Cardiovascular Disease in Georgia, 2005 Acknowledgments Georgia Department of Human Resources B.J. Walker, Commissioner Division of Public Health Stuart T. Brown, M.D., Director Chronic Disease Prevention and Health Promotion Branch Kimberly Redding, M.D., M.P.H., Acting Director Population Services Section Vicki Pilgrim, M.Ed. Acting Director Chronic Disease Prevention Program Management Unit Shonta Chambers, M.S.W., Acting Director Epidemiology Branch Susan Lance, D.V.M., Ph.D., Director Chronic Disease, Injury, and Environmental Epidemiology Section John M. Horan, M.D., M.P.H., Chief American Heart Association, Southeast Affiliate Laura Bracci, State Health Alliance Director Suggested Citation: 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. Further information on this report or on the two organizations can be obtained by contacting: Kevin Gregory, M.P.H. Georgia Department of Human Resources Division of Public Health, 14th Floor 2 Peachtree Street NW Atlanta, GA 30303 (404) 463-4628 ksgregory@dhr.state.ga.us Internet: www.health.state.ga.us Laura P. Bracci Georgia Health Alliance Director American Heart Association 1101 Northchase Parkway, Suite 1 Marietta, Georgia 30067 (678) 385-2072 laura.bracci@heart.org Internet: americanheart.org This report was prepared jointly by the Georgia Department of Human Resources, Division of Public Health, and the American Heart Association, Southeast Affiliate. This publication was supported by Grant Number U50/CCU421331-04 from the Centers for Disease Control and Prevention (CDC), State Cardiovascular Health Program. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC. Contents Highlights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 Cardiovascular Disease in Georgia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 Ischemic Heart Disease in Georgia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 Stroke in Georgia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Cardiovascular Disease Statistics by County . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Cardiovascular Disease Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 Secondary Prevention of CVD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 1 Highlights Cardiovascular disease (CVD), including heart disease and stroke, was the number one killer of Georgians in 2003, accounting for 23,295 deaths, or 35% of all deaths. The CVD death rate in Georgia was 12% higher than the national rate in 2003. For both men and women in Georgia, age-adjusted CVD death rates are higher for blacks than whites. In 2003, most CVD deaths in Georgia were classified as ischemic heart disease (41%) or stroke (18%). Georgia had the tenth highest CVD mortality rate among the 50 states in 2002; for stroke in particular, Georgia had the ninth highest mortality rate among the 50 states. CVD caused more than 142,000 hospitalizations and $3.3 billion in hospital charges in 2003. 3 in 4 (74%) of Georgia adults have at least two modifiable risk factors for CVD. One in ten (9%) of Georgia adults have 5 or more modifiable risk factors for CVD. The smoking rate among adults in Georgia has remained stable for the past decade; in 2003, one in four (23%) reported that they currently smoked. CVD risk factors are frequently acquired before becoming adults. Data from youth surveys show high prevalence of physical inactivity, poor diet, obesity, and smoking. The high CVD death rates should alert Georgians to the importance of working together to facilitate regular phys- ical activity, healthy eating, and not smoking. 2 Introduction Cardiovascular disease (CVD) includes all diseases of the heart and blood vessels, including ischemic heart disease, stroke, congestive heart failure, hypertensive disease, and atherosclerosis. CVD is the nation's leading killer of both men and women across all racial and ethnic groups. Each year in the United States, about 900,000 people die from CVD, which accounts for approximately 37% of all deaths.1,2 Over 6 million hospitalizations each year are due to CVD.1 According to the American Heart Association, CVD is a leading cause of disability in the nation. In Georgia, CVD caused 23,295 deaths in 2003, 35% of all deaths that year (Figure 1, Table 1). Heart disease (all forms) and stroke are the first and third most common causes of death in Georgia (Figure 1). Ischemic heart disease - the most common form of heart disease - and stroke account for about 20% of deaths in Georgia (Table 1). Death and disability from CVD are related to a number of risk factors, including smoking, inadequate physical activity, poor diet, obesity, high blood pressure, high cholesterol, and diabetes. The adoption of a healthier lifestyle can lower the risk of developing CVD or reduce the severity of existing disease. This report describes the burden of CVD in Georgia and has the following purposes: To present a brief overview of CVD death rates during the past two decades, including rates of ischemic heart disease and stroke To report county-specific death rates To report the number of CVD, ischemic heart disease, and stroke hospitalizations for Georgia residents To describe the prevalence of CVD risk factors in Georgia and to describe the prevalence of secondary prevention measures in Georgia. Figure 1. Leading causes of death, Georgia, 2003 (N=66,337) Heart disease Cancer Stroke Unintentional injury Chronic respiratory Diabetes Influenza/pneumonia Alzheimer's Kidney disease Septicemia Suicide Hypertension 4,285 3,466 3,241 1,720 1,679 1,632 1,475 1,343 961 894 13,997 0 Source: Georgia Vital Statistics 5000 10000 15000 Numbers of deaths 17,180 20000 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 3 Cardiovascular Disease in Georgia Age-adjusted death rate per 100,000 population Figure 2. 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. Figure 3. Cardiovascular disease death rates in Georgia by race and sex, 2003 600 500 497 Black White 400 395 374 300 272 200 100 0 Males Females Age-adjusted death rate per 100,000 population Table 2. Premature* cardiovascular disease deaths by race and sex, Georgia, 2003 Black males White males Black females White females Total CVD deaths (No.) 2,823 8,132 3,392 8,806 Premature* CVD deaths (No. (%)) 1,336 (47%) 2,248 (28%) 935 (28%) 1,065 (12%) *Premature death is death <65 years of age Cardiovascular disease death rates have declined in both Georgia and the U.S. during the past 23 years (Figure 2). The causes of the decline are presumably related to the decline in cigarette smoking during the 1980s, improved blood pressure control, populationwide 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 2). Through the entire time period, Georgia's CVD death rate was consistently above the U.S. rate. Among the 50 states in 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 was 1.4 times higher for males (411 per 100,000) than for females (292 per 100,000) in 2003. The age-adjusted death rate from CVD was 1.4 times higher for blacks (426 per 100,000) than for whites (325 per 100,000) in 2003. In 2003, the CVD death rate in Georgia was 1.3 times higher for black males than white males and 1.4 times higher for black females than white females (Figure 3). The reasons for higher rates among blacks are not well understood, but they may be a result of 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 in 2003. Since men experience CVD at a higher rate earlier in life, many people consider heart disease a "man's disease." Current health promotion campaigns are promoting awareness and education of the severity of CVD among women, the leading killer of women in Georgia. 