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Original Research |

Cardiovascular Mortality Associated With 5 Leading Risk Factors: National and State Preventable Fractions Estimated From Survey DataCardiovascular Mortality Associated With Leading Risk Factors

Shivani A. Patel, PhD; Munir Winkel, MSc; Mohammed K. Ali, MBChB; K.M. Venkat Narayan, MD; and Neil K. Mehta, PhD
[+] Article, Author, and Disclosure Information

This article was published online first at www.annals.org on 30 June 2015.


From Rollins School of Public Health, Emory University, Atlanta, Georgia.

Note: Drs. Patel and Mehta had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Grant Support: By grant 70769 from the Robert Wood Johnson Foundation.

Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-1753.

Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.

Reproducible Research Statement:Study protocol: Not applicable. Statistical code: The full code is available from Dr. Patel (e-mail, s.a.patel@emory.edu). Sample code is provided in the Supplement. Data set: BRFSS data are available at www.cdc.gov/brfss. NHANES data are available at www.cdc.gov/nchs/nhanes.htm.

Requests for Single Reprints: Shivani A. Patel, PhD, Hubert Department of Global Health, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Room 6002, Atlanta, GA 30322; e-mail, s.a.patel@emory.edu.

Current Author Addresses: Dr. Patel: Hubert Department of Global Health, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Room 6002, Atlanta, GA 30322.

Mr. Winkel: 3108 East Aileen Drive, Raleigh, NC 27606.

Dr. Ali: Hubert Department of Global Health, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Room 7041, Atlanta, GA 30322.

Dr. Narayan: Hubert Department of Global Health, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Room 7051, Atlanta, GA 30322.

Dr. Mehta: Hubert Department of Global Health, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Room 7035, Atlanta, GA 30322.

Author Contributions: Conception and design: S.A. Patel, M.K. Ali, K.M.V. Narayan, N.K. Mehta.

Analysis and interpretation of the data: S.A. Patel, M. Winkel, K.M.V. Narayan, N.K. Mehta.

Drafting of the article: S.A. Patel, N.K. Mehta.

Critical revision of the article for important intellectual content: S.A. Patel, M.K. Ali, K.M.V. Narayan, N.K. Mehta.

Final approval of the article: S.A. Patel, M.K. Ali, K.M.V. Narayan, N.K. Mehta.

Statistical expertise: S.A. Patel, M. Winkel, N.K. Mehta.

Obtaining of funding: K.M.V. Narayan, N.K. Mehta.

Administrative, technical, or logistic support: N.K. Mehta.

Collection and assembly of data: S.A. Patel, N.K. Mehta.


Ann Intern Med. 2015;163(4):245-253. doi:10.7326/M14-1753
Text Size: A A A

Background: Impressive decreases in cardiovascular mortality have been achieved through risk factor reduction and clinical intervention, yet cardiovascular disease remains a leading cause of death nationally.

Objective: To estimate up-to-date preventable fractions of cardiovascular mortality associated with elimination and reduction of 5 leading risk factors nationally and by state in the United States.

Design: Cross-sectional and cohort studies.

Setting: Nationally representative and state-representative samples of the U.S. population.

Participants: Adults aged 45 to 79 years.

Measurements: Self-reported risk factor status in the BRFSS (Behavioral Risk Factor Surveillance System) 2009–2010 was corrected to approximate clinical definitions. The relative hazards of cardiovascular death (International Classification of Diseases, 10th Revision, codes I00 to I99) associated with risk factors were estimated using data from NHANES (National Health and Nutrition Examination Survey) (1988–1994 and 1999–2004, followed through 2006).

Results: The preventable fraction of cardiovascular mortality associated with complete elimination of elevated cholesterol levels, diabetes, hypertension, obesity, and smoking was 54.0% for men and 49.6% for women in 2009 to 2010. When the more feasible target of reducing risk factors to the best achieved levels in the states was considered, diabetes (1.7% and 4.1%), hypertension (3.8% and 7.3%), and smoking (5.1% and 4.4%) were independently associated with the largest preventable fractions among men and women, respectively. With both targets, southern states had the largest preventable fractions, and western states had the smallest.

Limitation: Self-reported state data; mortality hazards relied on baseline risk factor status.

Conclusion: Major modifiable cardiovascular risk factors collectively accounted for half of cardiovascular deaths in U.S. adults aged 45 to 79 years in 2009 to 2010. Fewer than 10% of cardiovascular deaths nationally could be prevented if all states were to achieve risk factor levels observed in the best-performing states.

Primary Funding Source: Robert Wood Johnson Foundation.

Figures

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Figure.

Distribution of 5 leading modifiable cardiovascular risk factors in the United States, 2009–2010.

Prevalence of clinically defined cardiovascular risk factors, based on a correction of self-reported data in the BRFSS (Behavioral Risk Factor Surveillance System) 2009–2010 and shaded by quintile of national ranking, are shown.

Grahic Jump Location
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Appendix Figure.

State-level preventable fractions of cardiovascular mortality for men and women, based on a target of the best achieved levels of risk factors.

States are displayed in descending order of cardiovascular mortality, age-standardized to the national population in 2009–2010.

