Executive Summary: Heart Disease and Stroke Statistics—2016 Update

Abstract

HomeCirculationVol. 133, No. 4Executive Summary: Heart Disease and Stroke Statistics—2016 Update Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBExecutive Summary: Heart Disease and Stroke Statistics—2016 UpdateA Report From the American Heart Association Dariush Mozaffarian, MD, DrPH, FAHA, Emelia J. Benjamin, MD, ScM, FAHA, Alan S. Go, MD, Donna K. Arnett, PhD, MSPH, FAHA, Michael J. Blaha, MD, MPH, Mary Cushman, MD, MSc, FAHA, Sandeep R. Das, MD, MPH, Sarah de Ferranti, MD, MPH, Jean-Pierre Després, PhD, FAHA, Heather J. Fullerton, MD, MAS, Virginia J. Howard, PhD, FAHA, Mark D. Huffman, MD, MPH, FAHA, Carmen R. Isasi, MD, PhD, Monik C. Jiménez, ScD, Suzanne E. Judd, PhD, Brett M. Kissela, MD, MS, FAHA, Judith H. Lichtman, PhD, MPH, Lynda D. Lisabeth, PhD, MPH, FAHA, Simin Liu, MD, ScD, FAHA, Rachel H. Mackey, PhD, MPH, FAHA, David J. Magid, MD, MPH, Darren K. McGuire, MD, MHSc, FAHA, Emile R. MohlerIII, MD, FAHA, Claudia S. Moy, PhD, MPH, Paul Muntner, PhD, Michael E. Mussolino, PhD, FAHA, Khurram Nasir, MD, MPH, Robert W. Neumar, MD, PhD, Graham Nichol, MD, MPH, FAHA, Latha Palaniappan, MD, MS, FAHA, Dilip K. Pandey, MD, PhD, FAHA, Mathew J. Reeves, PhD, FAHA, Carlos J. Rodriguez, MD, MPH, FAHA, Wayne Rosamond, PhD, FAHA, Paul D. Sorlie, PhD, Joel Stein, MD, Amytis Towfighi, MD, Tanya N. Turan, MD, MSCR, FAHA, Salim S. Virani, MD, PhD, Daniel Woo, MD, MS, FAHA, Robert W. Yeh, MD, MSc, FAHA and Melanie B. Turner, MPHon behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee Dariush MozaffarianDariush Mozaffarian Search for more papers by this author , Emelia J. BenjaminEmelia J. Benjamin Search for more papers by this author , Alan S. GoAlan S. Go Search for more papers by this author , Donna K. ArnettDonna K. Arnett Search for more papers by this author , Michael J. BlahaMichael J. Blaha Search for more papers by this author , Mary CushmanMary Cushman Search for more papers by this author , Sandeep R. DasSandeep R. Das Search for more papers by this author , Sarah de FerrantiSarah de Ferranti Search for more papers by this author , Jean-Pierre DesprésJean-Pierre Després Search for more papers by this author , Heather J. FullertonHeather J. Fullerton Search for more papers by this author , Virginia J. HowardVirginia J. Howard Search for more papers by this author , Mark D. HuffmanMark D. Huffman Search for more papers by this author , Carmen R. IsasiCarmen R. Isasi Search for more papers by this author , Monik C. JiménezMonik C. Jiménez Search for more papers by this author , Suzanne E. JuddSuzanne E. Judd Search for more papers by this author , Brett M. KisselaBrett M. Kissela Search for more papers by this author , Judith H. LichtmanJudith H. Lichtman Search for more papers by this author , Lynda D. LisabethLynda D. Lisabeth Search for more papers by this author , Simin LiuSimin Liu Search for more papers by this author , Rachel H. MackeyRachel H. Mackey Search for more papers by this author , David J. MagidDavid J. Magid Search for more papers by this author , Darren K. McGuireDarren K. McGuire Search for more papers by this author , Emile R. MohlerIIIEmile R. MohlerIII Search for more papers by this author , Claudia S. MoyClaudia S. Moy Search for more papers by this author , Paul MuntnerPaul Muntner Search for more papers by this author , Michael E. MussolinoMichael E. Mussolino Search for more papers by this author , Khurram NasirKhurram Nasir Search for more papers by this author , Robert W. NeumarRobert W. Neumar Search for more papers by this author , Graham NicholGraham Nichol Search for more papers by this author , Latha PalaniappanLatha Palaniappan Search for more papers by this author , Dilip K. PandeyDilip K. Pandey Search for more papers by this author , Mathew J. ReevesMathew J. Reeves Search for more papers by this author , Carlos J. RodriguezCarlos J. Rodriguez Search for more papers by this author , Wayne RosamondWayne Rosamond Search for more papers by this author , Paul D. SorliePaul D. Sorlie Search for more papers by this author , Joel SteinJoel Stein Search for more papers by this author , Amytis TowfighiAmytis Towfighi Search for more papers by this author , Tanya N. TuranTanya N. Turan Search for more papers by this author , Salim S. ViraniSalim S. Virani Search for more papers by this author , Daniel WooDaniel Woo Search for more papers by this author , Robert W. YehRobert W. Yeh Search for more papers by this author and Melanie B. TurnerMelanie B. Turner Search for more papers by this author and on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee Originally published26 Jan 2016https://doi.org/10.1161/CIR.0000000000000366Circulation. 