4 CVD, however, is not just a disease of old age. The process of arterial narrowing, which causes heart attacks and strokes, may begin in the teenage years.3,4 The age at which blocked arteries actually kill varies greatly, and death can occur before old age. Of Georgians who died from CVD in 2003, 24% were younger than 65 years of age (Figure 4). 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 in 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 due to CVD. In 2003, CVD caused 142,000 hospitalizations resulting in $3.3 billion in hospital charges at acute care facilities. Number of deaths Figure 4. Cardiovascular disease deaths in Georgia by age group, 2003 8000 7000 6000 5000 4000 24% 3000 2000 1000 0 <45 45-54 55-64 65-74 75-84 85+ Age group in years 5 Ischemic Heart Disease in Georgia Ischemic heart disease, also known as coronary heart disease, refers to narrowing of the coronary arteries which reduces blood flow and oxygen to the heart. Ischemic heart disease includes acute myocardial infarctions ("heart attacks") and complications resulting from previous myocardial infarctions. Of the 23,295 cardiovascular deaths in Georgia in 2003, 9,579 (41%) were from ischemic heart disease. The death rate from ischemic heart disease has decreased during the past 23 years at an average decline of 3.5% per year (Figure 5). Unlike total cardiovascular disease, Georgia's death rate from ischemic heart disease is below the national rate, ranging from 5% to 14% below the US rate each year (Figure 5). In Georgia, the age-adjusted death rate from ischemic heart disease was 1.8 times higher for men (192 per 100,000) than for women (105 per 100,000) in 2003. The age-adjusted death rate from ischemic heart disease was similar for blacks (147 per 100,000) and whites (141 per 100,000) in 2003. Among men, whites had a slightly higher age-adjusted death rate than blacks; whereas among women, blacks had a slightly higher age-adjusted death rate than whites (Figure 6). Similar to overall CVD, the death rate from ischemic heart disease increases with age, but 26% of deaths in 2003 occurred in persons less than 65 years old. Age-adjusted death rate per 100,000 population Age-adjusted death rate per 100,000 population Figure 5. Ischemic heart disease death rates in Georgia and the United States, 1980-2003 400 350 US 300 GA 250 200 150 100 50 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. Figure 6. Ischemic heart disease death rates in Georgia by race and sex, 2003 Black White 250 200 182 197 150 124 101 100 50 0 Males Females 6 Stroke in Georgia Stroke, sometimes called cerebrovascular disease, refers to an infarct (loss of blood supply due to a blocked artery) or hemorrhage in the brain. Of the 23,295 CVD deaths in Georgia in 2003, 4,285 (18%) were due to stroke. Age-adjusted death rates from stroke have decreased during the past 23 years in both Georgia and the US (Figure 7); however since 1992, the rate of decline has slowed. In Georgia, the stroke death rate decreased an average of 4.4% per year from 1980 to 1992 but only decreased 1.2% per year from 1992 to 2003. Age-adjusted stroke death rates in Georgia are consistently above the US rate although the gap is narrowing, with Georgia's rate 32% above the US rate in 1980 but only 20% above the US rate in 2003. Unlike ischemic heart disease deaths, for which sex differences are more striking than racial differences, ageadjusted stroke deaths are much higher for blacks than whites. In Georgia, the age-adjusted death rates from stroke were similar for men (65 per 100,000) and women (63 per 100,000) in 2003. The age-adjusted death rate from stroke was 1.5 times higher for blacks (88 per 100,000) than for whites (58 per 100,000) in 2003. Reasons for the difference are not well understood but may include the higher prevalence of high blood pressure and decreased access to health care among blacks. Black males had a higher age-adjusted death rate from stroke than black females, but the rates for white males and white females were almost the same in 2003 (Figure 8). As for most other types of cardiovascular disease, the stroke mortality rate increases with age. Nonetheless, 19% of persons dying from stroke in Georgia in 2003 were less than 65 years old. Age-adjusted death rate per 100,000 population Age-adjusted death rate per 100,000 population Figure 7. Stroke death rates in Georgia and the United States, 1980-2003 140 120 GA 100 80 US 60 40 20 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. Figure 8. Stroke death rates in Georgia by race and sex, 2003 Black White 120 100 95 81 80 60 58 57 40 20 0 Males Females 7 Cardiovascular Disease Statistics by County Figure 9 (map) shows average annual age-adjusted CVD deaths rates by county during the period 1999 through 2003. Counties with the highest CVD death rates are clustered in the southeast region and along the state's western border. Figure 10 (map) shows average annual age-adjusted stroke death rates by county during 1999-2003, with the lowest rates in the counties surrounding Atlanta. Tables 3 and 4 (pages 10-17) show the following data for Georgia counties and public health districts respectively: the number of CVD deaths in 2003, the average annual age-adjusted mortality rate for CVD from 1999 to 2003, the number of stroke deaths and the corresponding age-adjusted rate, and the number of ischemic heart disease deaths and the corresponding age-adjusted rate. Average annual age-adjusted mortality rates were calculated for a 5-year period because counties with small populations had too few deaths to calculate a stable rate accurately for a shorter time period. Caution should be used when making comparisons among age-adjusted county death rates because counties with small populations are more likely to have wide variations in rates from year to year simply because of chance. The right-hand set of columns in Tables 3 and 4 shows the total charges for CVD hospitalizations in 2003, the 2003 CVD hospitalization rate, the number of hospitalizations for CVD in 2003, and the number of hospitalizations for stroke, ischemic heart disease, and congestive heart failure. Hospitalization data are based on county of residence, not location of hospital. Furthermore, the data are restricted to acute care, nonfederal facilities, which excludes patients seen at Veteran's Administration and military facilities. Caution should be used when making comparisons among counties because Georgia residents hospitalized outside of Georgia are not included in the tables. This may lead to an underestimation of hospitalizations for residents of counties near large cities in neighboring states (e.g. counties bordering Chattanooga, TN, or Jacksonville, FL). 