Abstract
Introduction:
This study evaluated recent trends in the prevalence of coronary heart disease in the U.S. population aged ≥40 years.
Methods:
A total of 21,472 adults aged ≥40 years from the 2001–2012 National Health and Nutrition Examination Survey were included in the analysis. The analysis was conducted in 2015. Coronary heart disease included myocardial infarction, angina, and any other type of coronary heart disease, which were defined as a history of medical diagnosis of these specific conditions. Angina was also defined as currently taking anti-angina medication or having Rose Angina Questionnaire responses that scored with a Grade ≥1. Trends from 2001 to 2012 were analyzed overall, within demographic subgroups, and by major coronary heart disease risk factors.
Results:
Between 2001 and 2012, the overall prevalence of coronary heart disease significantly decreased from 10.3% to 8.0% (p-trend<0.05). The prevalence of angina significantly decreased from 7.8% to 5.5% and myocardial infarction prevalence decreased from 5.5% to 4.7% (p-trend <0.05 for both groups). Overall coronary heart disease prevalence significantly decreased among women, adults aged >60 years, non-Hispanic whites, non-Hispanic blacks, adults who did not complete high school, adults with more than a high school education, and adults who had health insurance (p-trend <0.05 for all groups).
Conclusions:
The overall prevalence of coronary heart disease including angina and myocardial infarction decreased significantly over the 12-year survey period. However, this reduction was seen mainly among persons without established coronary heart disease risk factors. There was no change in coronary heart disease prevalence among those with specific coronary heart disease risk factors. (Am J Prev Med 2016;51(4):437–445) Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine
Introduction
Coronary heart disease (CHD), defined as angina; myocardial infarction (MI); and related disorders of the coronary arteries, is a leading cause of death in the U.S.1 A substantial burden of morbidity and mortality due to CHD is attributable to modifiable and treatable risk factors such as hypertension, dyslipidemia, smoking, diabetes, obesity, and overweight.2,3 Recent trends in the prevalence of CHD risk factors have shown a mixed picture: The prevalence of smoking has significantly decreased,4 but the prevalence of obesity has not changed and diabetes has increased.5,6 The prevalence of high blood pressure and measured abnormal cholesterol has not changed in the last 12 years, but control rates among those with hypertension and hypercholesterolemia have significantly improved over this time period.7-9 Increasing awareness, treatment, and reduction of CHD risk factors may have contributed to an overall decrease in CHD mortality.10,11 Further, the use of medical and surgical treatments has resulted in an overall decline in CHD-related deaths.10,11 Several reports have assessed recent trends in U.S. mortality attributable to CHD,2,3 yet comparatively less is known about recent trends in CHD and, specifically, MI and angina. The objectives of the present study were to use the most recently available data from the National Health and Nutrition Examination Survey (NHANES) to estimate recent U.S. trends in the prevalence of CHD overall, and MI and angina specifically, as well as provide trends according to demographic characteristics and selected CHD risk factors.
Methods
The NHANES has a complex, multistage sample design and is representative of the non-institutionalized civilian U.S. population.12 NHANES data collection consists of an initial health interview carried out in the respondent’s home and then a health examination in a mobile examination center. The interview contains questions on sociodemographic characteristics (age, gender, education, race/Hispanic origin, and health insurance) and questions on previously diagnosed medical conditions. More detailed information on the NHANES is available elsewhere.12 Informed consent was obtained from all adult participants, and the National Center for Health Statistics Research Ethics Review Board approved the protocol. This study was based on analysis of data for six 2-year NHANES survey cycles: 2001–2002, 2003–2004, 2005–2006, 2007–2008, 2009–2010, and 2011–2012. Overall interview response rates for these years ranged from 73% to 84%, and examination response rates ranged from 70% to 80%.13
Measures
The study variable for overall CHD was defined as a person who had angina and MI. Participants were classified as having an MI or other CHD if they answered affirmatively to ever having been told by a doctor or other health professional that they had a heart attack (also called MI). Participants were classified as having angina if they answered affirmatively to ever having been told they had angina, also called angina pectoris, or if they reported use of a prescription anti-angina medication in the past 30 days or had undiagnosed angina based on Rose Angina Questionnaire (Grade ≥1). Use of anti-angina medication prescriptions in the past 30 days was obtained during the in-person household interview using a medication inventory method. Participants who reported the use of the following anti-angina medications were classified with angina: nitroglycerin, isosorbide dinitrate, and isosorbide mono-nitrate. Further details of the NHANES prescription drug data collection are reported elsewhere.14,15 The Rose Angina Questionnaire uses an individual’s chest pain symptom history to define angina cases. This instrument is widely used in epidemiologic studies as a validated, standardized method for defining angina pectoris in the general population. The validity of this instrument has been assessed in a number of studies,16-18 comparing it with a clinical diagnosis of angina, electrocardiogram abnormalities, and as a predictor of mortality due to coronary artery disease. This allowed the study angina case definition to include undiagnosed as well as diagnosed cases. Congestive heart failure was not included in the definition of CHD in the present analysis.
Demographic variables were categorized as age (40–59 and ≥60 years); gender (male, female); education (less than high school, high school graduate [including GED], and more than high school); race/Hispanic origin (non-Hispanic white, non-Hispanic black, and Mexican American); and health insurance status (insured, not insured). Because of the relatively small sample sizes, participants of other race/Hispanic origins were included in overall prevalence estimates but not reported separately.
