Michael E. Mussolino

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

Risk Factors for Hip Fracture in White Men: The NHANES I Epidemiologic Follow‐up Study

This prospective population‐based study assessed predictors of hip fracture risk in white men. Participants were members of the Epidemiologic Follow‐up Study cohort of the First National Health and Nutrition Examination Survey, a nationally representative sample of noninstitutionalized civilians who were followed for a maximum of 22 years. A cohort of 2879 white men (2249 in the nutrition and weight‐loss subsample, 1437 in the bone density subsample) aged 45–74 years at baseline (1971–1975) were observed through 1992. Ninety‐four percent of the original cohort were successfully traced. Hospital records and death certificates were used to identify a total of 71 hip fracture cases (61 in the nutrition and weight‐loss subsample, 26 in the bone‐density subsample). Among the factors evaluated were age at baseline, previous fractures other than hip, body mass index, smoking status, alcohol consumption, nonrecreational physical activity, weight loss from maximum, calcium intake, number of calories, protein consumption, chronic disease prevalence, and phalangeal bone density. The risk adjusted relative risk (RR) of hip fracture was significantly associated with presence of one or more chronic conditions (RR = 1.91, 95% confidence interval [CI] = 1.19–3.06), weight loss from maximum ≥ 10% (RR = 2.27, 95% CI 1.13–4.59), and 1 SD change in phalangeal bone density (RR = 1.73, 95% CI 1.11–2.68). No other variables were significantly related to hip fracture risk. Although based on a small number of cases, this is one of the first prospective studies to relate weight loss and bone density to hip fracture risk in men.

Serum 25‐Hydroxyvitamin D and Hip Fracture Risk in Older U.S. White Adults

We used serum 25(OH)D data from NHANES III and incident hip fracture cases identified using linked mortality and Medicare records, and found that serum 25(OH)D was significantly related to reduced hip fracture risk in non‐Hispanic white adults ≥65 yr of age.

Coronary Heart Disease Incidence and Survival in African-American Women and Men: The NHANES I Epidemiologic Follow-up Study

