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Figure.
Age-Adjusted Mortality Rates in the United States, 2000-2014
Age-Adjusted Mortality Rates in the United States, 2000-2014

Rates shown for the total population and subgroups.

Table 1.  
Trends in Mortality
Trends in Mortality
Table 2.  
Mortality Rates and Annual Rates of Change
Mortality Rates and Annual Rates of Change
1.
Leading causes of death, 1900-1998. http://www.cdc.gov/nchs/data/dvs/lead1900_98.pdf. Accessed December 15, 2015.
2.
Hoyert  DL.  75 Years of mortality in the United States, 1935-2010.  NCHS Data Brief. 2012;(88):1-8.PubMed
3.
Murphy  SL, Xu  JQ, Kochanek  KD.  Deaths: final data for 2010.  Natl Vital Stat Rep. 2013;61(4):1-117.PubMed
4.
Ford  ES, Ajani  UA, Croft  JB,  et al.  Explaining the decrease in US deaths from coronary disease, 1980-2000.  N Engl J Med. 2007;356(23):2388-2398.PubMedArticle
5.
Ford  ES, Capewell  S.  Proportion of the decline in cardiovascular mortality disease due to prevention versus treatment: public health versus clinical care.  Annu Rev Public Health. 2011;32:5-22.PubMedArticle
6.
Labarthe  DR.  From cardiovascular disease to cardiovascular health: a quiet revolution?  Circ Cardiovasc Qual Outcomes. 2012;5(6):e86-e92.PubMedArticle
7.
Lloyd-Jones  DM, Hong  Y, Labarthe  D,  et al; American Heart Association Strategic Planning Task Force and Statistics Committee.  Defining and setting national goals for cardiovascular health promotion and disease reduction: the AHA’s strategic Impact Goal through 2020 and beyond.  Circulation. 2010;121(4):586-613.PubMedArticle
8.
Frieden  TR, Berwick  DM.  The “Million Hearts” initiative—preventing heart attacks and strokes.  N Engl J Med. 2011;365(13):e27.PubMedArticle
9.
Centers for Disease Control and Prevention. Underlying cause of death, 1999-2014 request. http://wonder.cdc.gov/ucd-icd10.html. Accessed January 14, 2016.
10.
Klein  RJ, Schoenborn  CA.  Age Adjustment Using the 2000 Projected US Population. Hyattsville, MD: National Center for Health Statistics; January 2001. Healthy People Statistical Notes, No. 20.
11.
Xu  J, Murphy  SL, Kochanek  KD, Bastian  BA.  Deaths: Final Data for 2013.  Natl Vital Stat Rep. 2016;64(2):1-119.PubMed
12.
Bauer  UE, Briss  PA, Goodman  RA, Bowman  BA.  Prevention of chronic disease in the 21st century: elimination of the leading preventable causes of premature death and disability in the USA.  Lancet. 2014;384(9937):45-52.PubMedArticle
13.
Mann  D, Reynolds  K, Smith  D, Muntner  P.  Trends in statin use and low-density lipoprotein cholesterol levels among US adults: impact of the 2001 National Cholesterol Education Program guidelines.  Ann Pharmacother. 2008;42(9):1208-1215.PubMedArticle
14.
Steinberg  BA, Bhatt  DL, Mehta  S,  et al.  Nine-year trends in achievement of risk factor goals in the US and European outpatients with cardiovascular disease.  Am Heart J. 2008;156(4):719-727.PubMedArticle
15.
Ma  J, Ward  EM, Siegel  RL, Jemal  A.  Temporal trends in mortality in the United States, 1969-2013.  JAMA. 2015;314(16):1731-1739.PubMedArticle
16.
Zhou  Y, Boudreau  DM, Freedman  AN.  Trends in the use of aspirin and nonsteroidal anti-inflammatory drugs in the general US population.  Pharmacoepidemiol Drug Saf. 2014;23(1):43-50.PubMedArticle
17.
Fang  J, George  MG, Gindi  RM,  et al.  Use of low-dose aspirin as secondary prevention of atherosclerotic cardiovascular disease in US adults (from the National Health Interview Survey, 2012).  Am J Cardiol. 2015;115(7):895-900.PubMedArticle
18.
Gu  Q, Paulose-Ram  R, Burt  VL, Kit  BK.  Prescription Cholesterol-Lowering Medication Use in Adults 40 and Over: United States, 2003-2012. Hyattsville, MD: National Center for Health Statistics; 2014. NCHS Data Brief, No. 177.
19.
Mozaffarian  D, Benjamin  EJ, Go  AS,  et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee.  Heart disease and stroke statistics—2016 update: a report from the American Heart Association.  Circulation. 2016;133(4):e38-e360.PubMedArticle
20.
Huffman  MD, Capewell  S, Ning  H, Shay  CM, Ford  ES, Lloyd-Jones  DM.  Cardiovascular health behavior and health factor changes (1988-2008) and projections to 2020: results from the National Health and Nutrition Examination Surveys.  Circulation. 2012;125(21):2595-2602.PubMedArticle
21.
National Center for Health Statistics. Vital Statistics Rapid Release. Quarterly provisional estimates for selected causes of death: United States, 2014—quarter 3, 2015. http://www.cdc.gov/nchs/products/vsrr/mortality-dashboard.htm. Published February 24, 2016. Accessed March 4, 2016.
22.
Imes  CC, Burke  LE.  The obesity epidemic: the United States as a cautionary tale for the rest of the world.  Curr Epidemiol Rep. 2014;1(2):82-88.PubMedArticle
23.
Mainous  AG  III, Baker  R, Koopman  RJ,  et al.  Impact of the population at risk of diabetes on projections of diabetes burden in the United States: an epidemic on the way.  Diabetologia. 2007;50(5):934-940.PubMedArticle
24.
Flegal  KM, Carroll  MD, Ogden  CL, Johnson  CL.  Prevalence and trends in obesity among US adults, 1999-2000.  JAMA. 2002;288(14):1723-1727.PubMedArticle
25.
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.PubMedArticle
26.
CDC’s Division of Diabetes Translation. National Diabetes Surveillance System. Long-term trends in diabetes. http://www.cdc.gov/diabetes/statistics/slides/long_term_trends.pdf. Published October 2014. Accessed March 20, 2016.
27.
Centers for Disease Control and Prevention.  National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States, 2014. Atlanta, GA: US Dept of Health & Human Services; 2014.
28.
Marken  S. US uninsured rate 11.9% in fourth quarter of 2015. http://www.gallup.com/poll/188045/uninsured-rate-fourth-quarter-2015.aspx. Published January 7, 2016. Accessed March 20, 2016.
29.
Sidney  S, Rosamond  WD, Howard  VJ, Luepker  RV; National Forum for Heart Disease and Stroke Prevention.  The “heart disease and stroke statistics—2013 update” and the need for a national cardiovascular surveillance system.  Circulation. 2013;127(1):21-23.PubMedArticle
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Brief Report
August 2016