The major CHD risk factors that were included in the analysis were hypertension, hypercholesterolemia, BMI, diabetes, and cigarette smoking. Using the NHANES health examination data, hypertension was defined as systolic blood pressure ≥140 mmHg, diastolic blood pressure ≥90 mmHg, or participant report of currently taking medication to lower high blood pressure.19 Hypercholesterolemia was defined as a measured total serum cholesterol of ≥240 mg/dL or self-report of currently taking medication to lower cholesterol.20
Although BMI is not currently considered a primary CHD risk factor, it is an accepted risk factor for diabetes and hypertension and was therefore included in the temporal trend reporting. BMI was calculated as measured weight in kilograms divided by height in meters squared rounded to the nearest tenth, and categorized as <18.5, underweight; 18.5–24.9, normal weight; 25.0–29.9, over-weight; and ≥30, obese. Owing to small sample sizes, people in the underweight category were included in total estimates but not reported separately. Diagnosed diabetes mellitus was defined by self-report of a healthcare provider diagnosis of diabetes. Current cigarette smoking was defined as having smoked at least 100 cigarettes during one’s lifetime and currently smoking every day or some days.
From 2001 to 2012, a total of 21,604 adults aged ≥40 years were both interviewed and examined. After excluding those with missing or invalid values for the questions defining CHD (n=132), 21,472 adults were included in the analysis. A total of the missing or invalid values were 34, 17, 20, 19, 25, and 17 from 2001–2002 to 2011–2012 in each survey period.
Statistical Analysis
Statistical analyses were conducted in 2015 using SAS, version 9.3, and SUDAAN, version 11.0. Examination sample weights that adjusted for differential selection probabilities, non-response, and non-coverage were used to produce estimates representative of the non-institutionalized civilian U.S. population. Age-adjusted prevalence estimates were calculated for gender, age, education level, race/ethnicity, health insurance categories, and selected risk factors using SUDAAN Proc Descript and the 2000 projected U.S. population age groups for 40–59 and ≥60 years.21 SEs of the prevalence estimates were estimated by Taylor Series linearization, a design-based approach. Statistical hypotheses were tested (univariately) using a two-tailed Student’s t-test at the α=0.05 level.22 Trends in CHD, MI, and angina by demographic characteristics and selected CHD risk factors were tested univariately using orthogonal contrast matricies.23 Statistical hypotheses were tested at α=0.05 using a Satterthwaite adjusted F-test.
Results
Table 1 presents age-adjusted CHD prevalence estimates from 2001 to 2012 by selected demographic variables. The prevalence of CHD among adults aged ≥40 years significantly decreased from 10.3% in 2001–2002 to 8.0% in 2011–2012 (p-trend <0.05). For women, there was a significant decreasing trend in CHD prevalence from 8.5% in 2001–2002 to 6.2% in 2011–2012 (p-trend < 0.05). Over the 12-year period, there was no significant change in CHD prevalence among adults aged 40–59 years, but there was a significant decreasing trend among those aged ≥60 years: from 19.5% in 2001–2002 to 14.9% in 2011–2012. CHD prevalence significantly decreased among non-Hispanic white and non-Hispanic black adults (p-trend <0.05 for both groups) but showed no change for Mexican American adults. Significant declines in CHD prevalence were also seen among adults who did not complete high school, adults with more than a high school education, and adults who had health insurance (p-trend <0.05 for all groups).
Table 1.
Age-Adjusted and Age-Specific Prevalence of CHD by Demographic Characteristics: Adults Aged ≥40 Years
| CHDa | |||||||
|---|---|---|---|---|---|---|---|
| Sociodemographic characteristics |
2001–2002, % (SE) (n=3,452) |
2003–2004, % (SE) (n=3,282) |
2005–2006, % (SE) (n=3,036) |
2007–2008, % (SE) (n=4,006) |
2009–2010, % (SE) (n=4,110) |
2011–2012, % (SE) (n=3,586) |
p-trend |
| Overall | 10.3 (0.8) | 11.0 (1.0) | 9.6 (0.6) | 8.7 (0.5) | 8.4 (0.5) | 8.0 (0.4) | 0.001 ** |
| Gender | |||||||
| Men | 12.4 (1.1) | 13.5 (1.5) | 12.1 (0.8) | 11.4 (0.8) | 11.6 (0.7) | 10.1 (0.7) | 0.06 |
| Women | 8.5 (0.9) | 8.9 (1.0) | 7.7 (0.9) | 6.4 (0.5) | 5.6 (0.5) | 6.2 (0.5) | <0.001** |
| Age (years) | |||||||
| 40–59 | 4.6 (1.0) | 4.8 (0.8) | 4.2 (0.5) | 3.7 (0.4) | 4.4 (0.4) | 3.6 (0.6) | 0.2 |
| ≥60 | 19.5 (1.5) | 20.9 (1.7) | 18.4 (1.1) | 16.6 (1.2) | 14.7 (0.9) | 14.9 (0.8) | <0.001** |
| Race/Hispanic originb | |||||||
| Whites, non-Hispanic | 10.6 (0.9) | 11.3 (1.1) | 9.8 (0.7) | 8.6 (0.7) | 8.7 (0.6) | 8.2 (0.6) | 0.004 ** |
| Blacks, non-Hispanic | 11.0 (1.4) | 8.9 (1.1) | 11.3 (1.1) | 7.4 (1.1) | 7.9 (1.0) | 7.5 (0.7) | 0.002 ** |
| Mexican Americans | 7.9 (1.0) | 8.3 (0.8) | 7.3 (0.6) | 8.0 (0.9) | 8.1 (1.1) | 6.7 (1.9) | 0.7 |
| Education | |||||||
| Less than high school | 14.7 (1.9) | 14.5 (2.3) | 14.8 (1.4) | 11.4 (1.0) | 10.8 (1.2) | 10.0 (0.8) | 0.004 ** |
| High school diploma | 10.3 (1.5) | 10.7 (1.5) | 9.1 (1.1) | 8.9 (1.0) | 10.2 (1.0) | 9.7 (1.7) | 0.7 |
| More than high school | 8.4 (0.7) | 10.1 (0.9) | 8.1 (0.7) | 7.3 (0.5) | 6.6 (0.6) | 6.7 (0.7) | 0.001 ** |
| Health insurance | |||||||
| Yes | 10.5 (0.8) | 11.1 (1.1) | 9.6 (0.5) | 8.8 (0.6) | 8.6 (0.5) | 8.0 (0.6) | 0.002 ** |
| No | 6.8 (1.8) | 8.7 (2.4) | 9.7 (2.9) | 6.5 (1.1) | 7.8 (0.9) | 7.1 (1.6) | 0.5 |
Note: Boldface indicates statistical significance (*p-trend<0.05; **p-trend <0.01).
