Heart Disease and Stroke Statistics—2009 Update

Abstract

HomeCirculationVol. 119, No. 3Heart Disease and Stroke Statistics—2009 Update Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBHeart Disease and Stroke Statistics—2009 UpdateA Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee WRITING GROUP MEMBERS Donald Lloyd-Jones, MD, ScM, FAHA, Robert Adams, MD, FAHA, Mercedes Carnethon, PhD, FAHA, Giovanni De Simone, MD, T. Bruce Ferguson, MD, Katherine Flegal, PhD, Earl Ford, MD, MPH, Karen Furie, MD, Alan Go, MD, Kurt Greenlund, PhD, Nancy Haase, Susan Hailpern, DPH, Michael Ho, MD, PhD, Virginia Howard, PhD, FAHA, Brett Kissela, MD, Steven Kittner, MD, Daniel Lackland, PhD, FAHA, Lynda Lisabeth, PhD, Ariane Marelli, MD, Mary McDermott, MD, James Meigs, MD, Dariush Mozaffarian, MD, PhD, FAHA, Graham Nichol, MD, FAHA, Christopher O'Donnell, MD, MPH, FAHA, Veronique Roger, MD, FAHA, Wayne Rosamond, PhD, FAHA, Ralph Sacco, MD, FAHA, Paul Sorlie, PhD, Randall Stafford, MD, PhD, FAHA, Julia Steinberger, MD, MSC, FAHA, Thomas Thom, Sylvia Wasserthiel-Smoller, PhD, Nathan Wong, PhD, Judith Wylie-Rosett, EdD, Yuling Hong, MD, PhD, FAHA and WRITING GROUP MEMBERS Search for more papers by this author , Donald Lloyd-JonesDonald Lloyd-Jones Search for more papers by this author , Robert AdamsRobert Adams Search for more papers by this author , Mercedes CarnethonMercedes Carnethon Search for more papers by this author , Giovanni De SimoneGiovanni De Simone Search for more papers by this author , T. Bruce FergusonT. Bruce Ferguson Search for more papers by this author , Katherine FlegalKatherine Flegal Search for more papers by this author , Earl FordEarl Ford Search for more papers by this author , Karen FurieKaren Furie Search for more papers by this author , Alan GoAlan Go Search for more papers by this author , Kurt GreenlundKurt Greenlund Search for more papers by this author , Nancy HaaseNancy Haase Search for more papers by this author , Susan HailpernSusan Hailpern Search for more papers by this author , Michael HoMichael Ho Search for more papers by this author , Virginia HowardVirginia Howard Search for more papers by this author , Brett KisselaBrett Kissela Search for more papers by this author , Steven KittnerSteven Kittner Search for more papers by this author , Daniel LacklandDaniel Lackland Search for more papers by this author , Lynda LisabethLynda Lisabeth Search for more papers by this author , Ariane MarelliAriane Marelli Search for more papers by this author , Mary McDermottMary McDermott Search for more papers by this author , James MeigsJames Meigs Search for more papers by this author , Dariush MozaffarianDariush Mozaffarian Search for more papers by this author , Graham NicholGraham Nichol Search for more papers by this author , Christopher O'DonnellChristopher O'Donnell Search for more papers by this author , Veronique RogerVeronique Roger Search for more papers by this author , Wayne RosamondWayne Rosamond Search for more papers by this author , Ralph SaccoRalph Sacco Search for more papers by this author , Paul SorliePaul Sorlie Search for more papers by this author , Randall StaffordRandall Stafford Search for more papers by this author , Julia SteinbergerJulia Steinberger Search for more papers by this author , Thomas ThomThomas Thom Search for more papers by this author , Sylvia Wasserthiel-SmollerSylvia Wasserthiel-Smoller Search for more papers by this author , Nathan WongNathan Wong Search for more papers by this author , Judith Wylie-RosettJudith Wylie-Rosett Search for more papers by this author , Yuling HongYuling Hong Search for more papers by this author and Search for more papers by this author and for the American Heart Association Statistics Committee and Stroke Statistics Subcommittee Originally published15 Dec 2008https://doi.org/10.1161/CIRCULATIONAHA.108.191261Circulation. 