Recent Trends in Cardiovascular Mortality in the United States and Public Health Goals

Author Affiliations
  • 1Division of Research, Kaiser Permanente Northern California, Oakland
  • 2Department of Endocrinology, Kaiser Permanente Northern California, South San Francisco
  • 3Department of Neurology, Kaiser Permanente Northern California, Walnut Creek
  • 4Departments of Epidemiology, Biostatistics and Medicine, University of California, San Francisco
  • 5Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California
  • 6Department of Cardiology, Kaiser Permanente Northern California, Oakland
  • 7Department of Medicine, University of California, San Francisco
JAMA Cardiol. 2016;1(5):594-599. doi:10.1001/jamacardio.2016.1326
Abstract

Importance  Heart disease (HD) and cancer are the 2 leading causes of death in the United States. During the first decade of the 21st century, HD mortality declined at a much greater rate than cancer mortality and it appeared that cancer would overtake HD as the leading cause of death.

Objectives  To determine whether changes in national trends had occurred in recent years in mortality rates due to all cardiovascular disease (CVD), HD, stroke, and cancer and to evaluate the gap between mortality rates from HD and cancer.

Design, Setting, and Participants  The Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research data system was used to determine national trends in age-adjusted mortality rates due to all CVD, HD, stroke, and cancer from January 1, 2000, to December 31, 2011, and January 1, 2011, to December 31, 2014, overall, by sex, and by race/ethnicity. The present study was conducted from December 30, 2105, to January 18, 2016.