Since a series of reviews and symposia in the early 1980s stimulated interest in and funding for studies of the clinical epidemiology of coronary heart disease in African-American persons [1-3], a considerable amount of new knowledge about the subject has accumulated. Many erroneous or outdated clinical concepts (for example, that coronary heart disease is rare or uncommon in African-American persons) have been put to rest [4-8]. In contrast to the many reports on white populations from the Framingham Study and other studies, the number of reports on the incidence of coronary heart disease from prospective, longitudinal studies of population-based cohorts of African-American women and men remains small [9]. Compared with white persons, African-American persons have higher rates of death from coronary heart disease at younger ages and lower rates after middle age; this makes examination of incidence data within age groups very important [1-5]. Such data are almost completely lacking, however, and several questions of vital importance to clinicians therefore remain incompletely answered. We analyzed data from a national cohort that was followed for 22 years to test the following hypotheses: 1) The incidence of first myocardial infarction or coronary heart disease or the rate of death from coronary heart disease in African-American persons differs from that in white persons, 2) these differences cannot be completely explained by standard risk factors for coronary heart disease and socioeconomic status, 3) survival after the first hospitalization for coronary heart disease among African-American persons differs from that among white persons, and 4) the incidence of coronary procedures done during or after hospitalization for coronary heart disease among African-American persons differs from that among white persons. Methods The first National Health and Nutrition Examination Survey (NHANES I) collected data from 1971 to 1975 on a nationwide probability sample of the civilian noninstitutionalized population of the United States (excluding Alaska, Hawaii, and reservation lands of American Indians) aged 1 to 74 years [10, 11]. Details of the plan, sample design, response rates, and the manner in which the study was conducted are published elsewhere, as are the procedures used to obtain informed consent and maintain confidentiality [10, 11]. Elderly persons, women of childbearing age, and persons residing in poverty areas were oversampled. The NHANES I Epidemiologic Follow-up Study is a longitudinal study of participants in NHANES I who were 25 to 74 years of age when the survey was conducted [12-17]. The personal interviews and physical and laboratory examinations of NHANES I provided the baseline data for the Follow-up Study. This analysis is based on four waves of follow-up data collection done in 1982 to 1984, 1986, 1987, and 1992. Information was obtained from an interview, medical records from health care facilities for the period between baseline and last follow-up interview, and death certificates for all decedents. A study that used both Medicare data and data from the follow-up study found that the follow-up study detected 80% of the hospital stays for coronary heart disease that were detected by either source [17]. This analysis included African-American and white persons who were 25 to 74 years of age at baseline for NHANES I. Of the 14 183 persons who were in this age group at baseline, 775 (5.5%) were lost to follow-up because they or their proxy was not interviewed during any follow-up wave or because no death certificate was available. Excluded from all analyses were 983 persons with unknown baseline history of heart disease, systolic blood pressure, serum cholesterol level, smoking status, family income, or level of education. Also excluded from analyses of coronary heart disease were 1019 persons who had a history of heart disease at baseline; these patients were defined as those who had ever been told by a physician that they had had a heart attack or heart failure or who had used any medicine, drugs, or pills for a weak heart during the 6 months before the baseline interview. After all exclusions, 11 406 persons examined at NHANES I survey locations 1 through 99 remained for analyses of coronary heart disease. The length of follow-up in the NHANES I Epidemiologic Follow-up Study for survivors who were free of coronary heart disease ranged from 8.0 to 22.1 years (median, 19.2 years). Incident cases of coronary heart disease met at least one of the following criteria: 1) the death certificate on which the underlying or primary cause of death was coded with ICD-9 [International Classification of Diseases, Ninth Revision] codes 410 through 414 or 2) there were one or more hospital stays during the follow-up period for which any discharge diagnosis was coded with ICD-9-CM (ICD-9, Clinical Modification) codes 410 to 414. An ICD-9-CM code of 410 served to identify incident cases of acute myocardial infarction that required hospitalization among the discharge diagnoses from the first recorded hospitalization in which coronary heart disease was the discharge diagnosis. Persons who were hospitalized for coronary heart disease that was not related to acute myocardial infarction were not considered to be at risk for subsequent incident cases of acute myocardial infarction requiring hospitalization. The date of occurrence was estimated as the date of first hospital admission with a diagnosis of coronary heart disease or the date of death for persons who died of coronary heart disease and whose hospital records did not list a diagnosis of coronary heart disease. For mortality analyses, cause of death was defined by the underlying cause of death: coronary heart disease with ICD-9 codes 410 to 414. Baseline Variables Blood samples were obtained, and frozen serum was sent to the Centers for Disease Control and Prevention for measurement of serum total cholesterol levels [10, 18]. The baseline questionnaire on medical history included questions about selected conditions and about medications used for these conditions during the preceding 6 months [10]. Ethnic group (race, designated black, white, and other) was determined by interviewer observation. A revised race variable was created during the 1982-1984 follow-up period to resolve discrepancies between the race observed by the NHANES I interviewer and the race reported by the respondent during the 1982-1984 follow-up period. Revised race codes were based on a case-by-case adjudication. At the beginning of the baseline physical examination, the physician measured the blood pressure with the examinee seated [10]. Information on smoking status was obtained at baseline for the subsample (approximately 50% of the whole) that underwent a more detailed baseline examination, as described elsewhere [10, 11]. For the remaining persons, information on smoking status at baseline was derived from responses to follow-up questions on lifetime smoking history or was imputed [19, 20]. The validity of this approach has been documented [19, 20]. Other baseline variables were measured as described elsewhere [10]. Statistical Analysis For the 25- to 54-, 55- to 64-, and 65- to 74-year-old age groups, approximate plots of cumulative probabilities of survival without coronary heart disease were based on Kaplan-Meier statistics calculated using the LIFETEST procedure in SAS software [21, 22]. Age-adjusted and risk-adjusted estimates of the risk for coronary heart disease in African-American persons relative to white persons were derived from Cox proportional-hazards regression models that were computed by using the PHREG procedure in SAS software [23, 24]. Separate analyses were done for groups categorized by age at baseline and sex. Results are shown for models that included age at baseline in single years and age plus other confounders, entered as continuous variables (systolic blood pressure, serum cholesterol level) or as indicator variables (history of current smoking, level of education < 12 years, family income <