2009;119:e21–e181is corrected byCorrectionCorrectionOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: December 15, 2008: Previous Version 1 Table of ContentsSummary…480/e211. About These Statistics…e282. Cardiovascular Diseases…e313. Subclinical Atherosclerosis…e534. Coronary Heart Disease, Acute Coronary Syndrome, and Angina Pectoris…e595. Stroke (Cerebrovascular Disease)…e716. High Blood Pressure…e877. Congenital Cardiovascular Defects…e968. Heart Failure…e1019. Other Cardiovascular Diseases…e105 — Arrhythmias (Disorders of Heart Rhythm)…e107 — Arteries, Diseases of (Including Peripheral Arterial Disease)…e108 — Bacterial Endocarditis…e106 — Cardiomyopathy…e107 — Rheumatic Fever/Rheumatic Heart Disease…e105 — Valvular Heart Disease…e106 — Venous Thromboembolism…e10910. Risk Factor: Smoking/Tobacco Use…e11311. Risk Factor: High Blood Cholesterol and Other Lipids…e11812. Risk Factor: Physical Inactivity…e12313. Risk Factor: Overweight and Obesity…e12714. Risk Factor: Diabetes Mellitus…e13215. End-Stage Renal Disease and Chronic Kidney Disease…e14016. Metabolic Syndrome…e14417. Nutrition…e14818. Quality of Care…e16019. Medical Procedures…e16820. Economic Cost of Cardiovascular Diseases…e17221. At-a-Glance Summary Tables…e174 — Men and Cardiovascular Diseases…e175 — Women and Cardiovascular Diseases…e176 — Ethnic Groups and Cardiovascular Diseases…e177 — Children, Youth, and Cardiovascular Diseases…e17822. Glossary…e179Appendix I: List of Statistical Fact Sheets. URL: http://www.americanheart.org/presenter.jhtml?identifier=2007We thank Drs Sean Coady, Eric L. Ding, Brian Eigel, Gregg C. Fonarow, Linda Geiss, Cherie James, Michael Mussolino, and Michael Wolz for their valuable comments and contributions. We acknowledge Tim Anderson and Tom Schneider for their editorial contributions, and Karen Modesitt for her administrative assistance.DisclosuresWriting Group DisclosuresWriting Group MemberEmploymentResearch GrantOther Research SupportSpeakers’ Bureau/HonorariaExpert WitnessOwnership InterestConsultant/Advisory BoardOtherDonald Lloyd JonesNorthwesternNIH/NHLBI†NonePfizer* (educational honoraria)NoneNoneAbbott*NoneRobert AdamsMedical University South CarolinaNHLBI†Duke Endowment, Health Sciences South Carolina*Boehringer Ingleheim†; Genentech*; sanofi-aventis*NoneREACHCAll Inc Telemedicine System†Boehringer Ingelheim*NoneMercedes CarnethonNorthwestern UniversityNoneNoneCommunity Health Plan of Seattle*NoneNoneNoneNoneGiovanni de SimoneFederico II University HospitalMinistry of Research, Italy*NoneNoneNoneNoneNoneNoneT. Bruce FergusonBrody School of Medicine at ECUBrody School of Medicine at ECU†NoneNoneNoneNoneNoneNoneKatherine FlegalCenters for Disease Control and PreventionNoneNoneNoneNoneNoneNoneNoneEarl FordCenters for Disease Control and PreventionNoneNoneNoneNoneNoneNoneNoneKaren FurieMassachusetts General HospitalNINDS*; AHA*; Bugher*Deane Institute for Integrative Research in Stroke and Atrial Fibrillation*NoneNoneNoneGE Healthcare*; Novartis Advisory Board*NoneAlan GoThe Permanente Medical GroupAmgen†; Site PI for a clinical trial sponsored by Johnson & Johnson†NoneNoneNoneNoneNoneNoneKurt GreenlundCenters for Disease Control and PreventionNoneNoneNoneNoneNoneNoneNoneNancy HaaseAmerican Heart AssociationNoneNoneNoneNoneNoneNoneNoneSusan HailpernNorthrop GrummanNoneNoneNoneNoneNoneNoneNone(Continued)Writing Group Disclosures, ContinuedWriting Group MemberEmploymentResearch GrantOther Research SupportSpeakers’ Bureau/HonorariaExpert WitnessOwnership InterestConsultant/Advisory BoardOtherP. Michael HoDenver VA Medical Center/University of Colorado Denver Medical School and HealthcareAmerican Heart Association†; Colorado Department of Public Health and Environment†; NHLBI†; VA Research and Development†NoneNovartis*NoneNoneNoneNoneYuling HongAmerican Heart AssociationNoneNoneNoneNoneNoneNoneNoneVirginia HowardUniversity of Alabama at BirminghamCo-investigator, Etiology of Geographic and Racial Differences in Stroke (REGARDS) NIH/NINDS U01 NS041588†; Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST) NIH/NINDS RO1 NS 38384†NoneNoneNoneNoneNoneNoneBrett KisselaUniversity of CincinnatiNIH-NINDS R-01 NS30678, “Hemorrhagic and Ischemic Strokes Among Blacks and Whites”†; NIH-NINDS R-01 NS039987, “Siblings with Ischemic Stoke Study (SWISS)” (James Meschia, PI)†; NIH-NINDS