David B. Matchar

Heart Disease and Stroke Statistics—2012 Update A Report From the American Heart Association

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e3 1. About These Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e7 2. American Heart Associations 2020 Impact Goals. . . . . . . . . . . . . . . . .e10 3. Cardiovascular Diseases . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . .e21 4. Subclinical Atherosclerosis . . . . . . . . . . . . . . . . . . . . .e45 5. Coronary Heart Disease, Acute Coronary Syndrome, and Angina Pectoris . . . . . . . . .e54 6. Stroke (Cerebrovascular Disease) . . . . . . . . . . . . . . . . . . . . . . . . . . . .e68 7. High Blood Pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .e88 8. Congenital Cardiovascular Defects . . . . . . . . . . . . . . . . . . . . . . . . . . . .e97 9. Cardiomyopathy and Heart Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . .e102 10. Disorders …

Heart Disease and Stroke Statistics—2013 Update A Report From the American Heart Association

Author(s): Go, Alan S; Mozaffarian, Dariush; Roger, Veronique L; Benjamin, Emelia J; Berry, Jarett D; Borden, William B; Bravata, Dawn M; Dai, Shifan; Ford, Earl S; Fox, Caroline S; Franco, Sheila; Fullerton, Heather J; Gillespie, Cathleen; Hailpern, Susan M; Heit, John A; Howard, Virginia J; Huffman, Mark D; Kissela, Brett M; Kittner, Steven J; Lackland, Daniel T; Lichtman, Judith H; Lisabeth, Lynda D; Magid, David; Marcus, Gregory M; Marelli, Ariane; Matchar, David B; McGuire, Darren K; Mohler, Emile R; Moy, Claudia S; Mussolino, Michael E; Nichol, Graham; Paynter, Nina P; Schreiner, Pamela J; Sorlie, Paul D; Stein, Joel; Turan, Tanya N; Virani, Salim S; Wong, Nathan D; Woo, Daniel; Turner, Melanie B; American Heart Association Statistics Committee and Stroke Statistics Subcommittee

Heart Disease and Stroke Statistics—2011 Update A Report From the American Heart Association

Rosamond, Paul D. Sorlie, Randall S. Stafford, Tanya N. Turan, Melanie B. Turner, Nathan D. Dariush Mozaffarian, Michael E. Mussolino, Graham Nichol, Nina P. Paynter, Wayne D. Ariane Marelli, David B. Matchar, Mary M. McDermott, James B. Meigs, Claudia S. Moy, Lackland, Judith H. Lichtman, Lynda D. Lisabeth, Diane M. Makuc, Gregory M. Marcus, John A. Heit, P. Michael Ho, Virginia J. Howard, Brett M. Kissela, Steven J. Kittner, Daniel T. Caroline S. Fox, Heather J. Fullerton, Cathleen Gillespie, Kurt J. Greenlund, Susan M. Hailpern, Todd M. Brown, Mercedes R. Carnethon, Shifan Dai, Giovanni de Simone, Earl S. Ford, Véronique L. Roger, Alan S. Go, Donald M. Lloyd-Jones, Robert J. Adams, Jarett D. Berry, Association 2011 Update : A Report From the American Heart −− Heart Disease and Stroke Statistics

Heart Disease and Stroke Statistics—2014 Update A Report From the American Heart Association

Author(s): Go, Alan S; Mozaffarian, Dariush; Roger, Veronique L; Benjamin, Emelia J; Berry, Jarett D; Blaha, Michael J; Dai, Shifan; Ford, Earl S; Fox, Caroline S; Franco, Sheila; Fullerton, Heather J; Gillespie, Cathleen; Hailpern, Susan M; Heit, John A; Howard, Virginia J; Huffman, Mark D; Judd, Suzanne E; Kissela, Brett M; Kittner, Steven J; Lackland, Daniel T; Lichtman, Judith H; Lisabeth, Lynda D; Mackey, Rachel H; Magid, David J; Marcus, Gregory M; Marelli, Ariane; Matchar, David B; McGuire, Darren K; Mohler, Emile R; Moy, Claudia S; Mussolino, Michael E; Neumar, Robert W; Nichol, Graham; Pandey, Dilip K; Paynter, Nina P; Reeves, Matthew J; Sorlie, Paul D; Stein, Joel; Towfighi, Amytis; Turan, Tanya N; Virani, Salim S; Wong, Nathan D; Woo, Daniel; Turner, Melanie B; American Heart Association Statistics Committee and Stroke Statistics Subcommittee