2016;133:447–454Table of Contents*Summary e391. About These Statistics e462. Cardiovascular Health e49Health Behaviors3. Smoking/Tobacco Use e684. Physical Inactivity e785. Nutrition e896. Overweight and Obesity e110Health Factors and Other Risk Factors7. Family History and Genetics e1218. High Blood Cholesterol and Other Lipids e1279. High Blood Pressure e13510. Diabetes Mellitus e14811. Metabolic Syndrome e16212. Chronic Kidney Disease e178Cardiovascular Conditions/Diseases13. Total Cardiovascular Diseases e18414. Stroke (Cerebrovascular Disease) e20415. Congenital Cardiovascular Defects and Kawasaki Disease e23516. Disorders of Heart Rhythm e24717. Sudden Cardiac Arrest e26818. Subclinical Atherosclerosis e27919. Coronary Heart Disease, Acute Coronary Syndrome, and Angina Pectoris e29220. Cardiomyopathy and Heart Failure e30721. Valvular, Venous, and Aortic Diseases e31622. Peripheral Artery Disease e324Outcomes23. Quality of Care e33024. Medical Procedures e34425. Economic Cost of Cardiovascular Disease e349Supplemental Materials26. At-a-Glance Summary Tables e35427. Glossary e358SummaryEach year, the American Heart Association (AHA), in conjunction with the Centers for Disease Control and Prevention, the National Institutes of Health, and other government agencies, brings together the most up-to-date statistics related to heart disease, stroke, and other cardiovascular and metabolic diseases and presents them in its Heart Disease and Stroke Statistical Update. The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, and others seeking the best available data on these conditions. Together, cardiovascular disease (CVD) and stroke produce immense health and economic burdens in the United States and globally. The Statistical Update brings together in a single document up-to-date information on the core health behaviors (including diet, physical activity [PA], smoking, and energy balance) and health factors (including blood pressure, cholesterol, and glucose) that define cardiovascular health; a range of major clinical disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, and peripheral arterial disease); and the associated outcomes (including quality of care, procedures, and economic costs). Since 2006, the annual versions of the Statistical Update have been cited >28 000 times in the literature. In 2014 alone, the various Statistical Updates were cited >5000 times.Each annual version of the Statistical Update undergoes major revisions to include the newest nationally representative data, add additional relevant published scientific findings, remove older information, add new sections or chapters, and increase the number of ways to access and use the assembled information. This year-long process, which begins as soon as the previous Statistical Update is published, is performed by the AHA Statistics Committee faculty volunteers and staff. For example, this year’s edition includes new data on the monitoring and benefits of cardiovascular health in the population, new metrics to assess and monitor healthy diets, additional information in many chapters on the global CVD and stroke burden, new information on stroke in young adults, a new focus on underserved and minority populations, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the AHA’s 2020 Impact Goals. Below are a few highlights from this year’s Update.Current Status of Cardiovascular Health in the United States (Chapter 2)The concept of cardiovascular health represents a heightened focus for the AHA, with 3 central and novel emphases:—An expanded focus on not only CVD prevention but also promotion of positive cardiovascular health, in addition to the treatment of established CVD—The prioritization of both health behaviors (healthy diet pattern, appropriate energy balance, PA, and nonsmoking) and health factors (optimal blood lipids, blood pressure, glucose levels) throughout the lifespan as primary goals unto themselves—Population-level health promotion strategies to shift the majority of the public toward greater cardiovascular health, in addition to targeting those individuals at greatest CVD risk, because CVD occurs at all risk levels across the population and because healthy lifestyles are uncommon throughout the US populationAmong children, the prevalence of ideal levels of cardiovascular health behaviors and factors currently varies from <1% for the healthy diet pattern to >80% for the smoking, blood pressure, and fasting glucose metrics.Among US adults, the prevalence of ideal levels of cardiovascular health behaviors and factors currently varies from about 1.5% for the healthy diet pattern to up to 78% for the smoking metric (never having smoked or being a former smoker who has quit for >12 months).Fewer children over time are meeting the ideal body mass index metric, whereas more are meeting the ideal smoking and total cholesterol metrics. Other metrics do not show consistent trends over time in children.More adults over time are meeting the smoking