U-01 NS041588, “Etiology of Geographic and Racial Differences in Stroke”; (REasons for Geographic and Racial Differences in Stroke, or REGARDS Study) (George Howard, PI)†NoneBoehringer-Ingelheim†Has served as an expert witness and performed record review for medicolegal cases related to stroke*NoneAdvisor to Northstar Neuroscience, Inc (without pay)*NoneSteven KittnerUniversity of Maryland School of Medicine/Baltimore Department of Veterans Affairs Medical CenterAHA Grant-in-Aid†; NIH grant†NoneGrand Rounds presentations at a variety of medical institutions on topics relating to stroke epidemiology and prevention*NoneNoneNoneNoneDaniel LacklandMedical University of South CarolinaNHLBI*; DOE*; Health Science South Carolina*NoneMerck*; Novartis*; sanofi-aventis*NoneNoneNoneNoneLynda LisabethUniversity of MichiganNoneNoneNoneNoneNoneNoneNoneAriane MarelliMcGill University Health CenterHeart and Stroke Foundation of Canada†NoneNoneNoneNoneNoneNoneMary McDermottNorthwestern University’s Feinberg School of MedicineALL NIH/NHLBI R01-HL073351-01-A1†; R01-HL076298-01†; R01-HL073912-01A2†; K12- HL083790-01†; R01 HL083064†; R01 HL088589† (PI on all); CO-I N01-HC-65236* (PI Daviglus)NoneNoneNoneNoneNoneNoneJames MeigsMassachusetts General HospitalNoneNoneNoneNoneNoneNoneNone(Continued)Writing Group Disclosures, ContinuedWriting Group MemberEmploymentResearch GrantOther Research SupportSpeakers’ Bureau/HonorariaExpert WitnessOwnership InterestConsultant/Advisory BoardOtherDariush MozaffarianBrigham and Women’s Hospital, Harvard Medical SchoolNHLBI† and NIEHS† (K08 HL 075628-01, R01 HL 085710-01, R01 ES 014433-01A2†; Searle Scholar Award grant from the Searle Funds at The Chicago Community Trust†; Genes and Environment Initiative from the Harvard School of Public Health†; the Gates Foundation/World Health Organization Global Burden of Diseases, Injuries, and Risk Factors Study†; GlaxoSmithKline†; Sigma Tau†; Pronova for an investigator-initiated trial†NoneAssociations and universities for speaking and reviewing on topics related to diet and cardiovascular disease, including from the US Food and Drug Administration*; Food and Agriculture Organization of the United Nations*; World Health Organization*; American Diabetes Association*; American Dietetic Association*; American Oil Chemists Society*; National Lipid Association*; Institute of Food Technologists*; International Life Sciences Institute*; Medical Society of Delaware*; Johns Hopkins University*; Columbia University*; University of New Hampshire*; University of Guelph*; and Washington University*NoneNoneNoneNoneGraham NicholUniversity of WashingtonNHLBI,† Bethesda, Md, Grantee, co-PI, Resuscitation Outcomes Consortium Data Coordinating Center; Canadian Institutes of Health Research*; Medtronic Inc.,* Grantee, Co-investigator, Resynchronization in Advanced Failure Trial (RAFT); Asmund S. Laerdal Foundation for Acute Medicine,* Stavanger, Norway, PI, Randomized Trial of CPR Training Aid in CommunityEquipment donation of training aids for overseas medical mission, Laerdal Inc. (2006)*; equipment donation of monitors/ defibrillators for overseas medical mission, Physio-Control Inc. (2007)*; Equipment donation of training materials for overseas medical mission, Channing-Bete Inc. (2007)*NoneNoneNoneConsultant, Northfield Laboratories*; Consultant, Paracor Medical Inc.*; Member of Board of Directors, Medic One Foundation*NoneChristopher O'DonnellNational Heart, Lung, and Blood Institute; Massachusetts General HospitalNoneNoneNoneNoneNoneNoneNoneVeronique RogerMayo Clinic Health Care CenterNoneNoneNoneNoneNoneNoneNoneWayne RosamondUniversity of North CarolinaNoneNoneNoneNoneNoneNoneNoneRalph SaccoUniversity of Miami Medical SchoolNINDS R37 29993 Northern Manhattan Study†; NINDS R01 040807 Family Study of Stroke Risk and Carotid Atherosclerosis†NoneBoehringer Ingelheim*; sanofi-aventis*NoneNoneBoehringer Ingelheim for design of clinical trial on stroke prevention†; GlaxoSmithKline*; sanofi-aventis*NonePaul SorlieNational Heart, Lung, and Blood Institute, NIHNoneNoneNoneNoneNoneNoneNoneRandall StaffordStanford UniversityProcter & Gamble†NoneBayer*NoneNoneNoneNoneJulia SteinbergerUniversity of MinnesotaNoneNoneNoneNoneNoneNoneNone Thom(Continued)Writing Group Disclosures, ContinuedWriting Group MemberEmploymentResearch GrantOther Research SupportSpeakers’ Bureau/HonorariaExpert WitnessOwnership InterestConsultant/Advisory BoardOtherThis table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $10 000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.