CHD was defined if the participants had at least one of the following conditions: (1) reported being diagnosed by a healthcare professional as having coronary heart disease, angina or heart attack (also called myocardial infarction); (2) reported taking anti-angina medication last 30 days; or (3) met the criteria for grade ≥1 angina by Rose Angina Questionnaire.
Other racial/ethnic groups are not shown separately.
CHD, coronary heart disease.
Overall, there were no consistent declines in CHD prevalence over the decade across all high-risk subgroups (Table 2). A significant decreasing trend in CHD was seen among overweight people (BMI=25–29). Otherwise, significant decreasing trends in CHD prevalence were only seen among those without major CHD risk factors: those without hypercholesterolemia, without hypertension, without diabetes, those of a normal weight, and those who did not currently smoke. There was no change in CHD prevalence among current smokers; obese individuals (BMI ≥30); or those with diagnosed hypertension, hypercholesterolemia, or diabetes over the 12-year study period.
Table 2.
Age-Adjusted Prevalence of CHD by Risk Factors and BMI: U.S. Adults Aged ≥40 Years
| CHDa | |||||||
|---|---|---|---|---|---|---|---|
| CHD risk factors |
2001–2002, % (SE) |
2003–2004, % (SE) |
2005–2006, % (SE) |
2007–2008, % (SE) |
2009–2010, % (SE) |
2011–2012, % (SE) |
p-trend |
| Hypercholesterolemia (n=19,165)b | |||||||
| Yes | 14.9 (1.8) | 14.4 (1.6) | 13.0 (0.7) | 12.2 (1.1) | 10.7 (1.0) | 13.1 (1.2) | 0.2 |
| No | 7.7 (0.6) | 8.7 (0.9) | 7.1 (0.8) | 5.8 (0.4) | 6.9 (0.7) | 3.6 (0.5) | <0.001** |
| Hypertension (n==19,420)c | |||||||
| Yes | 13.3 (1.6) | 13.8 (1.2) | 13.0 (1.3) | 11.8 (1.0) | 10.9 (0.7) | 11.4 (0.9) | 0.1 |
| No | 7.9 (0.6) | 8.1 (1.0) | 6.7 (0.8) | 6.0 (0.6) | 6.2 (0.8) | 4.5 (0.7) | <0.001** |
| BMI (n=19,556)d | |||||||
| 18.5–<25 | 7.1 (1.2) | 10.4 (1.4) | 6.0 (0.9) | 7.3 (0.6) | 6.0 (1.0) | 5.6 (0.8) | 0.03 * |
| 25–29 | 9.2 (1.2) | 10.6 (1.1) | 10.6 (0.8) | 7.9 (0.6) | 7.3 (0.8) | 7.0 (0.8) | 0.01 * |
| ≥30 | 13.1 (1.5) | 12.4 (1.3) | 11.2 (1.0) | 10.3 (1.4) | 11.3 (0.6) | 10.7 (0.8) | 0.06 |
| Diagnosed diabetes (n=20,405) | |||||||
| Yes | 17.6 (2.8) | 18.1 (2.8) | 20.9 (2.1) | 18.7 (1.5) | 16.4 (1.7) | 18.3 (2.7) | 0.6 |
| No | 9.0 (0.7) | 10.2 (0.8) | 8.2 (0.6) | 6.9 (0.5) | 7.2 (0.4) | 6.4 (0.5) | <0.001** |
| Current smokers (n=20,393)e | |||||||
| Yes | 10.8 (1.3) | 11.3 (1.7) | 11.0 (1.2) | 10.9 (1.3) | 11.7 (1.4) | 11.6 (1.1) | 0.7 |
| No | 9.7 (0.9) | 10.8 (1.0) | 9.1 (0.6) | 8.0 (0.6) | 7.9 (0.6) | 7.3 (0.5) | <0.001** |
Note: Boldface indicates statistical significance (*p-trend <0.05; **p-trend <0.01).
CHD was defined if the participants had at least one of the following: (1) reported being diagnosed by a healthcare professional as having coronary heart disease, angina or heart attack (also called myocardial infarction); (2) reported taking anti-angina medication last 30 days; or (3) met the criteria for grade ≥1 angina by Rose Angina Questionnaire.
Hypercholesterolemia was defined as a measured total serum cholesterol of ≥240 mg/dL or currently taking medication to lower cholesterol.
Hypertension was defined as systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg or currently taking medication.
BMI <18.5 is not shown separately.
A current cigarette smoker was defined as having smoked at least 100 cigarettes during one’s lifetime and currently smoking every day or some days.
CHD, coronary heart disease.