metric, whereas fewer are meeting the body mass index and glucose metrics. Trends for other metrics are not evident over time in adults.Effective Approaches to Improve Cardiovascular Health (Chapter 2)The current evidence supports a range of complementary strategies to improve cardiovascular health, including the following:—Individual-focused approaches, which target lifestyle and treatments at the individual level—Healthcare systems approaches, which encourage, facilitate, and reward efforts by providers and patients to improve health behaviors and health factors—Population approaches, which target lifestyle and treatments in schools or workplaces, local communities, and states, as well as throughout the nationSuch approaches can focus on both (1) improving cardiovascular health among those who currently have less than optimal levels and (2) preserving cardiovascular health among those who currently have ideal levels (in particular, children, adolescents, and young adults) as they age.The metrics with the greatest potential for improvement are health behaviors, including diet quality, PA, and body weight. However, each of the cardiovascular health metrics can be improved and deserves major focus.Health Behaviors (Chapters 3 to 6)Based on comparable risk assessment methods, poor lifestyle behaviors and lifestyle-related risk factors are the foremost causes of death and disability in the United States and in the world.Smoking/Tobacco Use (Chapter 3)Although tobacco use has declined substantially in the United States, it remains the second-leading cause of total deaths and disability. The percentage of adults who reported current cigarette use declined from 24.1% in 1998 to 16.9% in 2014; among high school students, the decline was from 36.4% in 1997 to 5.6% in 2013. Still, almost one third of coronary heart disease deaths are attributable to smoking and exposure to secondhand smoke.Declines in tobacco usage in the United States may be threatened by the >450 e-cigarette products that were available in 2014. To date, the risks and benefits of e-tobacco products remain controversial but are an area of intense investigation by scientists, as well as scrutiny by the US Food and Drug Administration. Public health experts are concerned that although e-cigarettes are thought to have a lower risk of harmful effects than conventional cigarettes, they may be a gateway to smoking traditional cigarettes or may promote relapse among former smokers, which could erode gains in the public’s awareness of the harms of tobacco products.Cigarette smoking is associated with 9% of annual aggregated healthcare spending in the United States. Annual smoking-attributable economic costs in the United States, including direct medical costs and lost productivity, are estimated to exceed $289 billion.Physical Inactivity (Chapter 4)In 2013, 15.2% of adolescents reported being inactive during the prior week, and inactivity was more likely to be reported by girls (19.2%) than boys (11.2%). Inactivity was more commonly reported by black (27.3%) and Hispanic (20.3%) girls than their white counterparts (16.1%); similarly, black (15.2%) and Hispanic (12.1%) boys reported more inactivity than white boys (9.2%).According to 2014 National Health Interview Survey data, only half of American adults met the current aerobic PA guidelines (≥150 minutes of moderate PA or 75 minutes of vigorous PA or an equivalent combination each week). Women (47.0%) were less likely to meet the guidelines than men (53.2%), and non-Hispanic blacks (43.5%) and Hispanics (41.3%) were less likely to meet them than non-Hispanic whites (53.5%).Unfortunately, the proportion of individuals meeting PA recommendations is likely to be lower than indicated by self-report data. Studies examining actual (with accelerometers, pedometers, etc) versus self-reported PA indicate that both men and women overestimate their PA substantially (by 44% and 138% for men and women, respectively).Nutrition (Chapter 5)The leading risk factor for death and disability in the United States is suboptimal diet quality, which in 2010 led to 678 000 annual deaths attributable to all causes. Major contributors were insufficient intakes of fruits, nuts/seeds, whole grains, vegetables, and seafood, as well as excess intakes of sodium. In the United States, an estimated 58 000 annual CVD deaths in 2010 were attributable to sodium intake >2.0 g/d, representing 1 in 16 (6.3%) of all CVD deaths and 1 in 8 (13.1%) CVD deaths before age 70 years. Globally, an estimated 1.65 million annual CVD deaths were attributable to sodium intake >2.0 g/d, representing nearly 1 in 10 (9.5%) of all CVD deaths.Between 2003 and 2012, certain aspects of diet quality improved in the United States, including increases in whole grains and reductions in sugar-sweetened beverages. The prevalence of both children and adults