Heart Disease and Stroke Statistics—2015 Update A Report From the American Heart Association

STRIDE (Stanford Translational Research Integrated Database Environment) is a research and development project at Stanford University to create a standards-based informatics platform supporting clinical and translational research. STRIDE consists of three integrated components: a clinical data warehouse, based on the HL7 Reference Information Model (RIM), containing clinical information on over 1.3 million pediatric and adult patients cared for at Stanford University Medical Center since 1995; an application development framework for building research data management applications on the STRIDE platform and a biospecimen data management system. STRIDEs semantic model uses standardized terminologies, such as SNOMED, RxNorm, ICD and CPT, to represent important biomedical concepts and their relationships. The system is in daily use at Stanford and is an important component of Stanford Universitys CTSA (Clinical and Translational Science Award) Informatics Program.on behalf of the American Heart Association Statistics Committee and Stroke Statistics Nathan D. Wong, Daniel Woo and Melanie B. Turner Elsayed Z. Soliman, Paul D. Sorlie, Nona Sotoodehnia, Tanya N. Turan, Salim S. Virani, Claudia S. Moy, Dariush Mozaffarian, Michael E. Mussolino, Graham Nichol, Nina P. Paynter, Lynda D. Lisabeth, Diane M. Makuc, Gregory M. Marcus, Ariane Marelli, David B. Matchar, Lichtman, Virginia J. Howard, Brett M. Kissela, Steven J. Kittner, Daniel T. Lackland, Judith H. Caroline S. Fox, Heather J. Fullerton, Cathleen Gillespie, Susan M. Hailpern, John A. Heit, Benjamin, Jarett D. Berry, William B. Borden, Dawn M. Bravata, Shifan Dai, Earl S. Ford, Writing Group Members, Véronique L. Roger, Alan S. Go, Donald M. Lloyd-Jones, Emelia J. Association 2012 Update : A Report From the American Heart −− Heart Disease and Stroke StatisticsHeart Disease, Stroke and other Cardiovascular Diseases • Cardiovascular disease is the leading global cause of death, accounting for 17.3 million deaths per year, a number that is expected to grow to more than 23.6 million by 2030. • In 2008, cardiovascular deaths represented 30 percent of all global deaths, with 80 percent of those deaths taking place in lowand middle-income countries. • Nearly 787,000 people in the U.S. died from heart disease, stroke and other cardiovascular diseases in 2011. That’s about one of every three deaths in America. • About 2,150 Americans die each day from these diseases, one every 40 seconds. • Cardiovascular diseases claim more lives than all forms of cancer combined. • About 85.6 million Americans are living with some form of cardiovascular disease or the after-effects of stroke. • Direct and indirect costs of cardiovascular diseases and stroke total more than

Executive Summary: Heart Disease and Stroke Statistics—2013 Update

320.1 billion. That includes health expenditures and lost productivity. • Nearly half of all African-American adults have some form of cardiovascular disease, 48 percent of women and 46 percent of men. • Heart disease is the No. 1 cause of death in the world and the leading cause of death in the United States, killing over 375,000 Americans a year. • Heart disease accounts for 1 in 7 deaths in the U.S. • Someone in the U.S. dies from heart disease about once every 90 seconds.Author(s): Mozaffarian, Dariush; Benjamin, Emelia J; Go, Alan S; Arnett, Donna K; Blaha, Michael J; Cushman, Mary; de Ferranti, Sarah; Despres, Jean-Pierre; Fullerton, Heather J; Howard, Virginia J; Huffman, Mark D; Judd, Suzanne E; Kissela, Brett M; Lackland, Daniel T; Lichtman, Judith H; Lisabeth, Lynda D; Liu, Simin; Mackey, Rachel H; Matchar, David B; McGuire, Darren K; Mohler, Emile R; Moy, Claudia S; Muntner, Paul; Mussolino, Michael E; Nasir, Khurram; Neumar, Robert W; Nichol, Graham; Palaniappan, Latha; Pandey, Dilip K; Reeves, Mathew J; Rodriguez, Carlos J; Sorlie, Paul D; Stein, Joel; Towfighi, Amytis; Turan, Tanya N; Virani, Salim S; Willey, Joshua Z; Woo, Daniel; Yeh, Robert W; Turner, Melanie B; American Heart Association Statistics Committee and Stroke Statistics Subcommittee