*Modest.†Significant.Thomas ThomNational Heart, Lung, and Blood Institute, NIH, DHHS, US GovernmentNoneNoneNoneNoneNoneNoneNoneSylvia Wasserthiel-SmollerAlbert Einstein College of MedicineNIH/NHLBI Hispanic Community Health Study†; Women’s Health Initiative†; Women’s Health Initiative Memory Study†NoneNoneNoneNoneNoneNoneNathan WongUniversity of California, IrvineMerck†; Pfizer†NoneNovartis*; Takeda†NoneNoneMerck*NoneJudith Wylie-RosettAlbert Einstein College of MedicineNoneNoneVA, 1199*NoneNoneMt. Sinai Medical Center Diabetes Prevention*; Yale School of Nursing*NonecirculationahaCirculationCirculationCirculation0009-73221524-4539Lippincott Williams & WilkinscirculationahaCirculationCirculationCirculation0009-73221524-4539Lippincott Williams & WilkinscirculationahaCirculationCirculationCirculation0009-73221524-4539Lippincott Williams & WilkinscirculationahaCirculationCirculationCirculation0009-73221524-4539Lippincott Williams & WilkinscirculationahaCirculationCirculationCirculation0009-73221524-4539Lippincott Williams & WilkinscirculationahaCirculationCirculationCirculation0009-73221524-4539Lippincott Williams & WilkinscirculationahaCirculationCirculationCirculation0009-73221524-4539Lippincott Williams & WilkinscirculationahaCirculationCirculationCirculation0009-73221524-4539Lippincott Williams & WilkinscirculationahaCirculationCirculationCirculation0009-73221524-4539Lippincott Williams & WilkinscirculationahaCirculationCirculationCirculation0009-73221524-4539Lippincott Williams & WilkinscirculationahaCirculationCirculationCirculation0009-73221524-4539Lippincott Williams & WilkinscirculationahaCirculationCirculationCirculation0009-73221524-4539Lippincott Williams & WilkinscirculationahaCirculationCirculationCirculation0009-73221524-4539Lippincott Williams & WilkinscirculationahaCirculationCirculationCirculation0009-73221524-4539Lippincott Williams & WilkinscirculationahaCirculationCirculationCirculation0009-73221524-4539Lippincott Williams & WilkinscirculationahaCirculationCirculationCirculation0009-73221524-4539Lippincott Williams & WilkinscirculationahaCirculationCirculationCirculation0009-73221524-4539Lippincott Williams & WilkinscirculationahaCirculationCirculationCirculation0009-73221524-4539Lippincott Williams & WilkinscirculationahaCirculationCirculationCirculation0009-73221524-4539Lippincott Williams & WilkinscirculationahaCirculationCirculationCirculation0009-73221524-4539Lippincott Williams & WilkinscirculationahaCirculationCirculationCirculation0009-73221524-4539Lippincott Williams & WilkinscirculationahaCirculationCirculationCirculation0009-73221524-4539Lippincott Williams & WilkinscirculationahaCirculationCirculationCirculation0009-73221524-4539Lippincott Williams & WilkinsSummary270120091. About These Statistics270120092. Cardiovascular Diseases270120093. Subclinical Atherosclerosis270120094. Coronary Heart Disease, Acute Coronary Syndrome, and Angina Pectoris270120095. Stroke (Cerebrovascular Disease)270120096. High Blood Pressure270120097. Congenital Cardiovascular Defects270120098. Heart Failure270120099. Other Cardiovascular Diseases2701200910. Risk Factor: Smoking/Tobacco Use2701200911. Risk Factor: High Blood Cholesterol and Other Lipids2701200912. Risk Factor: Physical Inactivity2701200913. Risk Factor: Overweight and Obesity2701200914. Risk Factor: Diabetes Mellitus2701200915. End-Stage Renal Disease and Chronic Kidney Disease2701200916. Metabolic Syndrome2701200917. Nutrition2701200918. Quality of Care2701200919. Medical Procedures2701200920. Economic Cost of Cardiovascular Diseases2701200921. At-a-Glance Summary Tables2701200922. Glossary27012009Each year, the American Heart