8 Figure 9. Cardiovascular disease death rates by county, Georgia, 1999-2003 Significatnly lower than state level No difference Significantly higher than state level Figure 10. Stroke death rates by county, Georgia, 1999-2003 Significatnly lower than state level No difference Significantly higher than state level 9 Table 3. Cardiovascular disease deaths, age-adjusted mortality rates, and hospitalizations by county, Georgia, 1999-2003 COUNTY CVD DEATHS 2003 CVD ANNUAL AAMR 1999-2003 DEATHS STROKE DEATHS 2003 STROKE ANNUAL AAMR 1999-2003 IHD DEATHS 2003 IHD ANNUAL AAMR 1999-2003 Georgia 23,295 APPLING ATKINSON BACON BAKER BALDWIN BANKS BARROW BARTOW BEN HILL BERRIEN BIBB BLECKLEY BRANTLEY BROOKS BRYAN BULLOCH BURKE BUTTS CALHOUN CAMDEN CANDLER CARROLL CATOOSA CHARLTON CHATHAM CHATTAHOOCHE CHATTOOGA CHEROKEE CLARKE CLAY CLAYTON CLINCH COBB COFFEE COLQUITT COLUMBIA COOK COWETA CRAWFORD CRISP DADE DAWSON DECATUR DEKALB DODGE DOOLY DOUGHERTY DOUGLAS EARLY ECHOLS EFFINGHAM ELBERT EMANUEL EVANS FANNIN 56 21 42 14 148 43 149 214 64 66 553 43 54 68 60 148 98 74 39 67 36 305 194 43 806 11 103 329 228 16 443 30 1,155 139 181 185 61 243 31 82 65 47 114 1,293 86 49 301 246 59 7 124 80 105 45 94 AAMR = Age-adjusted mortality rate CHF = Congestive heart failure CVD = Cardiovascular disease 10 IHD = Ischemic heart disease 367 4,285 404 12 423 3 470 7 400 2 402 28 424 10 397 24 365 33 395 11 364 14 405 132 365 9 401 15 407 12 348 13 373 27 471 14 438 14 428 6 340 5 374 4 423 65 388 32 450 8 358 137 788 1 398 17 398 60 341 48 424 3 390 66 504 4 321 177 440 26 404 36 311 33 477 16 351 47 374 3 387 23 407 8 380 8 430 17 291 262 444 10 408 10 366 69 402 39 395 13 388 2 394 18 396 16 435 18 461 8 300 15 68 9,579 154 78 17 121 56 7 157 98 25 259 94 6 144 90 73 199 78 19 209 73 69 157 59 112 168 60 28 182 70 30 161 74 189 170 65 14 131 63 19 178 71 19 113 73 18 140 81 48 103 88 39 187 106 21 153 95 23 210 44 32 134 60 18 155 99 125 191 55 111 225 71 12 192 58 277 142 - 4 352 64 63 235 62 138 145 71 98 146 114 7 169 57 199 181 57 13 228 56 425 121 71 74 204 69 70 171 62 76 144 119 19 217 76 98 137 73 18 187 78 32 140 63 40 233 66 19 168 68 28 116 60 463 113 69 37 210 72 31 211 77 113 141 65 95 165 79 26 187 95 3 127 63 54 208 91 34 191 85 43 169 161 24 166 50 46 149 CVD Total Charges 2003 $3,347,000,000 $8,300,000 $2,400,000 $3,700,000 $1,200,000 $21,900,000 $7,000,000 $22,400,000 $47,200,000 $9,500,000 $7,800,000 $110,500,000 $7,300,000 $5,400,000 $5,400,000 $10,700,000 $24,100,000 $10,400,000 $9,700,000 $2,000,000 $3,900,000 $6,300,000 $50,000,000 $5,300,000 $1,300,000 $113,600,000 $1,500,000 $18,900,000 $62,300,000 $30,100,000 $600,000 $87,800,000 $2,600,000 $210,600,000 $15,400,000 $12,200,000 $32,700,000 $7,000,000 $28,400,000 $8,000,000 $9,500,000 $800,000 $8,500,000 $5,800,000 $199,100,000 $12,200,000 $5,000,000 $41,300,000 $41,700,000 $1,700,000 $1,400,000 $17,600,000 $9,900,000 $13,600,000 $4,800,000 $13,500,000 CVD Rate 2003 1946 2298 2171 3178 1526 2120 2026 2275 2401 2557 2250 2608 2301 2273 2298 1822 2042 2427 2335 2463 1005 2512 2639 642 1140 1704 2075 2215 2159 1856 523 2029 2096 1734 2567 2110 1520 2723 1324 2741 2622 332 2145 1923 1582 3369 2643 1921 2404 644 2371 1744 2225 3131 1865 1830 HOSPITALIZATIONS Total CVD 2003 Stroke 2003 142,336 399 136 323 66 884 290 930 1,712 449 387 4,061 295 315 414 338 904 484 441 148 268 277 2,127 367 103 4,033 56 631 2,376 1,321 24 3,448 136 8,101 861 903 1,185 434 1,085 301 590 55 339 532 8,247 673 291 1,749 1,821 92 65 567 518 700 203540 23,164 71 23 67 10 128 64 139 237 53 73 599 45 55 74 61 153 81 80 26 36 39 330 66 14 760 7 93 351 252 5 449 17 1,253 140 147 192 95 173 33 102 <5 52 115 1,355 101 54 380 282 20 9 119 106 129 28 98 IHD 2003 50,098 150 49 111 16 349 107 329 755 185 119 1,457 103 116 127 125 328 144 180 37 60 111 907 83 26 989 21 255 1,129 338 5 1,262 53 3,494 244 297 456 126 471 143 209 21 132 142 2,400 292 120 420 834 17 16 204 144 203 73 228 CHF 2003 28,394 80 32 79 18 173 42 190 222 87 84 1,000 56 59 93 73 167 126 82 45 89 50 283 107 32 924 19 122 355 261 5 807 12 1,169 199 251 200 107 178 59 119 13 60 100 1,767 128 51 395 269 36 13 93 119 197 48 72 11 Table 3 continued . . . COUNTY FAYETTE FLOYD FORSYTH FRANKLIN FULTON GILMER GLASCOCK GLYNN GORDON GRADY GREENE GWINNETT HABERSHAM HALL HANCOCK HARALSON HARRIS HART HEARD HENRY HOUSTON IRWIN JACKSON JASPER JEFF DAVIS JEFFERSON JENKINS JOHNSON JONES LAMAR LANIER LAURENS LEE LIBERTY LINCOLN LONG LOWNDES LUMPKIN MCDUFFIE MCINTOSH MACON MADISON MARION MERIWETHER MILLER MITCHELL MONROE MONTGOMERY MORGAN MURRAY MUSCOGEE NEWTON CVD DEATHS 2003 210 352 234 89 1,850 75 15 265 123 116 64 833 119 405 42 114 66 92 39 255 285 53 162 47 63 70 40 36 79 69 21 216 45 92 46 28 262 57 97 34 56 92 39 126 28 91 77 25 55 81 661 172 CVD ANNUAL AAMR 1999-2003 299 410 383 386 333 359 370 326 386 382 409 282 319 364 495 434 357 389 377 344 369 376 413 429 537 442 423 384 368 414 388 435 352 443 476 453 412 320 453 403 397 420 442 485 373 425 445 511 399 344 415 370 DEATHS STROKE DEATHS 2003 STROKE ANNUAL AAMR 1999-2003 38 51 50 59 40 63 14 54 335 59 12 60 3 70 58 65 20 82 16 60 10 72 161 55 26 59 76 80 3 83 31 93 15 61 18 65 7 77 38 58 52 65 10 58 26 87 6 54 10 62 12 81 4 115 6 75 24 82 12 74 2 90 44 86 9 78 13 88 8 79 3 64 63 85 10 56 19 79 10 85 13 72 17 75 7 64 13 72 2 50 13 75 7 59 9 82 9 60 20 72 110 67 36 83 IHD DEATHS 2003 85 153 97 48 697 40 4 99 57 47 27 321 55 165 10 55 26 42 8 117 106 22 75 23 25 27 21 6 33 27 6 118 19 32 19 14 78 30 43 9 25 47 20 82 14 39 51 3 29 37 308 85 IHD ANNUAL AAMR 1999-2003 133 184 153 226 136 172 108 133 176 179 167 107 158 152 100 212 151 194 97 152 140 182 195 264 227 153 217 113 158 144 118 222 151 162 213 165 144 151 158 128 163 205 223 283 157 209 276 103 234 151 192 178 12 CVD Total Charges 2003 $33,400,000 $74,000,000 $42,500,000 $11,100,000 $300,900,000 $11,300,000 $1,800,000 $28,500,000 $34,600,000 $4,700,000 $7,300,000 $155,200,000 $17,500,000 $58,100,000 $5,800,000 $20,600,000 $8,000,000 $8,900,000 $5,100,000 $56,500,000 $53,500,000 $4,900,000 $24,200,000 $7,700,000 $7,400,000 $7,900,000 $4,600,000 $3,900,000 $14,500,000 $10,400,000 $3,600,000 $27,600,000 $7,700,000 $13,800,000 $4,500,000 $2,700,000 $30,600,000 $8,300,000 $11,000,000 $5,500,000 $5,700,000 $12,900,000 $3,000,000 $10,100,000 $2,100,000 $8,300,000 $12,500,000 $5,000,000 $7,800,000 $11,700,000 $63,900,000 $29,600,000 CVD Rate 2003 1517 2407 2101 2388 1848 2175 2029 1686 2687 1644 1692 1545 1763 1730 2312 2806 1378 1969 2302 2184 2700 2655 2379 3097 2795 2535 2441 2211 2157 2439 3495 2703 1429 1854 2152 1844 2199 2411 2347 1918 1941 2116 2098 2087 1652 1932 2271 2934 1875 1937 1726 2526 HOSPITALIZATIONS Total CVD 2003 Stroke 2003 1,339 2,367 1,659 583 11,596 587 69 1,340 1,166 412 299 5,985 725 2,123 224 794 356 558 243 2,277 2,681 285 981 357 347 448 220 224 525 396 231 1,283 292 528 207 111 1,651 461 494 222 267 540 137 513 135 441 490 219 321 601 3,012 1,517 181 345 234 112 1,829 89 12 204 169 90 50 886 127 459 32 111 70 87 38 357 333 40 151 54 48 70 29 39 85 59 26 211 43 99 32 17 314 91 102 29 41 97 22 99 23 81 70 36 67 101 587 255 IHD 2003 562 945 689 216 3,294 232 27 357 568 114 97 2,395 314 684 81 354 116 204 98 943 1,253 78 360 152 142 110 66 89 245 149 85 520 109 171 72 34 483 174 166 67 107 179 43 119 29 117 192 73 108 211 848 508 CHF 2003 184 418 265 112 2,696 113 9 370 158 93 55 981 107 389 45 127 65 112 39 460 465 51 172 54 75 123 52 42 84 92 49 223 57 107 42 25 265 76 89 56 53 102 35 130 48 109 113 41 62 123 621 343 13 Table 3 continued . . . COUNTY OCONEE OGLETHORPE PAULDING PEACH PICKENS PIERCE PIKE POLK PULASKI PUTNAM QUITMAN RABUN RANDOLPH RICHMOND ROCKDALE SCHLEY SCREVEN SEMINOLE SPALDING STEPHENS STEWART SUMTER TALBOT TALIAFERRO TATTNALL TAYLOR TELFAIR TERRELL THOMAS TIFT TOOMBS TOWNS TREUTLEN TROUP TURNER TWIGGS UNION UPSON WALKER WALTON WARE WARREN WASHINGTON WAYNE WEBSTER WHEELER WHITE WHITFIELD WILCOX WILKES WILKINSON WORTH CVD DEATHS 2003 67 56 172 76 108 69 54 193 47 67 12 69 38 676 172 12 67 40 223 112 21 140 25 8 96 33 69 63 163 126 125 47 32 231 42 38 85 156 275 213 186 23 91 103 8 16 71 250 38 53 44 74 CVD ANNUAL AAMR 1999-2003 337 412 381 406 420 477 384 448 415 388 330 321 549 381 361 418 441 395 456 404 359 411 434 324 415 454 506 457 399 348 449 287 458 460 448 456 290 466 439 405 427 383 423 454 352 403 362 369 394 388 421 383 DEATHS STROKE DEATHS 2003 STROKE ANNUAL AAMR 1999-2003 13 67 12 89 40 65 13 59 9 43 11 68 9 66 20 60 15 104 10 67 2 66 11 44 7 136 117 70 30 78 3 92 17 124 6 85 41 87 25 74 3 82 29 105 1 58 2 73 19 99 6 106 15 104 11 100 39 91 18 69 27 84 11 54 3 62 56 86 8 74 6 71 18 56 41 129 46 68 43 79 36 74 6 57 16 67 20 125 4 86 3 58 10 58 48 71 8 63 13 67 13 93 15 59 IHD DEATHS 2003 29 21 68 25 18 26 29 97 18 28 6 32 9 309 80 8 27 13 92 35 8 62 11 0 35 14 31 22 56 68 34 12 7 77 20 19 37 61 158 110 85 3 28 58 3 5 31 107 24 15 12 29 IHD ANNUAL AAMR 1999-2003 149 172 144 185 80 190 156 213 213 178 122 135 184 172 150 227 159 137 170 131 124 182 163 81 178 215 221 179 145 167 101 108 105 168 231 225 121 165 247 224 175 96 143 214 160 167 164 153 197 173 184 192 14 CVD Total Charges 2003 $10,500,000 $5,300,000 $35,400,000 $15,500,000 $12,700,000 $6,700,000 $7,800,000 $31,500,000 $6,400,000 $12,700,000 $400,000 $7,800,000 $3,300,000 $84,900,000 $28,100,000 $1,600,000 $9,200,000 $1,800,000 $39,700,000 $11,900,000 $1,900,000 $12,700,000 $2,700,000 $1,200,000 $10,800,000 $5,400,000 $8,300,000 $6,400,000 $9,700,000 $16,200,000 $12,600,000 $4,600,000 $4,300,000 $23,000,000 $3,600,000 $6,400,000 $10,900,000 $15,800,000 $11,100,000 $28,700,000 $16,600,000 $3,400,000 $8,400,000 $15,500,000 $1,100,000 $3,900,000 $12,800,000 $20,700,000 $3,800,000 $7,200,000 $8,400,000 $8,400,000 CVD Rate 2003 1,786 1,799 2,463 2,983 1,910 2,645 2,239 2,413 3,048 2,363 390 1,694 2,077 1,801 2,014 1,697 2,185 1,350 2,517 1,988 1,720 1,929 1,582 1,611 2,331 2,360 3,449 2,596 1,544 1,941 2,247 1,486 2,658 2,772 1,978 2,316 1,842 2,659 1,068 2,294 2,851 1,930 2,100 3,141 1,445 3,296 1,766 1,551 2,309 2,547 2,683 1,724 HOSPITALIZATIONS Total CVD 2003 Stroke 2003 412 71 236 45 1,446 188 642 84 550 90 440 64 311 46 984 134 319 38 540 71 15 <5 359 61 166 37 3,247 533 1,232 222 64 14 364 69 148 34 1,468 243 609 109 117 23 622 121 116 28 51 6 473 71 218 37 445 54 292 41 728 147 734 122 585 84 246 47 188 25 1,636 339 183 38 231 43 544 79 835 125 719 119 1,371 236 1,127 157 137 24 437 75 814 133 36 10 202 24 446 85 1,194 248 214 33 335 50 288 51 386 57 IHD 2003 126 76 695 249 242 170 131 408 133 250 <5 115 36 992 420 33 111 17 472 197 18 177 34 16 170 79 164 73 191 273 198 100 82 462 53 88 229 281 184 470 330 44 154 268 9 100 170 309 86 107 121 121 CHF 2003 76 34 209 154 86 101 63 174 60 90 <5 84 48 658 240 7 80 50 349 125 36 133 22 13 102 44 107 88 178 127 165 43 23 382 34 40 84 226 220 264 321 22 79 145 6 35 74 241 30 93 47 84 15 Table 4. Cardiovascular disease deaths, age-adjusted mortality rates, and hospitalizations by health district, Georgia, 1999-2003 DISTRICT CVD DEATHS 2003 CVD ANNUAL AAMR 1999-2003 DEATHS STROKE DEATHS 2003 STROKE ANNUAL AAMR 1999-2003 IHD DEATHS 2003 IHD ANNUAL AAMR 1999-2003 Georgia Northwest (Rome) North Georgia (Dalton) North (Gainesville) Cobb/Douglas Fulton Clayton (Morrow) East Metro (Lawrenceville) Dekalb LaGrange South Central (Dublin) North Central (Macon) East Central (August) West Central (Columbus) South (Valdosta) Southwest (Albany) Coastal (Savannah & Brunswick) Southeast (Waycross) Northeast (Athens) 23,295 1,805 937 1470 1401 1850 443 1177 1293 1985 608 1578 1483 1269 770 1328 1476 1256 1166 367 4,285 404 297 368 164 354 277 332 216 333 335 390 66 303 227 291 262 392 381 432 122 399 313 386 266 409 237 396 156 391 254 358 257 431 237 385 218 68 9,579 154 64 914 199 62 386 143 65 622 155 57 520 127 59 697 136 57 199 181 61 486 122 60 463 113 79 822 161 80 263 188 71 615 173 74 626 163 75 574 181 78 293 160 75 505 158 62 535 145 83 520 167 76 539 181 AAMR = Age-adjusted mortality rate CHF = Congestive heart failure CVD = Cardiovascular disease IHD = Ischemic heart disease 16 CVD Total Charges 2003 CVD Rate 2003 HOSPITALIZATIONS Total CVD 2003 Stroke 2003 $3,347,000,000 $279,200,000 $132,000,000 $209,400,000 $252,200,000 $300,900,000 $87,800,000 $212,900,000 $199,100,000 $289,200,000 $82,200,000 $285,400,000 $192,000,000 $125,700,000 $89,500,000 $112,800,000 $195,900,000 $143,100,000 $158,500,000 1946 2000 1915 1878 1825 1848 2029 1710 1582 2140 2828 2518 1960 1801 2281 1784 1670 2437 2067 142,336 10,241 5,848 8,942 9,922 11,596 3,448 8,734 8,247 12,671 4,062 11,661 7,941 6,087 4,833 6,324 7,407 7,443 6,929 23,164 1,466 977 1,607 1,535 1,829 449 1,363 1,355 2,070 606 1,658 1,329 1,159 844 1,214 1,325 1,164 1,214 IHD 2003 50,098 4,268 2,351 3,331 4,328 3,294 1,262 3,323 2,400 4,775 1,642 4,734 2,514 1,858 1,545 1,700 2,007 2,539 2,227 CHF 2003 28,394 1,770 990 1,573 1,438 2,696 807 1,564 1,767 2,468 745 2,403 1,704 1,268 910 1,552 1,737 1,667 1,335 17 Cardiovascular Disease Risk Factors Some CVD risk factors