Main Outcomes and Measures  Comparison of annual rates of change and trend in gap between HD and cancer mortality rates.

Results  The rate of the decline in all CVD, HD, and stroke mortality decelerated substantially after 2011, and the rate of decline for cancer mortality remained relatively stable. Reported as percentage (95% CI), the annual rates of decline for 2000-2011 were 3.79% (3.61% to 3.97%), 3.69% (3.51% to 3.87%), 4.53% (4.34% to 4.72%), and 1.49% (1.37% to 1.60%) for all CVD, HD, stroke, and cancer mortality, respectively; the rates for 2011-2014 were 0.65% (−0.18% to 1.47%), 0.76% (−0.06% to 1.58%), 0.37% (−0.53% to 1.27%), and 1.55% (1.07% to 2.04%), respectively. Deceleration of the decline in all CVD mortality rates occurred in males, females, and all race/ethnicity groups. For example, the annual rates of decline for total CVD mortality for 2000-2011 were 3.69% (3.48% to 3.89%) for males and 3.98% (3.81% to 4.14%) for females; for 2011-2014, the rates were 0.23% (−0.71% to 1.16%) and 1.17% (0.41% to 1.93%), respectively. The gap between HD and cancer mortality persisted.

Conclusions and Relevance  Deceleration in the decline of all CVD, HD, and stroke mortality rates has occurred since 2011. If this trend continues, strategic goals for lowering the burden of CVD set by the American Heart Association and the Million Hearts Initiative may not be reached.

Introduction

With the exception of the flu pandemic years of 1918-1920, heart disease (HD) has been the leading cause of death in the United States since 1910,1 with cancer and stroke among the 5 leading causes of death every year since 1924.2 From 2000 to 2010, age-adjusted mortality decreased 30% for HD and 36% for stroke, but cancer mortality declined only 13%.3 Heart disease mortality approached that of cancer, suggesting that cancer might soon replace HD as the leading cause of death.

The decrease in HD mortality in the United States has been attributed to expanded use of evidence-based medical therapies as well as changes in risk factors and lifestyle modifications at a population level.4,5 Longstanding emphasis on cardiovascular disease (CVD) prevention has led to a concept of cardiovascular health.6 The American Heart Association has a strategic goal of improving the cardiovascular health of all Americans by 20% while reducing deaths from CVD and stroke by 20% from 2010 to 2020.7 The Million Hearts Initiative was announced in 2011, with the goal of preventing 1 million myocardial infarctions and strokes by 2017.8

We evaluated the most recent trends in mortality attributed to all CVD, HD, stroke, and cancer from 2000 to 2014 to gauge whether there have been any recent changes in the pattern of decline in all CVD mortality and to assess trends in the gap between HD and cancer mortality.

Box Section Ref ID

Key Points

  • Question Are there changes in national trends in recent years in mortality rates due to cardiovascular disease (CVD), heart disease (HD), stroke, and cancer?

  • Findings The rate of decline in all CVD, HD, and stroke mortality decelerated substantially after 2011. Deceleration of the decline in all CVD mortality rates occurred in males, females, and all race/ethnicity groups, and the gap between HD and cancer mortality persisted.

  • Meaning If this deceleration trend continues, strategic goals for lowering the burden of CVD set by the American Heart Association and the Million Hearts Initiative may not be reached.

Methods
Mortality

Mortality rates throughout the United States for 2000-2014 were ascertained using the Centers for Disease Control and Prevention’s Wide-Ranging Online Data for Epidemiologic Research data set, which includes the assigned cause of death from all death certificates filed in the 50 states and the District of Columbia.9 Categorization of the presumed underlying cause of death used International Statistical Classification of Diseases and Related Health Problems, Tenth Edition codes as follows: all CVD (codes I00-I99), HD (codes I00-I09, I11, I13, and I20-I51), cerebrovascular disease (codes I60-I69), and cancer (malignant neoplasms [codes C00-C97]). Based on the National Human Subjects Protection Advisory Committee's recommendations, this study did not require institutional review board approval because it analyzes government-issued public use data without individual identifiable information. The present study was conducted from December 30, 2105, to January 18, 2016.