The prevalence of angina (diagnosed and undiagnosed) among adults significantly decreased from 7.8% in 2001–2002 to 5.5% in 2011–2012 (p-trend <0.05) (Table 3). Over this same time period, there was a significant decrease in angina prevalence for both men and women, in non-Hispanic whites and non-Hispanic blacks, in adults aged ≥40 years, in adults who had either less than or more than a high school education, and in adults who had health insurance (p-trend <0.05 for all groups). Also, there were significant changes in overall MI prevalence, from 5.5% in 2001–2002 to 4.7% in 2011–2012 (p-trend <0.05). The prevalence of MI decreased over the 12-year period in certain subgroups: women, adults aged ≥60 years, adults who had more than high school education, and in adults with health insurance (p-trend <0.05 for all groups) (Table 3).
Table 3.
Age-Adjusted and Age-Specific Prevalence of Angina and MI by Demographic Characteristics: Adults Aged ≥40 Years
| Anginaa (n=21,502) | MI (n=21,548) | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Socio- demographic characteristics |
2001– 2002, % (SE) (n =3,463) |
2003– 2004, % (SE) (n=3,281) |
2005– 2006, % (SE) (n=3,044) |
2007– 2008, % (SE) (n=4,007) |
2009– 2010, % (SE) (n=4,120) |
2011– 2012, % (SE) (n=3,587) |
p-trend | 2001– 2002, % (SE) (n =3,474) |
2003– 2004, % (SE) (n=3,289) |
2005– 2006, % (SE) (n=3,049) |
2007– 2008, % (SE) (n=4,016) |
2009– 2010, % (SE) (n=4,122) |
2011– 2012, % (SE) (n=3,598) |
p-trend |
| Overall | 7.8 (0.6) | 7.9 (0.9) | 6.9 (0.4) | 5.6 (0.5) | 5.0 (0.5) | 5.5 (0.5) | <0.001** | 5.5 (0.5) | 6.5 (0.6) | 5.6 (0.6) | 5.1 (0.4) | 4.7 (0.5) | 4.7 (0.3) | 0.04 * |
| Gender | ||||||||||||||
| Men | 8.1 (0.9) | 8.3 (1.2) | 6.8 (0.8) | 5.6 (0.5) | 5.4 (0.6) | 5.6 (0.8) | 0.01 * | 7.2 (0.7) | 8.5 (1.1) | 7.6 (0.8) | 6.9 (0.7) | 7.3 (0.7) | 5.9 (0.5) | 0.5 |
| Women | 7.1 (0.7) | 7.5 (1.0) | 6.8 (0.4) | 5.7 (0.7) | 4.5 (0.6) | 5.4 (0.5) | 0.001 ** | 4.1 (0.5) | 4.8 (0.7) | 4.0 (0.6) | 3.6 (0.3) | 2.5 (0.4) | 3.7 (0.6) | <0.001** |
| Age (years) | ||||||||||||||
| 40–59 | 4.9 (1.0) | 5.3 (1.0) | 4.0 (0.4) | 3.1 (0.4) | 3.7 (0.5) | 3.6 (0.7) | 0.03 * | 2.2 (0.6) | 3.2 (0.7) | 2.4 (0.3) | 2.1 (0.3) | 2.9 (0.5) | 2.1 (0.4) | 0.5 |
| ≥60 | 11.9 (0.8) | 11.9 (1.3) | 11.2 (1.0) | 9.7 (1.3) | 7.0 (0.6) | 7.1 (0.5) | <0.001** | 10.8 (0.9) | 11.7 (1.1) | 10.7 (1.2) | 9.8 (0.7) | 7.6 (0.8) | 8.8 (0.8) | 0.001 ** |
| Race/Hispanic originb | ||||||||||||||
| Whites, non-Hispanic | 7.5 (0.8) | 8.1 (0.9) | 6.5 (0.5) | 5.4 (0.7) | 4.7 (0.5) | 5.3 (0.7) | <0.001** | 5.8 (0.5) | 6.7 (0.7) | 5.8 (0.7) | 4.9 (0.5) | 5.0 (0.5) | 4.9 (0.5) | 0.06 |
| Blacks, non-Hispanic | 9.4 (1.0) | 5.6 (0.8) | 8.1 (0.9) | 6.2 (1.0) | 5.8 (0.8) | 6.1 (0.7) | 0.02 * | 6.0 (1.0) | 6.0 (0.9) | 5.6 (0.9) | 5.3 (0.7) | 5.0 (0.7) | 3.9 (0.6) | 0.1 |
| Mexican Americans | 5.4 (0.9) | 5.6 (1.3) | 6.4 (1.1) | 4.5 (0.6) | 5.4 (1.1) | 5.9 (2.1) | 0.7 | 4.9 (1.0) | 4.2 (0.6) | 3.1 (0.8) | 3.4 (0.7) | 4.6 (0.7) | 4.0 (1.4) | 0.3 |
| Education | ||||||||||||||
| Less than high school | 10.9 (1.7) | 11.2 (2.2) | 9.7 (1.3) | 7.5 (1.1) | 6.6 (07) | 6.9 (0.7) | 0.001 ** | 7.8 (1.3) | 9.2 (1.2) | 10.4 (1.4) | 5.1 (0.4) | 6.3 (1.2) | 6.3 (0.9) | 0.2 |
| High school diploma | 7.1 (1.4) | 7.1 (1.3) | 6.9 (0.7) | 6.3 (0.9) | 7.3 (0.8) | 6.6 (1.0) | 0.7 | 5.5 (0.9) | 5.8 (0.9) | 5.7 (0.9) | 5.2 (0.5) | 6.3 (0.9) | 5.5 (1.3) | 0.8 |
| More than high school | 6.4 (0.6) | 7.1 (0.7) | 5.7 (0.6) | 4.6 (0.5) | 3.2 (0.6) | 4.6 (0.6) | <0.001** | 4.4 (0.4) | 5.7 (0.7) | 3.9 (0.7) | 3.9 (0.5) | 3.4 (0.4) | 3.9 (0.4) | 0.01 * |
| Health insurance | ||||||||||||||
| Yes | 7.6 (0.6) | 7.9 (0.8) | 6.5 (0.4) | 5.6 (0.5) | 5.2 (0.4) | 5.2 (0.4) | <0.001** | 5.6 (0.5) | 6.5 (0.7) | 5.6 (0.6) | 5.1 (0.3) | 4.8 (0.4) | 4.8 (0.5) | 0.04 * |
| No | 4.7 (1.5) | 6.3 (2.0) | 10.4 (2.3) | 5.0 (1.6) | 3.0 (0.9) | 7.6 (1.4) | 0.4 | 4.6 (1.3) | 6.1 (2.3) | 4.9 (2.9) | 5.5 (1.2) | 4.2 (1.6) | 4.3 (1.7) | 0.3 |
Note: Boldface indicates statistical significance (*p-trend <0.05; **p-trend <0.01).