are modifiable, meaning that individuals can change their behavior to prevent, slow, or even reverse, the process of arterial blockage and decrease their risk of having a heart attack or stroke. Modifiable risk factors among adults include smoking, inadequate physical activity, poor diet, obesity, high blood pressure, high blood cholesterol level, and diabetes (Figure 11). Risk factors for CVD are not present exclusively among adults; many youth in Georgia adopt unhealthy habits early in life which contribute to the risk of heart disease (Figure 12). Some CVD risk factors cannot be changed, such as old age, male sex, and family history of heart attacks at a young age. Individuals with non-modifiable risk factors should be particularly diligent in eliminating modifiable risk factors. SMOKING The percentage of Georgia adults who currently smoke declined from 31% in 1984 to 19% in 1992; since then, the percentage of adults who smoke has been consistently higher than 20% (Figure 13). In 2003, 23% of Georgia adults reported that they currently smoke cigarettes (Figure 11). Lowering smoking rates is a public health priority. In addition to its well-known association with cancer, smoking is a major risk factor for CVD. Each year in Georgia smoking causes almost the same number of deaths from CVD as cancer, 4,226 and 4,235 deaths, respectively.5 The good news is that giving up smoking quickly reduces the risk for CVD.6 It is also important to prevent people, especially young people, from initiating smoking. Eighty percent of tobacco-users begin before their eighteenth birthday. If adolescents are kept tobacco-free, most will never start smoking.7 In 2003, 21% of Georgia high school students were current smokers. This rate is similar to the rate in adults (Figure 12). As of July 2005, the Georgia Smoke Free Air Act prohibits smoking in workplaces and public establishments. The new restrictions will reduce exposure to secondhand smoke and limit public venues for current smokers. PHYSICAL INACTIVITY, DIET AND OBESITY Regular, moderate, or vigorous physical activity can reduce the risk for CVD.8 CDC recommendations are 30 minutes, 5 days a week of moderate physical activity or 20 minutes, 3 days a week of vigorous physical activity. Fifty-eight percent of Georgia adults and 37% of Georgia high school students do not meet the CDC's recommended level of physical activity (Figures 11, 12). Forty-two percent of Georgia high school students reported watching at least 3 hours of TV per day in 2003 (Figure 12). Eating five or more servings of fruits or vegetables per day can help prevent heart disease, cancer, and other chronic conditions. In 2003, only 23% of Georgia adults reported that they ate at least five servings of fruits and vegetables per day (Figure 11). Only 17% of Georgia high school students report eating at least 5 daily servings of fruits and vegetables (Figure 12). 18 Obese adults are at increased risk for CVD.9 In both Georgia and the US, there has been a steady increase in the percentage of obese adults (body mass index greater than 30.0; see appendix for details). The percent of obese adults in Georgia was 25% in 2003 (Figure 11). Eleven percent of Georgia high school students were obese in 2003 (Figure 12). HIGH BLOOD PRESSURE High blood pressure is a major risk factor for both heart disease and stroke. The percentage of Georgians who reported having been told they had high blood pressure was 28% in 2003 (Figure 11). The percentage of Georgians with high blood pressure whose blood pressure is currently under control is not known. Nationally, only 69% of people with high blood pressure know it. Of those, 58% are treated with medications, and of those, 53% are controlled on medications. Only 31% of people with high blood pressure have it adequately controlled.10 For some people, high blood pressure can be controlled by losing weight and engaging in regular physical activity. Those who are unable to decrease their blood pressure by lifestyle modification alone require medications prescribed by a physician to successfully control high blood pressure. Percentage Percentage Figure 11. Prevalence of CVD risk factors among adults, Georgia, 2003 90 80 77 70 60 58 50 40 30 23 20 10 33 25 28 8 0 Current smoker Not meeting <5 fruits and Obese recommended vegetables per physical day activity Ever Ever high hypertension cholesterol (1) (2) Diabetes (1) The percentage of Georgians who reported having been told they had high blood pressure (2) Of persons who had their blood cholesterol level checked, the percentage told that they have high cholesterol Figure 12. Prevalence of CVD risk factors among high school students, Georgia, 2003 100 83 80 60 40 37 21 20 11 0 Current Not meeting <5 fruits and Obese Smokers recommended vegetables per day physical activity 42 >3 hours TV per day Percentage Figure 13. Percentage of adults reporting current smoking, Georgia, 1984-2003 35 30 25 20 15 10 5 0 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 19 HIGH CHOLESTEROL When there is too much cholesterol in blood, the excess can become trapped in the artery walls, gradually narrowing and damaging the arteries and increasing the risk of heart attack or stroke. Cholesterol is transported to and from cells by lipoproteins. Low-density lipoprotein (LDL), the "bad cholesterol," clogs the arteries; a high level of LDL increases the risk for heart disease. High-density lipoprotein (HDL), the "good cholesterol," removes cholesterol from the arteries; a high level of HDL decreases the risk for heart disease. A high total cholesterol level increases the risk for heart disease. Lowering high total blood cholesterol levels can decrease the risk of death from heart disease.11 The percentage of Georgian adults who report ever having had their blood cholesterol level checked increased from 53% in 1987 to 75% in 2003. Of persons who had been checked, the percentage told that they have high cholesterol increased from 15% in 1987 to 33% in 2003 (Figure 11). It is not known if the increase in the percentage of persons reporting high cholesterol represents a true increase in cholesterol levels among Georgians. Other explanations for the increase may include increased screening among high risk populations. Many people can control their cholesterol level by modifying their diet. For those who cannot, medication can lower blood cholesterol levels. In adults, a total cholesterol level of 200 mg/dL or higher is considered elevated; LDL levels >130 mg/dL or HDL levels <40mg/dL also increases a person's risk of CVD.10 The National Institutes of Health recommend that all adults get a fasting lipoprotein profile (total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides) every 5 years.11 20 DIABETES Persons with diabetes have two to three times the risk of death from cardiovascular disease