Statistical Analysis

Mortality rates were age-adjusted using the direct method, with the 2000 US Census10 as the standard population, using the following age categorization: younger than 1 year, 1 to 4, 5 to 14, 15 to 24, 25 to 34, 35 to 44, 45 to 54, 55 to 64, 65 to 74, 75 to 84, and 85 years or older. Poisson regression (with allowance for overdispersion, ie, variance > mean) was used for point and interval estimation of age-adjusted annual rates of change for January 1, 2000, to December 31, 2011, and January 1, 2011, to December 31, 2014, by fitting a piecewise linear spline for the 2 calendar time intervals, with a Wald test of the difference in rates (slopes).

Results
All CVD Mortality

Age-adjusted mortality rates declined from 2000 to 2014 for all CVD (341.3 in 2000 vs 219.9 in 2014; rate decline of 35.6%), HD (257.6 vs 167.0; rate decline of 35.2%), and stroke (60.9 vs 36.5; rate decline of 40.1%) (Table 1 and Figure, A). There was a deflection point in these trends in 2011, with substantial slowing in the decline from 2011 to 2014 (Table 2). From 2000 to 2011, the mean annual age-adjusted rate (percentage [95% CI]) of decline was 3.79% (3.61% to 3.97%) for all CVD, 3.69% (3.51% to 3.87%) for HD, and 4.53% (4.34% to 4.72%) for stroke; from 2011 to 2014, the respective rates of decline were 0.65% (−0.18% to 1.47%), 0.76% (−0.06% to 1.58%), and 0.37% (−0.53% to 1.27%) (Table 2). The US population and the total number of all CVD, HD, and stroke deaths increased from 2011 to 2014, with resultant slightly higher crude mortality rates in 2014 compared with 2011 for all CVD (253.3 vs 251.4 per 100 000 person-years), HD (192.7 vs 191.5 per 100 000 person-years), and stroke (41.7 vs 41.4 per 100 000 person-years).

Sex and Race/Ethnicity

Males had higher mortality rates than females for all conditions throughout the period (eTable 1 and eTable 2 in the Supplement and Figure, B and C). The annual rates (percentage [95% CI]) of decline of all CVD changed from 3.98% (3.81% to 4.14%) for females and 3.69% (3.48% to 3.89%) for males during 2000-2011 to 1.17% (0.41% to 1.93%) and 0.23% (−0.71% to 1.16%), respectively, during 2011-2014 (Table 2). Similar changes were evident for HD and stroke mortality.

Non-Hispanic (NH) blacks had the highest mortality for all CVD and HD in all years, followed by NH whites, NH American Indian/Alaskan Natives, Hispanics, and NH Asian/Pacific Islanders (Figure, D-F, and eFigure and eTables 3-7 in the Supplement). Each of the racial/ethnic groups, except NH American Indian/Alaskan Native, had significant differences in the annual change in mortality rates for all CVD, HD, and stroke between 2000-2011 and 2011-2014 (Table 2).

Cancer Mortality and Gap Between HD and Cancer Mortality

The overall decline in cancer mortality nationally was 19.2% between 2000 and 2014 (199.6 vs 161.2), and the annual rate of change was not significantly different in 2011-2014 compared with 2000-2011. The gap between HD and cancer mortality rates has remained essentially unchanged since 2011 (Table 1 and Figure, A).

Discussion

The rates of decline of all CVD, HD, and stroke decelerated dramatically between 2011 and 2014. If the rates of decline from 2000 to 2011 had persisted, HD mortality in the United States would have been below that of cancer mortality in 2013, but the pattern of HD and cancer being the first and second leading causes of death, respectively, has endured.11

Nationally, chronic diseases are the primary causes of disability and death.12 The Centers for Disease Control and Prevention advocates that public health and health care systems deploy integrated approaches that bundle proven interventions and address multiple risk factors and conditions simultaneously to create population-wide changes that may effectively address the burden of chronic diseases.12 Increased emphasis on measures to reduce risk factors at the individual and community levels, including public bans on smoking and lower target levels of low-density lipoprotein cholesterol and blood pressure, have contributed to improved control of risk factors over time.13,14

Ma et al15 found that HD and stroke declined more slowly in the latter part of the 2000-2013 period, from a 3.9% annual percentage change from 2000-2010 to 1.4% from 2010-2013 for HD and from 5.5% annual percentage change from 2001-2007 to 3.0% in 2007-2013 for stroke, so that our findings may represent a continuation of these trends to the point of near stagnation.15 It is unknown whether small annual reduction rates in HD and stroke mortality rates will persist. It is possible that the early part of the 21st century experienced a particularly high rate of decline in CVD mortality because of the implementation of the prevention programs noted earlier and that the decline might have slowed as implementation approached a saturation level in the community.