Angina was defined if the participant had at least one of the following conditions: (1) reported being diagnosed by a healthcare professional; (2) reported taking anti-angina medication in the last 30 days; or (3) having met the criteria for grade ≥1 angina by Rose Angina Questionnaire.
Other racial/ethnic groups are not shown separately.
MI, myocardial infarction.
Table 4 presents the age-adjusted prevalence of angina and MI by major CHD risk factors. During the 12-year period, there was a significant decreasing trend in the prevalence of angina among both adults with normal and those with elevated total cholesterol levels, in adults without hypertension, at all defined levels of BMI, in non-smoking adults, and among those without diabetes (p-trend <0.05 for all groups). Also, there was a significant decreasing trend in the prevalence of MI among adults who were overweight, non-hypertensive, non-diabetic, and non-smokers (p-trend <0.05 for all groups).
Table 4.
Age-Adjusted Prevalence of Angina and MI by CHD Risk Factors and BMI: Adults Aged ≥40 Years
| Anginaa | MI | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| CHD risk factors | 2001≥ 2002, % (SE) |
2003– 2004, % (SE) |
2005– 2006, % (SE) |
2007– 2008, % (SE) |
2009– 2010, % (SE) |
2011– 2012, % (SE) |
p-trend | 2001– 2002, % (SE) |
2003– 2004, % (SE) |
2005– 2006, % (SE) |
2007– 2008, % (SE) |
2009– 2010, % (SE) |
2011– 2012, % (SE) |
p-trend |
| Hypercholesterolemia (n=12,631)b | ||||||||||||||
| Yes | 11.1 (1.4) | 9.8 (1.0) | 9.6 (0.6) | 7.8 (0.8) | 6.3 (0.9) | 8.8 (1.3) | 0.03 * | 7.9 (1.1) | 9.0 (1.0) | 7.8 (0.8) | 6.7 (0.7) | 5.9 (0.9) | 7.8 (0.8) | 0.3 |
| No | 6.1 (0.5) | 6.5 (1.0) | 5.1 (0.7) | 3.8 (0.5) | 4.0 (0.4) | 2.1 (0.7) | 0.002 ** | 3.7 (0.3) | 5.0 (0.7) | 4.2 (0.7) | 3.6 (0.4) | 4.2 (0.6) | 1.2 (0.4) | 0.08 |
| Hypertension (n=19,486)c | ||||||||||||||
| Yes | 11.9 (1.6) | 9.8 (1.4) | 8.7 (1.0) | 7.9 (0.9) | 7.9 (1.0) | 8.7 (1.2) | 0.07 | 6.2 (0.9) | 7.9 (0.9) | 7.6 (1.0) | 6.8 (0.7) | 5.9 (0.6) | 6.3 (0.6) | 0.4 |
| No | 5.4 (0.4) | 5.1 (0.7) | 5.8 (0.8) | 4.3 (0.6) | 2.5 (0.3) | 2.8 (0.4) | <0.001** | 4.4 (0.6) | 5.1 (0.6) | 4.4 (0.5) | 3.7 (0.4) | 4.1 (0.7) | 3.0 (0.5) | 0.003 ** |
| BMI (n=19,620)d | ||||||||||||||
| 18.5–<25 | 4.3 (0.9) | 7.7 (1.8) | 4.8 (0.6) | 4.2 (1.0) | 2.7 (0.7) | 3.1 (1.0) | 0.01 * | 3.0 (0.6) | 5.6 (1.1) | 3.7 (0.7) | 4.3 (0.6) | 3.0 (0.5) | 3.4 (0.8) | 0.5 |
| 25–29 | 7.1 (0.6) | 6.3 (1.0) | 7.9 (0.9) | 4.4 (0.6) | 3.7 (0.6) | 4.5 (0.7) | <0.001** | 5.1 (0.9) | 6.2 (0.7) | 6.1 (0.8) | 4.4 (0.7) | 3.7 (0.5) | 4.0 (0.6) | 0.03 * |
| ≥30 | 11.5 (1.1) | 9.5 (0.9) | 7.2 (1.2) | 7.9 (1.1) | 7.8 (0.7) | 8.1 (1.0) | <0.001** | 6.2 (0.9) | 7.8 (1.0) | 6.5 (0.9) | 6.5 (0.7) | 7.0 (0.7) | 6.2 (0.5) | 0.6 |
| Diagnosed diabetes (n=20,476) | ||||||||||||||
| Yes | 17.2 (3.3) | 15.1 (3.6) | 13.1 (1.4) | 10.9 (1.5) | 11.0 (1.9) | 12.6 (2.4) | 0.2 | 10.6 (2.5) | 10.8 (1.7) | 13.6 (2.4) | 10.8 (0.9) | 10.2 (1.6) | 9.3 (1.6) | 0.6 |
| No | 6.6 (0.4) | 6.9 (0.6) | 6.1 (0.4) | 4.7 (0.4) | 4.1 (0.3) | 4.2 (0.5) | <0.001** | 4.3(0.4) | 5.9 (0.6) | 4.7 (0.5) | 4.3 (0.4) | 4.0 (0.4) | 4.0 (0.4) | 0.01 * |
| Current smokers (n=20,466)e | ||||||||||||||
| Yes | 6.9 (1.3) | 9.5 (2.0) | 8.6 (1.2) | 6.0 (1.3) | 7.6 (1.0) | 7.6 (0.9) | 0.2 | 6.5 (1.5) | 9.0 (1.5) | 6.6 (1.2) | 6.8 (0.7) | 7.4 (1.3) | 8.3 (1.5) | 0.5 |
| No | 7.6 (0.6) | 7.1 (0.8) | 6.3 (0.6) | 5.5 (0.5) | 4.4 (0.3) | 5.0 (0.6) | <0.001** | 4.6 (0.4) | 6.0 (0.6) | 5.4 (0.7) | 4.6 (0.4) | 4.4 (0.4) | 3.9 (0.3) | 0.001 ** |
Note: Boldface indicates statistical significance (*p-trend <0.05; **p-trend <0.01).
Angina was defined if the participant had at least one of the following conditions: (1) reported being diagnosed by a healthcare professional; (2) reported taking anti-angina medication in the last 30 days; or (3) met the criteria for grade 1 angina by Rose Angina Questionnaire.
Hypercholesterolemia was defined as a measured total serum cholesterol of ≥240 mg/dL or currently taking medication to lower cholesterol.
Hypertension was defined as systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg or currently taking medication.
BMI <18.5 is not shown separately.
A current cigarette smoker was defined as having smoked at least 100 cigarettes during one’s lifetime and currently smoking every day or some days.
CHD, coronary heart disease; MI, myocardial infarction.
Discussion