Accuracy of the Papanicolaou Test in Screening for and Follow-up of Cervical Cytologic Abnormalities: A Systematic Review

Author(s): Go, Alan S; Mozaffarian, Dariush; Roger, Veronique L; Benjamin, Emelia J; Berry, Jarett D; Borden, William B; Bravata, Dawn M; Dai, Shifan; Ford, Earl S; Fox, Caroline S; Franco, Sheila; Fullerton, Heather J; Gillespie, Cathleen; Hailpern, Susan M; Heit, John A; Howard, Virginia J; Huffman, Mark D; Kissela, Brett M; Kittner, Steven J; Lackland, Daniel T; Lichtman, Judith H; Lisabeth, Lynda D; Magid, David; Marcus, Gregory M; Marelli, Ariane; Matchar, David B; McGuire, Darren K; Mohler, Emile R; Moy, Claudia S; Mussolino, Michael E; Nichol, Graham; Paynter, Nina P; Schreiner, Pamela J; Sorlie, Paul D; Stein, Joel; Turan, Tanya N; Virani, Salim S; Wong, Nathan D; Woo, Daniel; Turner, Melanie B; American Heart Association Statistics Committee and Stroke Statistics Subcommittee

Guidelines for Carotid Endarterectomy A Multidisciplinary Consensus Statement From the Ad Hoc Committee, American Heart Association

Since the implementation of widespread screening with the Papanicolaou (Pap) test, rates of cervical cancer in the United States have decreased from 14.2 per 100 000 in 1973 to 7.8 per 100 000 in 1994. Nevertheless, cervical cancer is still the ninth-leading cause of cancer deaths among U.S. women (1). Most of these deaths occur in women who have never had a Pap test, but some occur in women who recently received negative test results. Approximately two thirds of false-negative results are caused by sampling error, and the rest are caused by detection error. Sampling error occurs when abnormal cells are not collected or are not transferred to the Pap slide, and detection error occurs when abnormal cells on the Pap slide are missed or misinterpreted. The most common sampling error is lack of cells from the cervical transformation zone. To reduce sampling error, an endocervical cytobrush and a spatula can be used instead of a cotton swab. However, a recent meta-analysis found that the Pap test did not differ in sensitivity or specificity when different sampling devices were used (2). The Food and Drug Administration (FDA) has approved another potential solution: liquid-based monolayer preparation (ThinPrep, Cytyc Corp., Boxborough, Massachusetts). With this technique, the sample is collected as in the conventional Pap test, but cells are then placed in a fixative solution. The cells are dispersed, collected onto a filter, and transferred to a microscopic slide for interpretation. Because samples are fixed immediately after collection, fewer cellular morphologic artifacts occur. Fewer cells on the slide are obscured because the process reduces the amounts of other sampled material, such as blood and mucus, and deposits cells on the slide in a monolayer. To reduce detection error, some researchers advocate rescreening slides initially reported to be normal. The Clinical Laboratory Improvement Amendments of 1988 mandate rescreening of a 10% random sample of normal slides as a quality assurance measure. Rescreening can also be performed on a higher proportion of slides by using computerized technologies. The FDA has approved two such systems, one that is algorithm-based (AutoPap QC System, TriPath Imaging, Inc., Redmond, Washington), and one that uses neural networks (PAPNET, Neuromedical Systems, Inc., Suffern, New York). PAPNET uses neural network computerized imaging of Papanicolaou smear slides to identify cells or clusters of cells that require review; it then displays up to 128 images per slide that are likely to contain abnormalities. A cytotechnologist reviews these images and decides whether to review the actual slide using light microscopy. AutoPap uses its algorithm-based decision-making technology to identify slides that exceed a certain threshold for the likelihood of abnormal cells. The laboratory can select different thresholds, corresponding to 10%, 15%, or 20% review rates. In contrast to random rescreening, AutoPap selects a sample of slides that is enriched with abnormalities, thereby including most of the slides that contain abnormalities missed by manual screening. Another approach to reducing detection error is improving the sensitivity of the initial screening step. The FDA has recently approved a new method (AutoPap Primary Screening System, TriPath Imaging) for this indication. AutoPap Primary Screening System uses proprietary computerized algorithms to identify slides that exceed a certain threshold for the likelihood of abnormal cells. A cytotechnologist then reviews these slides. The system allows laboratories to concentrate on the 75% of slides that most likely contain abnormal cells while immediately archiving the remainder. Sampling and detection errors are reduced when Pap test screening is repeated frequently. However, cost-effectiveness analyses have concluded that if persons are screened more than every 3 years, cost-effectiveness ratios exceed