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In Response
Posted on September 3, 2015
William B. Grant PhD, Luca Mascitelli, MD, Mark R. Goldstein, MD, FACP
Sunlight, Nutrition, and Health Research Center , Multinational Land Force, Medical Service, NCH Physician Group
Conflict of Interest: None Declared
The paper by Patel and colleagues used data from 50 states plus the District of Columbia to develop a model to explain risk factors for cardiovascular disease (CVD) mortality in 2009-2010 (1). Their model included elevated cholesterol level, diabetes, hypertension, obesity, and current smoking. Since the data from NHANES used in their model were provided, we decided to reexamine their model. The data were analyzed using SPSS 20.0 (IBM, Armonk, New York). In single linear regression analyses, only three of the factors were significantly correlated with CVD mortality rates, with hypertension most important, followed by current smoking, and obesity. In a multiple-linear regression analysis, obesity was not significantly correlated with CVD. The adjusted R2 for hypertension and current smoking was 0.81.

However, one important factor was omitted explicitly from their model: ethnic background. African Americans have much higher CVD mortality rates than Asians, Hispanics or whites, and comprise large fractions of populations of many states (2). When fraction of population African American was run with hypertension, and current smoking, obesity, the best model results were obtained (adjusted R2= 0.88). However, the risk factors are not independent. Hypertension is highly correlated with current smoking, African-American population, and obesity, in that order, but not with cholesterol or diabetes.

The primary mechanism increasing blood pressure appears to be oxidative stress from reactive oxygen species (2). The Taiwan Society of Cardiology and the Taiwan Hypertension Society for the management of hypertension have issued guidelines for the management of hypertension "starting with life style modification (LSM) including S-ABCDE (Sodium restriction, Alcohol limitation, Body weight reduction, Cigarette smoke cessation, Diet adaptation, and Exercise adoption)." (3).

Another recent paper found that lower income and educational level were strongly correlated with CVD mortality rates and that minority and low socioeconomic groups explained 44% of the variation in U.S. CVD mortality rates (4). This finding suggests that even if the important CVD risk factors were identified, many who might die from CVD would be unable to change lifestyle due to economic and educational level constraints.

While other studies indicate that cholesterol is a risk factor for CVD, targeting cholesterol may not be wise. An observational study in Wales, UK involving 1773 middle-aged men followed for an average of 15.4 years found a sub-hazard ratio related to cholesterol for CVD mortality of 1.20 (95% CI, 1.05-1.37) but 0.81 (0.72-0.90) for non-CVD mortality (5).


References
1. Patel SA, Winkel M, Ali MK, Narayan KM, Mehta NK. Cardiovascular mortality associated with 5 leading risk factors: National and state preventable fractions estimated from survey data. Ann Intern Med. 2015;163:245-53.PMID:26121190
2. Montezano AC, Dulak-Lis M, Tsiropoulou S, Harvey A, Briones AM, Touyz RM. Oxidative stress and human hypertension: vascular mechanisms, biomarkers, and novel therapies. Can J Cardiol. 2015;31:631-41. PMID: 25936489
3. Chiang CE, Wang TD, Ueng KC, Lin TH, Yeh HI, Chen CY, et al. 2015 guidelines of the Taiwan Society of Cardiology and the Taiwan Hypertension Society for the management of hypertension. J Chin Med Assoc. 2015;78:1-47. PMID: 25547819
4. Gebreab SY, Davis SK, Symanzik J, Mensah GA, Gibbons GH, Diez-Roux AV. Geographic variations in cardiovascular health in the United States: contributions of state- and individual-level factors.J Am Heart Assoc. 2015;4:e001673. PMID:26019131
5. Patterson CC, Blankenberg S, Ben-Shlomo Y, Heslop L, Bayer A, Lowe G, et al. Which biomarkers are predictive specifically for cardiovascular or for non-cardiovascularmortality in men? Evidence from the Caerphilly Prospective Study (CaPS).Int J Cardiol. 2015;201:113-118. PMID:26298350




Author's Response
Posted on October 8, 2015
Shivani A. Patel, PhD, Neil K. Mehta, PhD, Mohanned K. Ali, MDChB
Emory Univeristy
Conflict of Interest: None Declared
We recently reported that approximately half of national cardiovascular deaths among U.S. Americans aged 45-79 years could be attributed collectively to elevated cholesterol levels, diabetes, hypertension, obesity, and smoking—five modifiable biomedical risk factors for cardiovascular disease (1). Contrary to the conclusion by Grant et al., we in fact controlled for race/ethnicity, along with educational attainment, in estimating the input hazard ratios for the attributable fraction calculations (please see Methods and Statistical Appendix) (1).

We also estimated preventable fractions of cardiovascular mortality associated with each of the five risk factors individually. We found that hypertension and smoking were associated with the largest preventable fractions of cardiovascular mortality nationally among both men and women. In contrast, elevated cholesterol individually were associated with preventable fractions that could not be statistically distinguished from zero among women.

The focus of our analysis was the independent contribution of modifiable biomedical risk factors for cardiovascular disease on cardiovascular mortality. We wholeheartedly endorse investigation into the well-established “upstream” social determinants of cardiovascular health—such as race/ethnic background, education, and income—to better inform public health practice and health policy. Public-health oriented efforts to reduce the onset of biomedical risk factors in the population and social welfare policies to improve socioeconomic conditions in which risk factors and disease more broadly arise are complementary goals.

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