Association, 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 on heart disease, stroke, other vascular diseases, and their risk factors and presents them in its Heart Disease and Stroke Statistical Update. The Statistical Update is a valuable resource for researchers, clinicians, healthcare policy makers, media professionals, the lay public, and many others who seek the best national data available on disease morbidity and mortality and the risks, quality of care, medical procedures and operations, and costs associated with the management of these diseases in a single document. This year’s edition includes several areas not covered in previous editions. Below are a few highlights from this year’s Update.Death Rates From Cardiovascular Disease Have Declined, Yet the Burden of Disease Remains HighThe 2005 overall death rate from cardiovascular disease (CVD) (International Classification of Diseases 10, I00–I99) was 278.9 per 100 000. The rates were 324.7 per 100 000 for white males, 438.4 per 100 000 for black males, 230.4 per 100 000 for white females, and 319.7 per 100 000 for black females. From 1995 to 2005, death rates from CVD declined 26.4%. Preliminary mortality data for 2006 show that CVD (I00–I99; Q20–Q28) accounted for 34.2% (829 072) of all 2 425 900 deaths in 2006, or 1 of every 2.9 deaths in the United States.On the basis of 2005 mortality rate data, nearly 2400 Americans die of CVD each day—an average of 1 death every 37 seconds. The 2006 overall preliminary death rate from CVD was 262.9. More than 150 000 Americans killed by CVD (I00–I99) in 2005 were <65 years of age. In 2005, 32% of deaths from CVD occurred before the age of 75 years, which is well before the average life expectancy of 77.9 years.Coronary heart disease (CHD) caused about 1 of every 5 deaths in the United States in 2005. CHD mortality in 2005 was 445 687. In 2009, an estimated 785 000 Americans will have a new coronary attack, and about 470 000 will have a recurrent attack. It is estimated that an additional 195 000 silent first myocardial infarctions occur each year. About every 25 seconds, an American will have a coronary event, and about every minute someone will die from one.Each year, about 795 000 people experience a new or recurrent stroke. About 610 000 of these are first attacks, and 185 000 are recurrent attacks. Preliminary data from 2006 indicate that stroke accounted for about 1 of every 18 deaths in the United States. On average, every 40 seconds someone in the United States has a stroke. From 1995 to 2005, the stroke death rate fell 29.7%, and the actual number of stroke deaths declined 13.5%.In 2005, 1 in 8 death certificates (292 214 deaths) in the United States mentioned heart failure.Control of Risk Factors Remains an Issue for Many AmericansData from the National Health and Nutrition Examination Survey 2005–2006 found that between 1999–2000 and 2005–2006, mean serum total cholesterol levels in adults ≥20 years of age declined from 204 mg/dL to 199 mg/dL. This decline was observed for men ≥40 years of age and for women ≥60 years of age. There was little change over this time period for other sex/age groups. In 2005–2006, approximately 65% of men and 70% of women had been screened for high cholesterol in the previous 5 years. In 2005–2006, 16% of adults had serum total cholesterol levels of ≥240 mg/dL.Despite recommendations that some proportion of activity be vigorous (activity that causes heavy sweating and a large increase in breathing and/or heart rate), 62% of adults >18 years of age who responded to the 2006 National Health Interview Survey reported no vigorous activity lasting >10 minutes per session.On the basis of data from the National Health and Nutrition Examination Survey (National Center for Health Statistics), the prevalence of overweight (body mass index–for–age values at or above the 95th percentile) in children 6 to 11 years of age increased from 4.0% in 1971–1974 to 17.0% in 2003–2006. The prevalence of body mass index–for–age values at or above the 95th percentile in adolescents 12 to 19 years of age increased from 6.1% to 