The use of the cardiopreventive medications (ie, aspirin and statins) has increased in recent years. The percentage of adults (age ≥18 years) reporting regular aspirin use increased from 11.7% in 2005 to 19.0% in 2010,16 as assessed by the National Health Interview Survey,17 with a 70% prevalence of low-dose aspirin use for secondary prevention of CVD noted in 2012. Statin use among adults 40 years or older increased from 16.3% in 2003-2004 to 23.2% in 2011-2012 based on National Health and Nutrition Examination Survey (NHANES) data.18

The American Heart Association uses 7 metrics for the assessment of cardiovascular health.19 Based on NHANES data,19 the percentage of adults achieving ideal cardiovascular health for blood pressure, cholesterol, and smoking increased from 1999 to 2012; the percentage meeting ideal levels for body mass index and glucose decreased from 1999 to 2012; and the percentage meeting the ideal level for diet was near zero. The percentage of adults meeting ideal cardiovascular health for physical activity could not be compared over time because of assessment method changes.

Based on NHANES data from 1988 to 2008,20 if current trends continue, estimated cardiovascular health is projected to improve by 6% between 2010 and 2020, which is short of the American Heart Association’s goal of 20% improvement.19 Anticipated declines in the prevalence of smoking, high cholesterol levels, and hypertension (in males) would be offset by substantial increases in the prevalence of obesity and diabetes.20

A significant concern is the possibility that CVD mortality rates stop decreasing and perhaps even increase, as suggested by provisional estimates though the third quarter of 2015 of higher mortality rates than in 2014 for HD and stroke,21 in part owing to the increasing prevalence of obesity and diabetes at epidemic proportions.22,23 The NHANES estimate of the prevalence of adult obesity increased from 22.9% in 1988-1994 to 34.9% in 2011-2012,24,25 and the prevalence of diabetes nearly tripled, from 2.5% in 1990 to 7.2% in 2013.26 An estimated 29 million US adults have diabetes.27

It is hoped that increased access to medical care and preventive services resulting from the Affordable Care Act will lead to improved cardiovascular outcomes. The health insurance mandate of the Affordable Care Act has been associated with a 30% decline in the percentage of uninsured adults from 17.1% in the fourth quarter of 2013, just before the mandate began, to 11.9% in the fourth quarter of 2015.28

The age-adjusted total CVD and stroke mortality rates both declined by 6.6% from 2010 to 2014. Total CVD and stroke mortality rates would need to decrease by more than 2% annually—much higher than the recent rate of decline—to achieve the American Heart Association’s 2020 goal of 20% reductions. The Million Hearts Initiative’s primary goal of preventing 1 million myocardial infarctions and strokes cannot be measured, since we do not have adequate data to estimate their incidence,29 but a leveling of the decline in CVD mortality rates during the implementation of the Million Hearts Initiative is inconsistent with achievement of its goal.

Conclusions

Given the high absolute burden and associated costs of HD and stroke,19 continued vigilance and innovation are essential in our efforts to address the ongoing challenge of CVD prevention. However, the recent deceleration in the rate of decline in HD mortality is alarming and warrants expanded innovative efforts to improve population-level CVD prevention.

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Article Information

Corresponding Author: Stephen Sidney, MD, MPH, Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612 (steve.sidney@kp.org).

Accepted for Publication: April 8, 2016.

Published Online: June 29, 2016. doi:10.1001/jamacardio.2016.1326.

Author Contributions: Dr Sidney had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Sidney, Go, Rana.

Acquisition, analysis, or interpretation of data: Sidney, Quesenberry, Jaffe, Sorel, Nguyen-Huynh, Kushi, Rana.

Drafting of the manuscript: Sidney, Rana.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Quesenberry.

Obtained funding: Sidney.

Administrative, technical, or material support: Sidney, Sorel.