as persons who do not have diabetes.12 The prevalence of diabetes among adults has increased nationwide during the past decade.13 Among children, the prevalence of diabetes has increased, due to an increase in type 2 diabetes, which is associated with obesity.14 In Georgia, the prevalence of diabetes among adults increased from 4% in 1993 to 8% in 2003 (Figure 11). Similar data are not available for children. Maintaining healthy body weight and staying physically active can prevent type 2 diabetes. Persons with diabetes can prevent complications by keeping their blood sugar as close to normal as possible, refraining from smoking, eating a healthy diet, getting regular physical activity, and maintaining normal blood pressure. MULTIPLE RISK FACTORS Since risk factors work in combination to increase risk, it is important to consider multiple risk factors. Of the seven major modifiable risk factors, 74% of Georgia adults have at least two. Approximately 9% of Georgians have 5 or more risk factors. Only 6% of Georgia adults live with no major modifiable CVD risk factors (Table 5). The majority of individuals in high risk groups do not discuss appropriate behavior modifications with medical professionals. In high-risk populations, fewer than half received medical advice regarding adopting healthier lifestyles (Table 6). In addition to conducting a personalized risk assessment, a medical professional can provide counseling or direct individuals to resources to aid in the modification of risk factors. Table 5. Adults by number of modifiable risk factors*, Georgia, 2003 Number of Risk Number of Factors 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, ever having high cholesterol, consuming <5 daily fruits and vegetables, and diabetes Table 6. 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 Obese adults Obese adults Obese adults Obese adults Adults reporting ever having high cholesterol Adults consuming fewer than 5 fruits and vegetables per day Adults not meeting recommended level of physical activity Lifestyle Issue Lose weight Eat fewer high fat or high cholesterol foods Eat more fruits and vegetables Increased physical activity Eat fewer high fat and high cholesterol foods Eat more fruits and vegetables Be more physically active Discussed issue with health professional 38% 35% 43% 48% 48% 30% 37% 21 Secondary Prevention of CVD Secondary prevention involves efforts to further reduce risk among individuals who have already experienced a CVD event. In 2003, approximately 8% of Georgia adults reported a previous heart attack, ischemic heart disease, or a stroke (Figure 14). For individuals with a history of a previous CVD event, the risk for a subsequent event is substantial.15 It is important for these individuals to take steps to prevent a recurrence. There is a strong association between modifiable risk factors and a history of CVD event. The percentage of persons experiencing a CVD event was higher among people who had several modifiable risk factors. Three quarters 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 15). Cardiac rehabilitation was utilized by 26% of Georgia adults who had reported past heart attack or stroke during 2003. The American Heart Association defines cardiac rehabilitation as coordinated, multifaceted interventions designed to optimize a cardiac patient's physical, psychological, and social functioning, in addition to stabilizing, slowing, or even reversing the progression of the underlying atherosclerotic processes, thereby reducing morbidity and mortality. These comprehensive and long-term programs often involve baseline patient assessment, nutritional counseling, aggressive risk factor management, counseling, and exercise training. Exercise-based cardiac rehabilitation is associated with lower total and cardiac mortality rates when compared to usual medical care.16 The American Heart Association recommends consideration of the use of aspirin for persons who have had a heart attack, unstable angina, ischemic stroke or transient ischemic attack.17 For certain types of heart conditions, other medications may be useful in reducing the risk of recurrence. The majority of Georgia adults were able to correctly identify the major symptoms of heart attack and stroke (Table 7). Early recognition of CVD events can expedite treatment and reduce complications and severity. The CDC estimates that 60% of cardiac deaths occur either before reaching a hospital or in the emergency room.18 The Georgia Coverdell Stroke Registry (GCSR) was established in 2005 to improve the care of acute stroke patients in hospital settings. This program addresses quality improvement in multiple areas of stroke care, from rapid screening, diagnosis, and intervention for patients experiencing an acute stroke, to secondary prevention measures such as blood pressure control, smoking cessation, and treatment of elevated cholesterol in order to reduce the incidence of recurrent stroke after hospital discharge. In addition, the program will also help improve the utilization of rehabilitation services for those who have experienced an acute stroke in the an effort to reduce long-term disability due to stroke. The GCSR is a component of the state of Georgia Cardiovascular Health Initiative, which is a part of a national effort funded by the CDC to reduce heart disease and stroke related morbidity and mortality. 22 Percentage diagnosed by a medical professional Age-adjusted percentage w/ history of heart attack, stroke, or coronary heart disease Figure 14. Percentage of adults reporting a previous heart attack, angina, or stroke, Georgia, 2003 9 8 8 7 6 6 5 4 3 2 1 0 Any event Heart attack, angina or coronary heart disease 2 Stroke Figure 15. 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 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, ever having high cholesterol, consuming <5 daily fruits and vegetables, and diabetes Table 7. Awareness of heart attack and stroke symptoms among adults, Georgia, 2003 Heart Attack Symptoms Chest pain or discomfort Shortness of breath Pain or discomfort in arm/shoulders Feeling weak, lightheaded or faint Pain or discomfort in jaw, neck or back Correctly identified 94% 86% 85% 66% 45% Stroke Symptoms Body numbness or weakness, especially on one side Sudden confusion or trouble speaking Sudden dizziness trouble walking, or loss of balance Sudden vision trouble Severe unexplained headache Correctly identified 93% 87% 85% 64% 62% 23 Conclusions This report summarizes the most recent information available on cardiovascular disease deaths and hospitalizations in Georgia. The burden of cardiovascular disease in Georgia is immense. CVD is the leading cause of death in Georgia, resulting in over 142,000 hospitalizations and charges of $3.3 billion in 2003. 