta, GA 30303-3186

PRESORTED STANDARD U.S. POSTAGE
PAID ATLANTA, GA PERMIT NO. 4528

December 2005

Volume 21 Number 12

Reported Cases of Selected Notifiable Diseases in Georgia Profile* for September 2005

Selected Notifiable Diseases
Campylobacteriosis Chlamydia trachomatis Cryptosporidiosis E. coli O157:H7 Giardiasis Gonorrhea Haemophilus influenzae (invasive) Hepatitis A (acute) Hepatitis B (acute) Legionellosis Lyme Disease Meningococcal Disease (invasive) Mumps Pertussis Rubella Salmonellosis Shigellosis Syphilis - Primary Syphilis - Secondary Syphilis - Early Latent Syphilis - Other** Syphilis - Congenital Tuberculosis

Total Reported for September 2005
2005
70 3037
24 8 62 1470 8 14 13 4 1 0 0 5 0 266 55 1 6 4 15 0 38

Previous 3 Months Total

Ending in September

2003

2004 2005

257

197

231

9237

9411

8297

40

63

42

14

2

12

248

284

154

4691

4471

4016

17

23

20

148

78

43

214

126

33

12

16

9

2

5

3

5

1

5

1

0

0

8

5

13

0

0

0

809

827

718

285

165

139

34

20

12

114

128

48

182

73

33

205

212

120

3

1

0

138

122

123

Previous 12 Months Total

Ending in September

2003

2004

2005

700

552

618

36162

35025

32625

116

160

144

31

21

28

869

891

730

18343

16363

15376

78

121

107

548

632

161

610

548

268

35

44

28

11

12

4

33

22

21

2

1

3

32

28

42

0

1

0

1991

2086

1858

1879

715

545

120

130

86

431

494

367

793

482

246

851

826

759

12

5

3

523

532

474

* The cumulative numbers in the above table reflect the date the disease was first diagnosed rather than the date the report was received at the state office, and therefore are subject to change over time due to late reporting. The 3 month delay in the disease profile for a given month is designed to minimize any changes that may occur. This method of summarizing data is expected to provide a better overall measure of disease trends and patterns in Georgia.

** Other syphilis includes latent (unknown duration), late latent, late with symptomatic manifestations, and neurosyphilis.

Report Period
Latest 12 Months: 11/04-10/05 Five Years Ago: 11/00-10/01 Cumulative: 07/81-10/05

Total Cases Reported* <13yrs >=13yrs Total

4

1,727 1,731

4

1,280 1,284

224

29,076 29,300

Percent Female

AIDS Profile Update
Risk Group Distribution (%) MSM IDU MSM&IDU HS Blood Unknown

25.2

32.0

5.8

2.0

10.1

1.5

48.6

26.6

32.1

9.9

2.2

17.6

1.6

36.6

19.4

45.3

15.7

4.9

14.3

1.9

18.0

Race Distribution (%) White Black Other

22.9 74.9

2.1

19.9 75.5

4.7

31.8 65.6

2.5

MSM - Men having sex with men

IDU - Injection drug users

HS - Heterosexual

* Case totals are accumulated by date of report to the Epidemiology Section

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