Between 2001 and 2012, there was a significant downward trend in the prevalence of CHD. The prevalence of angina and MI significantly decreased over the 12-year survey period. The decreasing prevalence of CHD (including angina and MI) might result from a combination of prevention efforts and improvements in the management of risk factors. In addition, supporting results from Carroll et al.24 showed significant decreasing trends from 1988 to 2010 in the level of total, highdensity lipoprotein, and low-density lipoprotein cholesterol in both adults who were taking cholesterol-lowering medications and those who were not taking any medications.Reasons for a reduction in the prevalence of CHD, angina, and MI in the lower CHD–risk groups could relate to general trends in lifestyle changes, such as improved diet, increased level of physical activity, or other factors such as prophylactic aspirin use among U.S. adults.24,25 Furthermore, anti-smoking prevention efforts have resulted in a decreased prevalence of cigarette smoking, which may have contributed to the decrease in CHD prevalence.4 The contribution of lifestyle changes including physical activity, weight loss, and diet improvement in addition to medication use to control risk factors to reduce the CHD prevalence needs be investigated.
Improvements in the management of CHD risk factors are likely to contribute to overall decreasing CHD prevalence that has occurred.26 Treatment and control of high blood pressure have significantly increased during the last 12 years.8,27,28 Also, mean total cholesterol in the U.S. population has decreased, likely due to the increased use of statins to lower cholesterol over the last 10 years.25,29,30 Despite the fact that the prevalence of diabetes has increased, overall control of glucose levels in the general population has improved significantly.31-34 Previous research has shown that among diabetic individuals with hypertension, the proportion who were treated with medication, lifestyle, or behavioral modification therapy increased significantly from 76.5% to 87.8% between NHANES III (1988–1994) and NHANES 1999–2004,30 and the proportion with controlled blood pressure increased from 15.9% to 51.9% between NHANES III (1988–1994) and NHANES 2011–2012.30,35,36
The prevalence of CHD reported in this study included not only self-reported medical provider diagnosed angina as in previous studies but also the use of anti-angina medications and undiagnosed angina as defined by the Rose Questionnaire. This more detailed case definition could lead to a higher prevalence of angina and, consequently, of CHD compared with previous reports. These detailed definitions, however, may provide more-precise prevalence estimates owing to the use of multiple questions, which has increased the reliability of responses in some studies. On the other hand, individuals who were institutionalized (i.e., in hospitals and nursing homes) were excluded from the NHANES survey sample design, a fact that could potentially bias CHD prevalence estimates lower.
Limitations
There are several potential limitations to this study. Some key variables such as CHD, angina, and MI in the study are based on self-report, where inaccurate recall by the participant could bias prevalence estimates. For example, a participant may deny having any history of diagnosed angina, but be currently taking angina medications. To minimize the degree of inaccuracies that may exist in these self-reported data (i.e., misclassification due to self-reported data on ever being diagnosed with angina), the authors included all individuals currently taking anti-angina medications as well as those with undiagnosed angina as identified by the validated Rose Questionnaire in the angina case definition. A sensitivity analysis that compared the effect of defining angina with and without undiagnosed cases found a 0%–0.1% difference in the overall prevalence of CHD for each of the 2-year periods. The other self-reported variables in this study are current smoking, diagnosed MI, ischemic heart disease, diabetes, and congestive heart failure. For these conditions, previous methodology studies have shown relatively high rates of validation against clinical records and examination data, indicating their utility for disease surveillance studies.37–41
Conclusions
The overall prevalence of CHD significantly decreased over the 12-year survey period. A declining trend was observed in most of the subgroups in demographic characteristics except the group without health insurance and subgroups without the presence of specific CHD risk factors (hypertension, hypercholesterolemia, overweight/obesity, and diabetes).