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. The burden of CVD is greater among particular populations. Blacks have higher rates of CVD than whites, especially for stroke. Furthermore, men have higher rates of CVD than women. The practical implications of these findings are clear. Because most heart attacks and strokes result from a process of arterial blockage that begins at an early age, a greater effort should be made to reduce the prevalence of risk factors among all Georgians, including children and adolescents. Reducing CVD risk factors involves not smoking, engaging in regular physical activity, eating a healthy diet, maintaining a healthy weight, controlling high blood pressure, reducing blood cholesterol, and preventing diabetes. Sustained behavioral changes are often difficult to make, even for highly motivated individuals. Therefore, it is critical that entire communities make policy and environmental changes that make it easier for individuals to change their behavior. Community leaders and parents can act as role models. Additionally, local environments, such as schools and workplaces, can implement policies that facilitate healthy behaviors. Some changes in the environment include 100% tobacco-free policies, opportunity for physical activity during the work day, and healthy vending machine and cafeteria choices. Much of the death and disability from CVD in Georgia is preventable. If we focus attention on realistic ways of reducing risk, we can continue the decline in CVD death rates that Georgia has experienced in much of the past two decades. Georgians can work together to reduce the number of individuals who suffer and die from cardiovascular disease by advocating for healthier communities and following treatment recommendations. As we move forward it is imperative that we encourage everyone in our state to "Live Healthy." 24 References 1. American Heart Association. Heart and Stroke Statistics- 2005 Update. Dallas, TX: American Heart Association; 2005. 2. 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. 3. Strong JP, Malcom GT, McMahan CA, et al. Prevalence and extent of atherosclerosis in adolescents and young adults: implications for prevention from the Pathobiological Determinants of Atherosclerosis in Youth Study. JAMA 1999;281:727-735. 4. Sternby NH, Fernandez-Britto JE, Nordet P. Pathobiological determinants of atherosclerosis in youth (PBDAY Study), 1986-96. Bull World Health Organ 1999;77:250-257. 5. Figueroa A, Kanny D, Chowdhurry PP, Powell KE. 2004 Georgia Tobacco Surveillance Report. Georgia Department of Human Resources, Division of Public Health, Chronic Disease, Injury, and Environmental Epidemiology Section, September 2004. Publication Number:DPH04/232HW. 6. US Department of Health and Human Services. The health benefits of smoking cessation: a report of the Surgeon General. Rockville, MD: Office on Smoking and Health, 1990. DHHS publication (CDC) 90-8416. 7. Centers for Disease Control. Cigarette Smoking Among High School Students. MMWR 1999; 48(31): 686-692. 8. U.S. Department of Health and Human Services. Physical activity and health: a report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 1996. 9. Sowers JR. Obesity as a cardiovascular risk factor. Am J Med. 2003 Dec 8;115 Suppl 8A:37S-41S. 10. Hajjer, I, Kotchen TA. Trends in Prevalence, Awareness, Treatment, and Control of Hypertension in the United States, 1988-2000. JAMA 2003;290:199-206. 11. Third report of the National Cholesterol Education Program Expert Panel on detection evaluation, and treat- ment of high blood cholesterol in adults (Adult Treatment Panel III). 12. National Diabetes Education Program. The link between diabetes and cardiovascular disease. Atlanta, Georgia: National Institute of Health, CDC, June, 2001. 13. Mokdad AH, Ford ES, Bowman BA, et al. Diabetes trends in the U.S.: 1990-1998. Diabetes Care 2000;23:1278-1283. 14. American Diabetes Association. Type 2 diabetes in children and adolescents. Diabetes Care 2000;23:381-389. 15. Hurst, W. The Heart, Arteries and Veins. 10th ed. New York, NY: McGraw-Hill; 2002. 16. Leon AS, Franklin BA, Costa F, et al. Cardiac rehabilitation and secondary prevention of coronary heart disease. Circulation 2005;111:369-376. 17. American Heart Association. Aspirin in Heart Attack and Stroke Prevention. Available at http://www.americanheart.org/presenter.jhtml?identifier=4456, Accessed October 11, 2005. 18. Centers for Disease Control and Prevention. State-specific mortality from sudden cardiac death--United States, 1999. MMWR 2002; (51)06; 123-6. 19. Kanny D, Thompson S, Gregory K, Clanton J. Georgia Behavioral Risk Factor Surveillance System, 2003 Report. Georgia Department of Human Resources, Division of Public Health, Chronic Disease, Injury, and Environmental Epidemiology Section, June 2005. http://health.state.ga.us/pdfs/epi/brfssreport.03.pdf. 20. Kanny D, Powell KE. 2003 Georgia Student Healthy Survey Report. Georgia Department of Human Resources, Division of Public Health, November 2003. http://health.state.ga.us/pdfs/epi/cdiee/gshsreport.0304.pdf. 25 Appendix: methods, definitions, and abbreviations METHODS Age-adjusted mortality rates for the US from 1980 through 1998 and for Georgia from 1980 though 1993 were obtained via WONDER at http://wonder.cdc.gov from the compressed mortality file compiled by the National Center for Health Statistics, CDC. Age-adjusted mortality rates for Georgia from 1994 though 1998 were obtained from OASIS at http://oasis.state.ga.us. The following ICD-9 codes were used: CVD, 390-434, 436-448; ischemic heart disease, 410-414, 429.2; and stroke, 430-434, 436-438. The 2000 U.S. standard population was used as the standard population. Age-adjusted mortality rates for the US from 1999 through 2002 were obtained via WONDER at http://wonder.cdc.gov from the compressed mortality file compiled by the National Center for Health Statistics, CDC. Age-adjusted mortality rates for Georgia from 1999 though 2003 were obtained from OASIS at http://oasis.state.ga.us. The following ICD-10 codes were used for CVD: CVD, I00-78; ischemic heart disease, I20-25; stroke, I60-69; heart failure, I50; other CVD, CVD codes not already categorized. ICD-10 codes for stroke included subarachnoid hemorrhage, I60; other cerebral hemorrhage, I61-62; occlusion, I63; acute ill-defined, I64; other ill-defined, I67; sequelae, I69. ICD-10 codes for non-CVD causes of death included cancer, C00-C97; chronic respiratory disease, J40-J47; unintentional injuries, V01-X59, Y85-86; diabetes, E10-14; Alzheimers, G30; kidney disease, N00-07, N17-19, N2527; influenza and pneumonia, J10-18. Age-adjusted death rates for Georgia were calculated using the direct method with population estimates from the U.S. Bureau of the Census (release date: August 30, 2000) and the 2000 U.S. standard population as the standard. Age-adjusted death rates for the