17.6% in that same time frame. Among infants and children between the ages of 6 and 23 months, the prevalence of high weight-for-age was 7.2% in 1976–1980 and 11.5% in 2003–2006 (National Health and Nutrition Examination Survey, National Center for Health Statistics).Just over 12% of preschool children 2 to 5 years of age were overweight in 2003–2006.The 2009 Update Expands Data Coverage of Congenital Cardiovascular Defects and Nutritional/Dietary Intake and Adds a New Chapter on Epidemiology and Statistics of Subclinical Atherosclerosis and a Subsection on Family History of CVDSeveral chapters and sections that have been added or revised for this year’s Update merit specific mention. First, we have added a new chapter (Chapter 3) that describes the epidemiology of subclinical atherosclerosis. It has been known for decades that atherosclerosis, the underlying cause of the majority of clinical CVD events, is typically present for decades before the onset of a clinical CVD event or symptoms. As discussed in Chapters 2 and 4, the initial manifestation of clinical atherosclerotic CVD too often is a fatal event, such as sudden cardiac death, or a devastating nonfatal event, such as a large nonfatal myocardial infarction or a disabling stroke. Advances in imaging technology over the past several decades have made it possible to detect and evaluate the burden of subclinical atherosclerosis in a variety of different vascular beds. Two modalities, ultrafast computed tomography for imaging of coronary artery calcification (CAC) and B-mode ultrasound for measurement of carotid intima-media thickness (IMT), have been studied widely in diverse population samples and have greatly enhanced our understanding of the development and progression of subclinical atherosclerosis, as well as its relationship to subsequent clinical events. The American Heart Association Statistics Committee felt that, given the extensive literature in this area and the increasing consideration of use of these modalities in clinical practice, it was time to provide a review of the epidemiological data from representative, nonreferral population samples to provide a measure of context for the data on subclinical atherosclerosis in the scientific and lay media.For example, the National Heart, Lung, and Blood Institute’s Coronary Artery Risk Development in Young Adults (CARDIA) study and Multi-Ethnic Study of Atherosclerosis (MESA) have helped to define age-, sex-, and race-specific levels of CAC in a diverse population. In younger adults in CARDIA, 33 to 45 years of age, 15.0% of men and 5.1% of women already had CAC, and 1.6% had a CAC score >100. Among older adults in MESA, the prevalence and 75th percentile levels of CAC were highest in white men and lowest in black and Hispanic women, as shown in Table 3-1 in Chapter 3. Significant ethnic differences persisted after adjustment for risk factors, with the relative risk of having CAC being 22% lower in blacks, 15% lower in Hispanics, and 8% lower in Chinese, as compared with whites. Longitudinal data from MESA also highlight the risks associated with the presence and extent of CAC. Chart 3-3 in Chapter 3 shows the relative risks or hazard ratios associated with CAC scores of 1 to 100, 101 to 300, and >300 compared with those without CAC (score=0), after adjustment for standard risk factors. Persons with CAC scores of 1 to 100 were approximately 4 times more likely and those with CAC scores >100 were 7 to 10 times more likely to suffer a coronary event than those without CAC.Carotid IMT, in the absence of frank atherosclerotic plaque, is thought to represent an earlier and more continuous manifestation of atherosclerosis than CAC. Analyses from the Bogalusa Heart Study, CARDIA, MESA, and the Cardiovascular Health Study have helped to describe the epidemiology of carotid IMT across the spectra of age, sex, and race. Concurrent levels of risk factors in young adulthood and early levels of risk factors, even those measured in people 4 to 17 years of age, were significantly associated with carotid IMT at a mean age of 32 years. Higher body mass