Footnotes
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of NIH, CDC, or the Food and Drug Administration.
No financial disclosures were reported by the authors of this paper.
References
- 1.American Heart Association. Heart disease and stroke statistics—2015 update. Circulation . 2015;131:e29–e322. 10.1161/CIR.0000000000000152. [DOI] [PubMed] [Google Scholar]
- 2.Wang H, Steffen LM, Jacobs DR, et al. Trends in cardiovascular risk factor levels in the Minnesota Heart Survey (1980-2002) as compared with the National Health and Nutrition Examination Survey (1976-2002): a partial explanation for Minnesota’s low cardiovascular disease mortality? Am J Epidemiol. 2011;173(5):526–538. 10.1093/aje/kwq367. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Mensah GA, Brown DW, Croft JB, Greenlund KJ. Major coronary risk factors and death from coronary heart disease: baseline and follow-up mortality data from the Second National Health and Nutrition Examination Survey (NHANES II). Am J Prev Med . 2005;29(5) (suppl 1):68–74. 10.1016/j.amepre.2005.07.030. [DOI] [PubMed] [Google Scholar]
- 4.Dube SR, Asman K, Malarcher A, Carabollo R. Cigarette smoking among adults and trends in smoking cessation—United States, 2008. MMWR Morb Mortal Wkly Rep . 2009;58(44):1227–1232. [PubMed] [Google Scholar]
- 5.Cowie CC, Rust KF, Byrd-Holt DD, et al. Prevalence of diabetes and high risk for diabetes using A1C criteria in the U.S. population in 1988–2006. Diabetes Care . 2010;33:562–568. 10.2337/dc09-1524. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011–2012. JAMA . 2014;311 (8):806–814. 10.1001/jama.2014.732. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Carroll MD, Lacher DA, Sorlie PD, et al. Trends in serum lipids and lipoproteins of adults, 1960–2002. JAMA . 2005;294(14):1773–1781. 10.1001/jama.294.14.1773. [DOI] [PubMed] [Google Scholar]
- 8.Yoon SS, Ostchega Y, Louis T. Recent trends in the prevalence of high blood pressure and its treatment and control, 1999–2008. NCHS Data Brief. 2010;No. 48:1–8. [PubMed] [Google Scholar]
- 9.Gillespie C, Kuklina EV, Briss PA, Blair NA, Hong Y. Vital signs: prevalence, treatment, and control of hypertension—United States, 1999–2002 and 2005–2008. MMWR Morb Mortal Wkly Rep . 2011;60 (4):103–108. [PubMed] [Google Scholar]
- 10.Ford ES, Ajani UA, Croft JB, et al. Explaining the decrease in U.S. deaths from coronary disease, 1980–2000. N Engl J Med. 2007; 356:2388–2398. 10.1056/NEJMsa053935. [DOI] [PubMed] [Google Scholar]
- 11.Fox CS, Evans JC, Larson MG, Kannel WB, Levy D. Temporal trends in coronary heart disease mortality and sudden cardiac death from 1950 to 1999: the Framingham Heart Study. Circulation . 2004;110:522–527. 10.1161/01.CIR.0000136993.34344.41. [DOI] [PubMed] [Google Scholar]
- 12.National Center for Health Statistics. National Health and Nutrition Examination Survey (NHANES). Questionnaires, datasets, and related documentation. www.cdc.gov/nchs/nhanes/nhanes_questionnaires.htm. Accessed January 27, 2015. [Google Scholar]
- 13.National Center for Health Statistics. National Health and Nutrition Examination Survey (NHANES). NHANES response rates and population totals. www.cdc.gov/nchs/nhanes/response_rates_CPS.htm. Accessed January 21, 2016. [Google Scholar]
- 14.National Center for Health Statistics. National Health and Nutrition Examination Survey (NHANES). www.cdc.gov/nchs/nhanes/nhanes2007-2008/RXQ_RX_E.htm. AccessedJanuary 27, 2015.
- 15.National Center for Health Statistics. National Health and Nutrition Examination Survey (NHANES). 2007–2008 data documentation, codebook, and frequencies. www.cdc.gov/nchs/nhanes/nhanes1999-2000/RXQ_DRUG.htm. Accessed January 27, 2015. [Google Scholar]
- 16.Rose GA, Blackburn H. Cardiovascular survey methods. Monogr Ser World Health Organ . 1968;56:1–188. [PubMed] [Google Scholar]
- 17.Blackwelder WC, Kagan A, Gordon T, Rhoads GG. Comparison of methods for diagnosing angina pectoris: the Honolulu Heart Study. Int J Epidemiol . 1981;10:211–215. 10.1093/ije/10.3.211. [DOI] [PubMed] [Google Scholar]
- 18.Simpson Jr, White A. Getting a handle on the prevalence of coronary heart disease. Br Heart J . 1990;64:291–292. 10.1136/hrt.64.5.291. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289 (19):2560–2572. 10.1001/jama.289.19.2560. [DOI] [PubMed] [Google Scholar]
- 20.Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA. 2001;285:2486–2497. 10.1001/jama.285.19.2486. [DOI] [PubMed] [Google Scholar]
- 21.Klein RJ, Schoenborn C. Age adjustment using the 2000 projected U.S. population. In Healthy People 2010 Statistical Notes. Hyattsville, MD: CDC/National Center for Health Statistics, 2001: 1–10. [PubMed] [Google Scholar]
- 22.Wolter KM. Introduction to Variance Estimation. 2nd ed. New York, NY: Springer, 2007. [Google Scholar]
- 23.Skinner CJ, Holt D, Smith TMF. Analysis of Complex Surveys. Chichester: John Wiley & Sons, 1989. [Google Scholar]
- 24.Carroll MD, Kit BK, Lacher DA, Shero ST, Mussolino ME. Trends in lipids and lipoproteins in U.S. adults, 1988–2010. JAMA. 2012;308 (15):1545–1554. 10.1001/jama.2012.13260. [DOI] [PubMed] [Google Scholar]
- 25.U.S. Preventive Services Task Force . Aspirin for the prevention of cardiovascular disease. www.uspreventiveservicestaskforce.org/uspstf/uspsasmi.htm. Published 2009.Accessed January 10, 2015.