US in 2003 were obtained from the National Vital Statistics Report, Vol 53, No. 15, February 28, 2005. The average annual percentage change in age-adjusted death rates represents the average of the relative change between each pair of consecutive years. Data on hospitalizations at acute care hospitals in Georgia were provided by the Office of Health Information and Policy after compilation by the Georgia Hospital Association. Analyses were restricted to Georgia residents. The following ICD-9-CM codes were used for principal diagnosis: CVD, 390-448; ischemic heart disease, 410-414; stroke, 430-438; heart failure, 428; hypertensive disease, 401-404; atherosclerosis, 440. Age-adjusted mortality rates for counties and districts were calculated using data from death certificates provided by Vital Statistics Branch and Office of Health Information and Policy. The number of deaths for 1999 through 2003 was determined using the ICD-10 codes above (CVD, I00-78; ischemic heart disease, I20-25; stroke, I60-69). Age-adjusted mortality rates were calculated using county population estimates from the US Bureau of Census and the year 2000 U.S. standard population as the standard. The z-test was used to compare county rates to the state rate with significance at p<0.05. The source of the formula for the z-test and the standard error for an age-adjusted rate was the National Center for Health Statistics, National Vital Statistics Report, volume 48, number 11, July 24, 2000, page 104. Data on behaviors, health history, and health knowledge among adults were obtained from the 2003 Georgia Behavioral Risk Factor Surveillance System, a telephone survey conducted annually with a sample of adults aged 18 years and older.19 The sample is weighted so that it reflects the total adult population of the state. Data for Table 6 were obtained from module 9, "Cardiovascular Disease." Data for heart attack and stroke symptoms were obtained from module 8, "Heart Attack and Stroke." CVD risk factors assessed by the BRFSS include the following: Current smoker: Defined as someone who has smoked at least 100 cigarettes in his lifetime and smokes now. High blood pressure: Defined as ever having been told by a doctor, nurse, or health professional that your blood pressure was high. High cholesterol: Defined as ever having been told by a doctor or health professional that your blood cholesterol level was high. 26 Physical activity recommendations: 30 minutes, 5 days a week (moderate physical activity) or 20 minutes, 3 days a week (vigorous physical activity). Obese: Defined as a body mass index [BMI] > 30.0 kilograms per meter squared, based on self-reported height and weight. BMI equals weight (in kilograms) divided by height (in meters) squared. Using weight (in pounds) and height (in inches), BMI equals 705 times weight divided by height squared. Daily servings of fruits and vegetables: Number of servings of fruits or vegetables per day based on self-reporting of consumption during the past day, week, month, or year. Diabetes: Defined as ever having been told by a doctor that you have diabetes. Previous cardiovascular disease: Defined as ever having been told by a doctor that you had a heart attack and/or myocardial infarction, angina and/or coronary heart disease, or a stroke. Prevalence data on CVD risk factors among high school students were obtained from the 2003 Georgia Student Health Survey (GSHS) conducted by the Georgia Department of Human Resources, Division of Public Health, in collaboration with the Georgia Department of Education.20 The questionnaire was modeled after the core Youth Risk Behavior Survey, developed by the Centers for Disease Control. Each student record is weighted so that it reflects the likelihood of sampling each student. CVD risk factors assessed by the GSHS are defined according to the above BRFSS terms, except: Current Smoker: Defined as smoking cigarettes on one or more of the past 30 days. Daily servings of fruits and vegetables: Number of servings of fuits or vegetables per day in the past 7 days. Obese: Body mass index for age 95th percentile, based on self-reported height and weight. TV Watching: Hours of TV watched per day on an average school day. GLOSSARY Age-adjusted death rate: a rate calculated based on a standard age distribution to enable comparison of rates in populations with different age structures Angina: pain or discomfort in the chest that occurs when the heart does not receive enough blood Atherosclerosis: deposits of cholesterol and other substances in the walls of arteries Cardiovascular disease: includes a wide variety of diseases of the heart and blood vessels, including ischemic heart disease (heart attacks), high blood pressure, stroke, and hypertensive heart disease. Cholesterol: fatty substance in blood that gets deposited in blood vessel walls, causing atherosclerosis, when blood cholesterol levels are high HDL (high-density lipoprotein): carries cholesterol away from other parts of the body back to the liver for removal from the body Heart attack (also known as myocardial infarction): death or damage to the heart muscle caused by an insufficient supply of oxygen due to blockage of one or more coronary arteries Heart failure: condition in which the heart cannot pump enough blood to meet the body's needs Hospital charges: a hospital's full established rates, which do not necessarily reflect costs or reimbursement 27 Ischemic heart disease(also known as coronary heart disease): includes heart attacks and related problems caused by a narrowing of the coronary arteries LDL (low-density lipoprotein): contains most of the cholesterol in the blood and carries it to tissues and organs via arteries; it is the main source of damaging buildup and blockage in the arteries Modifiable Risk Factor: a risk factor that can be changed in order to slow, or reverse, the disease process and decrease the risk of disease Prevalence: the percentage of a population that has a disease or a risk factor at a specific point in time Risk factor: a habit, characteristic, or finding on clinical examination that is associated with an increased probability of a disease Stroke: occurs when blood vessels to the brain burst or become clogged by a blood clot or some other particle resulting in lack of blood flow and oxygen to the brain and death of brain cells ABBREVIATIONS AAMR = Age-adjusted mortality rate BMI = Body mass index CDC = Centers for Disease Control and Prevention CHF = Congestive heart failure CVD = Cardiovascular disease HDL = High-density lipoprotein IHD = Ischemic heart disease ICD-9 = The International Classification of Diseases, 9th Revision ICD-9-CM= The International Classification of Diseases, 9th Revision, Clinical Modification ICD-10 = The International Classification of Diseases, 10th Revision LDL = Low-density lipoprotein 28