index and low-density lipoprotein cholesterol levels measured at 4 to 17 years of age were associated with increased risk for being above the 75th percentile for carotid IMT later on in young adulthood. Higher systolic blood pressure and low-density lipoprotein cholesterol and lower high-density lipoprotein cholesterol in young adulthood were also associated with having high carotid IMT. These data highlight the importance of adverse risk factor levels and obesity in early childhood and young adulthood in the early development of atherosclerosis. In the Cardiovascular Health Study, among older Americans, after a mean follow-up of 6.2 years, those with maximal carotid IMT in the highest quintile had a 4- to 5-fold greater risk for incident heart attack or stroke than that of those in the bottom quintile. After adjustment for other risk factors, there was still a 2- to 3-fold greater risk for the top versus the bottom quintile. These data should help to provide some context for physicians and patients to help understand the evolving roles of subclinical atherosclerosis imaging in research and clinical practice.As in prior years, we continue to highlight (in Chapter 2) the importance of maintaining low risk factor burden through young adulthood to middle and older ages. An extensive body of literature has demonstrated that individuals who survive to middle age (eg, age 50) without developing traditional CVD risk factors, such as hypercholesterolemia, hypertension, diabetes, or smoking, enjoy a broad array of health benefits, including substantially greater longevity, substantially reduced short- and long-term and remaining lifetime risks for CVD events even in the face of greater longevity, lower risks for both CVD death and non-CVD death, better health-related quality of life in older age, and substantially reduced total and annual Medicare expenditures.A new section in Chapter 2 also highlights some of the increasing knowledge available about the complex association between family history of CVD and future risk for CVD among offspring and siblings. In future updates, we anticipate including greatly expanded information and discussion of results from genetic studies that may help elucidate novel underlying mechanisms and pathways of atherosclerosis and CVD development.The chapter on congenital cardiovascular disease (Chapter 7) has been completely revised to provide updated and more useful information. Whereas surveillance for congenital heart defects is incomplete, these data reflect more contemporary estimates and represent the best available data. For example, on the basis of present estimates, 9 congenital heart defects per 1000 live births, or 36 000 infants born with congenital heart defects, are expected in the United States per year. Of these, several studies suggest that 9200, or 2.3 per 1000 live births, require invasive treatment or result in death in the first year of life.We have substantially revised and updated the chapter (Chapter 17) describing current nutritional intake data, trends and changes in intakes, estimated effects on cardiovascular risk factors and cardiovascular outcomes, and current costs and trends for all foods. New tables and charts added to the chapter this year include: Table 17-1, on dietary consumption by US adults (>20 years of age) of selected foods and nutrients related to cardiometabolic health; Table 17-2, on dietary consumption by US children and teenagers of selected foods and nutrients related to cardiometabolic health; Chart 17-1, on age-adjusted trends in macronutrients and total calories consumed by US adults (20 to 74 years of age); Chart 17-2, on per capita calories consumed from different beverages by US adults (≥19 years of age); and Chart 17-3, on total US food expenditures away from home and at home.Reporting and monitoring quality-of-care measures stratified by patient’s race/ethnicity and sex are important steps toward addressing disparities in health care through organizational quality improvement. In Chapter 18, new data on quality of care and quality-of-care measures stratified by race/