meeting the dietary goals improved between 2003 to 2004 and 2011 to 2012. The prevalence of ideal levels of diet (healthy diet score >80) increased from 0.2% to 0.6% in children and from 0.7% to 1.5% in adults. During this period, the proportion of youths aged 5 to 19 years with poor scores on the dietary metric for cardiovascular health decreased steadily from 69.2% to 54.6%, whereas for adults, the decrease was from 50.3% to 41.0%.Although healthier diets cost modestly more than unhealthful diets, comparing extremes of unhealthful versus healthful food-based diet patterns, the more healthful patterns cost on average ≈$1.50 per day more. Similarly priced options are also common; in a comparison of 20 fruits and vegetables versus 20 common snack foods such as cookies, chips, pastries, and crackers, the average price per portion of fruits and vegetables was 31 cents, with an average of 57 calories per portion, versus 33 cents and 183 calories per portion for snack foods.Obesity (Chapter 6)Although the overall prevalence of obesity in US youth did not change between 2003 to 2004 and 2011 to 2012, the prevalence decreased among those aged 2 to 5 years. Obesity decreased among those of higher socioeconomic status but increased among those of lower socioeconomic status. In addition, the overall prevalence of severe obesity in US youth continued to increase, especially among adolescent boys.Overweight and obesity predispose individuals to most major risk factors, including physical inactivity, hypertension, hyperlipidemia, and diabetes mellitus.Excess body weight is among the leading causes of death and disability in the United States and globally, with burdens expected to increase in coming years.Among overweight and obese individuals, existing cardiometabolic risk factors should be monitored and treated intensively with diet quality, PA, and pharmacological or other treatments as necessary. Each of these interventions provides benefits independent of weight loss and maintenance.Estimated mean annual per capita healthcare expenses attributable to obesity are $1160 for men and $1525 for women.Health Factors (Chapters 7 to 12)The prevalence and control of cardiovascular health factors remains a major issue for many Americans.Family History and Genetics (Chapter 7)Familial aggregation of CVD is related to clustering of specific lifestyle and other risk factors, each of which has environmental and genetic contributors. Patients with a family history of coronary artery disease have a higher prevalence of traditional CVD risk factors, underscoring opportunities for prevention.The risk of most CVD conditions is higher in the presence of a family history, including CVD (45% higher odds with sibling history), stroke (50% higher odds with history in a first-degree relative), atrial fibrillation (AF; 80% higher odds with parental history), heart failure (70% higher odds with parental history), and peripheral arterial disease (80% higher odds with family history). This excess risk reflects genetic, epigenetic, and shared behavioral and environmental risk factors.High Blood Cholesterol and Other Lipids (Chapter 8)75.7% of children and 46.6% of adults have ideal cholesterol levels (untreated total cholesterol <170 mg/dL for children and <200 mg/dL for adults). Prevalence of ideal levels has improved over the past decade in children but remained the same in adults.According to 2009 to 2012 data, >100 million US adults ≥20 years of age have total cholesterol levels ≥200 mg/dL; almost 31 million have levels ≥240 mg/dL.During 2003 to 2012, the percentage of adults aged ≥40 years who had used a cholesterol-lowering medication in the past 30 days increased from 20% to 28%.High Blood Pressure (Chapter 9)Based on 2009 to 2012 data, 32.6% of US adults ≥20 years of age have hypertension, which represents ≈80.0 million US adults. African American adults have among the highest prevalence of hypertension in the world. Among non-Hispanic black men and women, the age-adjusted prevalence of hypertension was 44.9% and 46.1%, respectively.National Health and Nutrition Examination Survey (NHANES) data from 2009 to 2012 revealed that among US adults with hypertension, 54.1% were controlled, 76.5% were currently treated, 82.7% were aware they had hypertension, and 17.3% were undiagnosed.From 2003 to 2013, the death rate attributable to high blood pressure increased 8.2%, and the actual number of deaths rose 34.7% (National Heart, Lung, and Blood Institute tabulation). During this 10-year period, the corresponding values were a 14.4% and 30.9% increase in non-Hispanic whites; a 1.7% and 75.5% increase in Hispanics; and a 9.1% decrease and 18.4% increase in non-Hispanic blacks.Diabetes Mellitus (Chapter 10)Diabetes mellitus affects 1 in 10 US adults, with 90% to 95% of cases being type 2 diabetes mellitus. Diabetes mellitus disproportionately