GUIDELINES FOR CAROTID ENDARTERECTOMY: A STATEMENT FOR HEALTHCARE PROFESSIONALS FROM A SPECIAL WRITING GROUP OF THE STROKE COUNCIL, AMERICAN HEART ASSOCIATION

50 000 per life-year saved (3, 4). Precise estimates of cytologic test sensitivity and specificity are important because they may be used to determine policy decisions, such as recommendations for optimal frequency of screening, management of mild abnormalities, and use of newer methods. Our primary objective was to systematically review the operating characteristics of conventional and new methods (computer screening and monolayer slide preparation) of Pap testing in the detection of cervical cancer and its precursors. We also evaluated test performance among women with previous cytologic abnormalities. The Agency for Healthcare Research and Quality (AHRQ), under contract to Duke University (Durham, North Carolina), funded the study. An AHRQ-approved advisory panel assisted in the design, conduct, and reporting of this work, and the evidence report on which this manuscript is based was reviewed by an external peer review panel (5). Methods Data Sources Data sources, including MEDLINE (from 1966), EMBASE (from 1980), HealthStar (from 1975), CancerLit (from 1983), and CINAHL (from 1983) were searched through October 1999 by using a strategy developed with a medical librarian (Table 1). Searches were limited to English-language studies in humans. We manually searched newly published relevant journal issues, bibliographies of included studies, and recent systematic reviews (6-9). To locate unpublished studies, we also contacted relevant professional societies and manufacturers of cytologic devices. Table 1. Search Strategy Study Selection We identified studies of conventional Pap testing (with or without manual rescreening), Pap testing using monolayer slide preparation (ThinPrep), Pap testing with primary computer screening (AutoPap or PAPNET), and Pap testing with computer rescreening (AutoPap or PAPNET). Other recently developed methods, the AutoCyte PREP System and the AutoCyte SCREEN system (TriPath Imaging, Inc., Burlington, North Carolina), had not been approved by the FDA at the time of our review and were not evaluated in this study. Study samples included women undergoing Pap testing for primary screening and those undergoing evaluation for previous cytologic abnormalities. The main outcome measures were the sensitivity and specificity of the cytologic test for detecting cases. Cytologic abnormality was defined by one of three thresholds: atypical squamous cells of undetermined significance (ASCUS), low-grade squamous intraepithelial lesions (LSIL), and high-grade squamous intraepithelial lesions (HSIL). Cases were defined as histologic diagnosis of cervical intraepithelial neoplasia (CIN), grades I to III, or carcinoma. Equivalent categories in other classification schemes (10-14) were also used (Figure). Figure. Map of classification schemes for cervical cytology. We included studies of the conventional Pap test if a reference standard of histologic examination or colposcopy was reasonably concurrent to the cytologic screening test (within 3 months) and if sufficient data were reported to complete all four cells of a 2 2 table. Comparison with such a reference standard provides a more relevant outcome for clinical decision makers because colposcopic or histologic diagnoses form the basis of most clinical management decisions. Only one study of ThinPrep (15) provided enough information to allow us to extract data on sensitivity and specificity compared with a gold standard of histologic examination or colposcopy. We therefore used a separate set of screening criteria for studies of the new methods, based on cytology society guidelines (16, 17) and FDA documents [18]: 1) The study must prospectively compare screening tests or test and reference standard on the same set of patients or slides; 2) if cytologic examination is the reference standard, discordant results from the two study tests must be adjudicated by an independent panel of experienced cytology professionals; 3) at least 50% of patients testing positive for HSIL must be verified by histologic examination or colposcopy; and 4) the study design must allow for separate analyses of sensitivity (or relative true-positive rate) and specificity (or relative false-positive rate). Data based on a cytologic reference standard cannot be integrated with data based on a histologic reference standard (19-23). However, when negative test results are not verified with the reference standard, information about incremental characteristics of test performance may be obtained by directly comparing independently applied conventional and new tests (21). In this case, both tests must be applied independently to all patients, and all positive results on either test must be verified with the reference standard. A relative true-positive rate and a relative false-positive rate, which can be used to determine relative estimates of the performance of the new test, can then be calculated. Two investigators independently screened each study. Differences of opinion were reconciled by consensus. The title and abstract of each citation were screened first, and the full report was screened second. Of the 1193 bibliographic references we reviewed, 761 (approximately 64%) were excluded on the basis of title or abstract. We reviewed the full reports of 346 studies of the conventional Pap test and 86 studies of the new methods (18 on AutoPap, 42 on PAPNET, and 26 on ThinPrep). We developed a numeric quality score to evaluate included citations. Nine members of the studys working group (6 clinicians, 2 economists, and 1 health policy analyst) initially identified more than 12 evaluation criteria on the basis of previously reported criteria (6, 24, 25). We used a consensus process to narrow this list to 7. Blinded to the rest of the group, each participant then independently assigned numerical weights to the criteria. The means of these votes were calculated. Each participant received a copy of his or her responses, depicted graphically in relation to the mean for each criterion, and was requested to confirm or