Depression and hip fracture risk: the NHANES I epidemiologic follow-up study

5000). Modification of the effect of ethnic group according to age or education was assessed in regression models and is reported only if the modification was significant. In the incidence analyses, duration of follow-up was calculated as the time from the date of examination to the date of coronary event or, for participants who did not have a coronary event, the date of last follow-up interview or death. For analyses of coronary disease-related mortality, participants whose underlying cause of death was a condition other than coronary heart disease were censored on their date of death; survivors were censored on the date of the last follow-up interview with the participant or proxy [24]. For analysis of survival after first diagnosis of coronary heart disease, 1858 persons who were hospitalized at least once and had a discharge diagnosis of coronary heart disease (ICD-9-CM codes 410 to 414) were followed from the date of the first recorded hospitalization for which the discharge diagnosis was coronary heart disease until death or the last follow-up contact. Duration of follow-up ranged from 0 days to 20.4 years (median, 4.2 years). Kaplan-Meier curves were examined and Cox proportional-hazards regression models were computed to obtain estimates of risk for death from all causes for African-American persons relative to white persons; these models controlled for age at first hospitalization for coronary heart disease and a discharge diagnosis of acute myocardial infarction at the first hospitalization for coronary heart disease. Separate models were run for men and women, for admission ages 25 to 64 years and 65 years and older, and for all admission ages combined. Survivors were censored on the date of the last follow-up interview with the participant or proxy. For analysis of coronary procedures, incidence rates per 1000 person-years were computed among persons who we

Diabetes mellitus, coronary heart disease incidence, and death from all causes in African American and European American women: The NHANES I epidemiologic follow-up study.

Objective. Since hip fracture is the most devastating consequence of osteoporosis from a public health standpoint, addressing whether depression is predictive of fracture risk is important. The purpose of this study is to determine whether individuals with high depressive symptomatology are more likely to suffer an osteoporotic hip fracture than subjects with intermediate or low depressive symptomatology. Methods. Data from the first National Health and Nutrition Examination Survey (NHANES I) were obtained from a nationally representative sample of noninstitutionalized civilians. A cohort aged 25 through 74 at baseline (1971–1975) was observed through 1992. Subjects were followed-up for a maximum of 22 years. Included in the analyses were 6,195 white and black subjects. Ninety-five percent of the original cohort completed the study. Hospital records and death certificates were used to identify a total of 122 hip fracture cases. Results. In an unadjusted Cox proportional hazards regression model for all individuals, depression was predictive of hip fracture (hazard ratio [HR] = 1.90; 95% confidence interval [CI] = 1.13, 3.21; p=0.016). In a multivariate proportional hazards model controlling for (1) age at baseline, (2) gender, (3) race, (4) body mass index, (5) smoking status, (6) alcohol consumption, and (7) physical activity level, high depressive symptomatology remained predictive of hip fracture (HR=1.70; 95% CI=0.99, 2.91; p=0.055). Conclusions. This study gives evidence of a prospective association between depression and hip fracture. Additional studies are needed to verify these findings and to elucidate the pathways for the effects of depression on hip fracture incidence.

Body fat distribution and hypertension incidence in women and men. The NHANES I Epidemiologic Follow-up Study

Few data are available on risk for coronary heart disease in African American women with diabetes mellitus, a well-established coronary risk factor in European American women. This study tests the hypothesis that medical history of diabetes predicts coronary heart disease incidence in African American women in a national cohort. Participants in the NHANES I Epidemiologic Follow-up Study in this analysis were 1035 African American and 5732 European American women aged 25-74 years without a history of coronary heart disease. Average follow-up for survivors was 19 years (maximum 22 years). Risk of incident coronary heart disease by baseline diabetes status was estimated. Proportional hazards analyses for African American women aged 25-74 revealed significant associations of coronary heart disease risk with diabetes after adjusting for age (RR = 2.40; 95% CI, 1.58-3.64, P < 0.01). After adjusting for age, smoking, and low education, there was an elevated risk in diabetics age 25-74 (RR = 2. 34; 95% CI, 1.54-3.56, P < 0.01); this association did not differ significantly from that for European American women. Excess coronary incidence in African American compared to European American women aged 25-64 was statistically explained by controlling for diabetes history, age, education, and smoking but only partly explained by age and diabetes history. In African American women aged 25-74, diabetes was also associated with increased coronary heart disease, cardiovascular, and all-cause mortality. The population attributable risk of coronary heart disease incidence associated with a medical history of diabetes was 8.7% in African American women and 6.1% in European American women. Medical history of diabetes was a significant predictor of coronary heart disease incidence and mortality in African American women and explained some of the excess coronary incidence in younger African American compared to European American women.