affects racial/ethnic minorities. Type 2 diabetes mellitus is increasingly common in children and adolescents; the disease historically was diagnosed primarily in adults ≥40 years of age. The prevalence of type 2 diabetes mellitus in children/adolescents has increased by 30.5% between 2001 and 2009, and it now constitutes ≈50% of all childhood diabetes mellitus.Diabetes mellitus is associated with reduced longevity; men and women with diabetes mellitus live an average of 7.5 and 8.2 years less, respectively, than their counterparts without diabetes mellitus.Metabolic Syndrome (Chapter 11)From 1999 to 2010, the age-adjusted national prevalence of metabolic syndrome in the United States peaked (in 2001–2002) and began to fall. This is attributable to decreases in the age-adjusted prevalence among women and no change in men. In addition, there has been variation in the trends over time for each individual component of the metabolic syndrome. Generally, the national prevalences of hypertriglyceridemia and elevated blood pressure have decreased, whereas hyperglycemia and elevated waist circumference have increased. However, these trends also vary significantly by sex and race/ethnicity.Perhaps most importantly with respect to meeting the 2020 goals, the prevalence of metabolic syndrome increases with greater cumulative life-course exposure to sedentary behavior and physical inactivity; screen time, including television viewing; fast food intake; short sleep duration; and intake of sugar-sweetened beverages. Each of these risk factors is reversible with lifestyle change.Cardiovascular Conditions/Diseases (Chapters 13 to 22)Rates of death attributable to CVD have declined in the United States, but the burden remains high.Total Cardiovascular Diseases (Chapter 13)The 2013 overall rate of death attributable to CVD was 222.9 per 100 000 Americans. The death rates were 269.8 for males and 184.8 for females. The rates were 270.6 for non-Hispanic white males, 356.7 for non-Hispanic black males, 197.4 for Hispanic males, 183.8 for non-Hispanic white females, 246.6 for non-Hispanic black females, and 136.4 for Hispanic females.From 2003 to 2013, death rates attributable to CVD declined 28.8%. In the same 10-year period, the actual number of CVD deaths per year declined by 11.7%. Yet in 2013, CVD still accounted for 30.8% (800 937) of all 2 596 993 deaths, or ≈1 of every 3 deaths in the United States.On the basis of 2013 death rate data, >2200 Americans die of CVD each day, an average of 1 death every 40 seconds. Approximately 155 000 Americans who died of CVD in 2013 were <65 years of age. In 2013, 35% of deaths attributable to CVD occurred before the age of 75 years, which is younger than the current average life expectancy of 78.8 years.For the first time since 1983, more males (402 851) died of CVD than females (398 086).Stroke (Chapter 14)In 2013, stroke fell from the fourth to the fifth leading cause of death in the United States, behind diseases of the heart, cancer, chronic lower respiratory diseases, and unintentional injury.From 2003 to 2013, the relative rate of stroke death fell by 33.7% and the actual number of stroke deaths declined by 18.2%. Yet each year, ≈795 000 people continue to experience a new or recurrent stroke (ischemic or hemorrhagic). Approximately 610 000 of these are first events and 185 000 are recurrent stroke events. In 2013, stroke caused ≈1 of every 20 deaths in the United States. On average, every 40 seconds, someone in the United States has a stroke, and someone dies of one approximately every 4 minutes.The decline in stroke mortality over the past decades, a major improvement in population health observed for both sexes and all race and age groups, has resulted from reduced stroke incidence and lower case fatality rates. The significant improvements in stroke outcomes are concurrent with cardiovascular risk factor control interventions. The hypertension control efforts initiated in the 1970s appear to have had the most substantial influence on the accelerated decline in stroke mortality, with lower blood pressure distributions in the population. Control of diabetes mellitus and high cholesterol and smoking cessation programs, particularly in combination with hypertension treatment, also appear to have contributed to the decline in stroke mortality.Approximately 10% of all strokes occur in people 18 to 50 years of age. Between 1995 and 2008, National Health Interview Survey data reveal that hospitalizations for ischemic stroke increased among adolescents and young adults (aged 5–44 years), whereas subarachnoid hemorrhage hospitalizations decreased during that same time period.Stroke death rates declined more among people aged ≥65 years (−54.1%; from 534.1 to 245.2 per 100 000) than among those aged 45 to 64 years (−53.6%; from 43.5 to 20.2 per 100 000) or those