Determining clinically important differences in health status measures: a general approach with illustration to the Health Utilities Index Mark II.

BACKGROUND AND PURPOSE Indications for carotid endarterectomy have engendered considerable debate among experts and have resulted in publication of retrospective reviews, natural history studies, audits of community practice, position papers, expert opinion statements, and finally prospective randomized trials. The American Heart Association assembled a group of experts in a multidisciplinary consensus conference to develop this statement. METHODS A conference was held July 16-18, 1993, in Park City, Utah, that included recognized experts in neurology, neurosurgery, vascular surgery, and healthcare planning. A program of critical topics was developed, and each expert presented a talk and provided the chairman with a summary statement. From these summary statements a document was developed and edited onsite to achieve consensus before final revision. RESULTS The first section of this document reviews the natural history, methods of patient evaluation, options for medical management, results of surgical management, data from position statements, and results to date of prospective randomized trials for symptomatic and asymptomatic patients with carotid artery disease. The second section divides 96 potential indications for carotid endarterectomy, based on surgical risk, into four categories: (1) Proven: This is the strongest indication for carotid endarterectomy; data are supported by results of prospective contemporary randomized trials. (2) Acceptable but not proven: a good indication for operation; supported by promising but not scientifically certain data. (3) Uncertain: Data are insufficient to define the risk/benefit ratio. (4) Proven inappropriate: Current data are adequate to show that the risk of surgery outweighs any benefit. CONCLUSIONS Indications for carotid endarterectomy in symptomatic good-risk patients with a surgeon whose surgical morbidity and mortality rate is less than 6% are as follows. (1) Proven: one or more TIAs in the past 6 months and carotid stenosis > or = 70% or mild stroke within 6 months and a carotid stenosis > or = 70%; (2) acceptable but not proven: TIAs within the past 6 months and a stenosis 50% to 69%, progressive stroke and a stenosis > or = 70%, mild or moderate stroke in the past 6 months and a stenosis 50% to 69%, or carotid endarterectomy ipsilateral to TIAs and a stenosis > or = 70% combined with required coronary artery bypass grafting; (3) uncertain: TIAs with a stenosis < 50%, mild stroke and stenosis < 50%, TIAs with a stenosis < 70% combined with coronary artery bypass grafting, or symptomatic, acute carotid thrombosis; (4) proven inappropriate: moderate stroke with stenosis < 50%, not on aspirin; single TIA, < 50% stenosis, not on aspirin; high-risk patient with multiple TIAs, not on aspirin, stenosis < 50%; high-risk patient, mild or moderate stroke, stenosis < 50%, not on aspirin; global ischemic symptoms with stenosis < 50%; acute dissection, asymptomatic on heparin. Indications for carotid endarterectomy in asymptomatic good-risk patients performed by a surgeon whose surgical morbidity and mortality rate is less than 3% are as follows. (1) Proven: none. As this statement went to press, the National Institute of Neurological Disorders and Stroke issued a clinical advisory stating that the Institute has halted the Asymptomatic Carotid Atherosclerosis Study (ACAS) because of a clear benefit in favor of surgery for patients with carotid stenosis > or = 60% as measured by diameter reduction. When the ACAS report is published, this indication will be recategorized as proven. (2) acceptable but not proven: stenosis > 75% by linear diameter; (3) uncertain: stenosis > 75% in a high-risk patient/surgeon (surgical morbidity and mortality rate > 3%), combined carotid/coronary operations, or ulcerative lesions without hemodynamically significant stenosis; (4) proven inappropriate: operations with a combined stroke morbidity and mortality > 5%.