The relation between fish consumption, death from all causes, and incidence of coronary heart disease: the NHANES I Epidemiologic Follow-up Study

OBJECTIVE: To test the hypothesis that an elevated ratio of subscapular to triceps skinfold thickness (SFR), one measure of truncal obesity, is associated with increased incidence of essential hypertension.DESIGN: Data from the NHANES I Epidemiologic Follow-up Study (NHEFS) were analyzed.SUBJECTS: A cohort of 4303 women and 2579 men with complete data who were normotensive at baseline in 1971–1975.MEASUREMENTS: Incidence of hypertension, blood pressure 160/95 mm Hg or greater or on blood pressure medication at follow-up in 1982–1984.RESULTS: There was a statistically significant increase in risk of hypertension over approximately 10 y follow-up in white women aged 25–74 y with SFR in the fifth compared to the first quintile independent of age and body mass index (BMI) (relative risk=1.52, 95% confidence interval 1.13–2.06, P=0.006). The association was somewhat diminished after controlling for baseline blood pressure, change in BMI and other risk variables. An even stronger association was seen for subscapular skinfold and hypertension incidence. In white men aged 25–74 y, a significant association of high SFR with age-, BMI-adjusted risk of hypertension was seen (RR=1.41, 95% CI 1.01–1.96, P=0.04). Data for black women or black men failed to reveal significant variation in hypertension risk among quintiles of SFR or subscapular skinfold except in black women with low baseline BMI.CONCLUSIONS: Data from NHEFS confirm the association of higher truncal obesity with increased incidence of hypertension in white women. Further studies are needed, especially in larger samples of black women.

Bone mineral density and mortality in women and men: the NHANES I epidemiologic follow-up study.

1 time/week (adjusted relative risk 0.85, 95% CI 0.68-1.06). Similar but nonsignificant trends were seen in white and black women, but not black men. In white men, risk of noncardiovascular death but not cardiovascular death was also significantly reduced in those consuming fish once or more a week. No consistent association of fish consumption and coronary heart disease incidence or mortality was seen. White men consuming fish once a week had significantly lower risk of death over a 22-year follow-up than those never consuming fish. This was mostly attributable to reductions in death from noncardiovascular causes. Similar patterns, though not significant, were seen in women. Further studies are needed to confirm these findings and to elucidate mechanisms for the effect of fish consumption on noncardiovascular mortality.

Depression and Bone Mineral Density in Young Adults: Results From NHANES III

PURPOSE We sought to assess the long-term association of bone mineral density with total, cardiovascular, and non-cardiovascular mortality. METHODS The First National Health and Nutrition Examination Survey data were obtained from a nationally representative sample of non-institutionalized civilians. A cohort aged 45 through 74 years at baseline (1971-1975) was observed through 1992. Subjects were followed for a maximum of 22 years. Included in the analyses were 3501 white and black subjects. Death certificates were used to identify a total of 1530 deaths. RESULTS Results were evaluated to determine the relative risk for death per 1 SD lower bone mineral density, after controlling for age at baseline, smoking status, alcohol consumption, history of diabetes, history of heart disease, education, body mass index, recreational physical activity, and blood pressure medication. Bone mineral density showed a significant inverse relationship to mortality in white men and blacks, but did not reach significance in white women. Based on 1 SD lower bone mineral density, the relative risk for white men was 1.16 (95% confidence interval (CI), 1.07-1.26, p<.01), while for white women the relative risk was 1.10 (95% CI, 0.99-1.23, p=.07), and in blacks the relative risk was 1.22 (95% CI, 1.05-1.42, p<.01). Bone mineral density was also associated with non-cardiovascular mortality in all three race-gender groups. An association between bone mineral density and cardiovascular mortality was found only in white men. CONCLUSIONS Bone mineral density is a significant predictor of death from all causes (white men, blacks), cardiovascular (white men only) and other causes combined, in whites and blacks.