aged 18 to 44 years (−45.9%; from 3.7 to 2.0 per 100 000).Atrial Fibrillation (Chapter 16)Multiple lines of evidence have increased awareness of the burden of unrecognized AF. In individuals without a history of AF with recent pacemaker or defibrillator implantation, subclinical atrial tachyarrhythmias were detected in 10.1% of patients. Subclinical atrial tachyarrhythmias were associated with a 5.6-fold higher risk of clinical AF and ≈13% of ischemic strokes or embolism. A recent systematic review suggested that one needs to screen 170 community-based individuals at least 65 years of age to detect 1 case of AF.In the Framingham Heart Study, there have been striking temporal trends in the epidemiology of AF documented over 50 years. The age-adjusted incidence and prevalence of AF in the white participants increased ≈4-fold, yet the multivariable adjusted hazard of stroke (74%) and death (25%) associated with AF declined over the same time period. Less is known about the epidemiology of AF over time in ethnic/racial minorities.Secondary analyses of observational and randomized data generally support benefits of risk factor modification for primary prevention of AF. There is also growing evidence supporting the value of risk factor reduction, particularly weight management and exercise, in secondary prevention of AF recurrences and symptoms.Sudden Cardiac Arrest (Chapter 17)Each year ≈359 800 people experienced emergency medical services–assessed out-of-hospital cardiac arrests in the United States. Survival to hospital discharge after nontraumatic emergency medical services–treated cardiac arrest with any first recorded rhythm was 10.6% for patients of any age. Of the ≈20 150 bystander-witnessed out-of-hospital cardiac arrests in 2011, 31.4% of victims survived to hospital discharge.Each year, ≈209 000 people are treated for in-hospital cardiac arrest.Subclinical Atherosclerosis (Chapter 18) and Coronary Heart Disease (Chapter 19)CAC was noted as highly predictive of CHD event risk across all age groups, suggesting that once CAC is known, chronological age has less importance. Compared with a CAC score of 0, CAC >100 imparted an increased multivariable-adjusted CHD event risk in younger individuals (45-54 years old) with an HR of 12.4. The respective risk was similar even in the very elderly (75-84 years of age) with an HR of 12.1.Coronary heart disease alone caused ≈1 of every 7 deaths in the United States in 2013. In 2013, 370 213 Americans died of coronary heart disease. Each year, an estimated ≈660 000 Americans have a new coronary attack (defined as first hospitalized myocardial infarction or coronary heart disease death) and ≈305 000 have a recurrent attack. It is estimated that an additional 160 000 silent myocardial infarctions occur each year. Approximately every 34 seconds, 1 American has a coronary event, and approximately every 1 minute 24 seconds, an American will die of one.Heart Failure (Chapter 20)In 2013, 1 in 9 death certificates (284 388 deaths) in the United States mentioned heart failure. Heart failure was the underlying cause in 58 309 of those deaths. The number of any-mention deaths attributable to heart failure was approximately as high in 1995 (287 000) as it was in 2013 (284 000). Additionally, hospital discharges for heart failure remained stable from 2000 to 2010, with first-listed discharges of 1 008 000 and 1 023 000, respectively.Mortality declines in heart failure have been documented, likely related to evidence-based approaches to treat heart failure risk factors and to implementation of angiotensin-converting enzyme inhibitors, β-blockers, coronary revascularization, implantable cardioverter-defibrillators, and cardiac resynchronization therapeutic strategies.Valvular, Venous, and Aortic Diseases (Chapter 21) and Peripheral Artery Disease (Chapter 22)Data suggest that the prevalence of any valve disease is 2.5%, with no difference between men and women.In 2013, 50 222 deaths were related to valvular HD. Of those, 67.5% were due to aortic valve disorders.PAD affects ≈8.5 million Americans aged ≥40 years and is associated with significant morbidity and mortality.In 2013, PAD any-mention mortality was 61 097. PAD was the underlying cause in 13 639 of those deaths.The risk factors for PAD are similar but not identical to those for CHD. DM and cigarette smoking are stronger risk factors for PAD than for CHD. Most studies suggest that the prevalence of PAD is similar in men and women. Metabolic syndrome in older persons (driven most prominently by the HBP component) and elevated inflammation markers are also risk factors.Cardiovascular Quality of Care, Procedure Utilization, and Costs (Chapters 23 to 25)The Statistical Update provides critical data in several sections on the magnitude of healthcare delivery and costs, as well as the quality of healthcare delivery, r