- 26.Will JC, Yuan K, Ford E. National trends in the prevalence and medical history of angina: 1988 to 2012. Circ Cardiovasc Qual Outcomes. 2014;7(3):407–413. 10.1161/CIRCOUTCOMES.113.000779. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Egan BM, Zhao Y, Axon RN. U.S. trends in prevalence, awareness, treatment, and control of hypertension, 1988–2008. JAMA. 2010;303:2043–2050. 10.1001/jama.2010.650. [DOI] [PubMed] [Google Scholar]
- 28.Yoon SS, Gu Q, Nwankwo T, Wright JD, Hong Y, Burt V. Trends in blood pressure among adults with hypertension: United States, 2003-2012. Hypertension. 2015;65:54–61. 10.1161/HYPERTENSIONAHA.114.04012. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Schober SE, Carroll MD, Lacher DA, Hirsch R. High serum total cholesterol—an indicator for monitoring cholesterol lowering efforts: U.S. adults, 2005-2006. NCHS Data Brief. 2007;2:1–8. [PubMed] [Google Scholar]
- 30.Suh DC, Kim CM, Choi IS, Plauschinat CA, Barone JA. Trends in blood pressure control and treatment among type 2 diabetes with comorbid hypertension in the United States: 1988-2004. J Hypertens . 2009;27(9):1908–1916. 10.1097/HJH.0b013e32832d4aee. [DOI] [PubMed] [Google Scholar]
- 31.Looker HC, Krakoff J, Andre V, et al. Secular trends in treatment and control of type 2 diabetes in an American Indian population: a 30-year longitudinal study. Diabetes Care. 2010;33(11):2383–2389. 10.2337/dc10-0678. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.National Center for Chronic Disease Prevention and Health Promotion, CDC. Age-adjusted percentage of civilian, noninstitutionalized population with diagnosed diabetes, by sex, United States, 1980–2008. www.cdc.gov/diabetes/statistics/prev/national/figbysex.htm. Accessed-January 10, 2015.
- 33.CDC. Prevalence of self-reported cardiovascular disease among persons aged > or =35 years with diabetes—United States, 1997-2005. MMWR Morb Mortal Wkly Rep. 2007;56(43):1129–1132. [PubMed] [Google Scholar]
- 34.American Diabetes Association. Standards of medical care in diabetes–2010. Diabetes Care. 2010;33(suppl 1):S11–S61. 10.2337/dc10-S011. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Gu Q, Burt VL, Dillon CF, Yoon SS. Trends in antihypertensive medication use and blood pressure control among United States adults with hypertension: the national health and nutrition examination survey, 2001 to 2010. Circulation. 2012;126(17):2105–2114. 10.1161/CIRCULATIONAHA.112.096156. [DOI] [PubMed] [Google Scholar]
- 36.Nwankwo T, Yoon SS, Burt VL, Gu Q. Hypertension in adults in the United States, 2011–2012. NCHS Data Brief. 2013;No. 133:1–8. [PubMed] [Google Scholar]
- 37.Caraballo RS, Giovino GA, Pechacek TF, Mowery PD. Factors associated with discrepancies between self-reports on cigarette smoking and measured serum cotinine levels among persons aged 17 years or older: Third National Health and Nutrition Examination Survey, 1988–1994. Am J Epidemiol. 2001;153:807–814. 10.1093/aje/153.8.807. [DOI] [PubMed] [Google Scholar]
- 38.Yeager DS, Krosnick JA. The validity of self-reported nicotine product use in the 2001–2008 National Health and Nutrition Examination Survey. Med Care. 2010;48:1128–1132. 10.1097/MLR.0b013e3181ef9948. [DOI] [PubMed] [Google Scholar]
- 39.Margolis KL, Lihong QI, Brzyski R, et al. Women Health Initiative Investigators. Validity of diabetes self-reports in the Women’s Health Initiative: comparison with medication inventories and fasting glucose measurements. Clin Trials. 2008;5(3):240–247. 10.1177/1740774508091749. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40.Goldman N, Lin IF, Weinstein M, Lin YH. Evaluating the quality of self-reports of hypertension and diabetes. J Clin Epidemiol. 2003;56 (2):148–154. 10.1016/S0895-4356(02)00580-2. [DOI] [PubMed] [Google Scholar]
- 41.Edwards WS, Winn DM, Kurlantzick V, et al. Evaluation of national health interview survey diagnostic reporting. Vital Health Stat 2 . 1994. (120):1–116. [PubMed] [Google Scholar]