Study supervision: Sidney, Jaffe, Rana.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Go reported receiving research grant support related to cardiovascular disease from AstraZeneca, CSL Behring, and Sanofi outside the present study. No other disclosures were reported.

Funding/Support: Funding for this work was provided by the Cardiovascular Research Network with funding through grant U19 HL91179-01 from the National Heart, Lung, and Blood Institute and grant RC2 HL101666 from the American Recovery and Reinvestment Act of 2009 (Drs Sidney and Go), and by grant U24 CA171524 from the National Cancer Institute–sponsored Cancer Research Network (Dr Kushi).

Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: Karin M. Winter, MS (Division of Research, Kaiser Permanente Northern California), provided administrative and technical support. There was no financial compensation.

References
1.
Leading causes of death, 1900-1998. http://www.cdc.gov/nchs/data/dvs/lead1900_98.pdf. Accessed December 15, 2015.
2.
Hoyert  DL.  75 Years of mortality in the United States, 1935-2010.  NCHS Data Brief. 2012;(88):1-8.PubMed
3.
Murphy  SL, Xu  JQ, Kochanek  KD.  Deaths: final data for 2010.  Natl Vital Stat Rep. 2013;61(4):1-117.PubMed
4.
Ford  ES, Ajani  UA, Croft  JB,  et al.  Explaining the decrease in US deaths from coronary disease, 1980-2000.  N Engl J Med. 2007;356(23):2388-2398.PubMedArticle
5.
Ford  ES, Capewell  S.  Proportion of the decline in cardiovascular mortality disease due to prevention versus treatment: public health versus clinical care.  Annu Rev Public Health. 2011;32:5-22.PubMedArticle
6.
Labarthe  DR.  From cardiovascular disease to cardiovascular health: a quiet revolution?  Circ Cardiovasc Qual Outcomes. 2012;5(6):e86-e92.PubMedArticle
7.
Lloyd-Jones  DM, Hong  Y, Labarthe  D,  et al; American Heart Association Strategic Planning Task Force and Statistics Committee.  Defining and setting national goals for cardiovascular health promotion and disease reduction: the AHA’s strategic Impact Goal through 2020 and beyond.  Circulation. 2010;121(4):586-613.PubMedArticle
8.
Frieden  TR, Berwick  DM.  The “Million Hearts” initiative—preventing heart attacks and strokes.  N Engl J Med. 2011;365(13):e27.PubMedArticle
9.
Centers for Disease Control and Prevention. Underlying cause of death, 1999-2014 request. http://wonder.cdc.gov/ucd-icd10.html. Accessed January 14, 2016.
10.
Klein  RJ, Schoenborn  CA.  Age Adjustment Using the 2000 Projected US Population. Hyattsville, MD: National Center for Health Statistics; January 2001. Healthy People Statistical Notes, No. 20.
11.
Xu  J, Murphy  SL, Kochanek  KD, Bastian  BA.  Deaths: Final Data for 2013.  Natl Vital Stat Rep. 2016;64(2):1-119.PubMed
12.
Bauer  UE, Briss  PA, Goodman  RA, Bowman  BA.  Prevention of chronic disease in the 21st century: elimination of the leading preventable causes of premature death and disability in the USA.  Lancet. 2014;384(9937):45-52.PubMedArticle
13.
Mann  D, Reynolds  K, Smith  D, Muntner  P.  Trends in statin use and low-density lipoprotein cholesterol levels among US adults: impact of the 2001 National Cholesterol Education Program guidelines.  Ann Pharmacother. 2008;42(9):1208-1215.PubMedArticle
14.
Steinberg  BA, Bhatt  DL, Mehta  S,  et al.  Nine-year trends in achievement of risk factor goals in the US and European outpatients with cardiovascular disease.  Am Heart J. 2008;156(4):719-727.PubMedArticle
15.
Ma  J, Ward  EM, Siegel  RL, Jemal  A.  Temporal trends in mortality in the United States, 1969-2013.  JAMA. 2015;314(16):1731-1739.PubMedArticle
16.
Zhou  Y, Boudreau  DM, Freedman  AN.  Trends in the use of aspirin and nonsteroidal anti-inflammatory drugs in the general US population.  Pharmacoepidemiol Drug Saf. 2014;23(1):43-50.PubMedArticle
17.
Fang  J, George  MG, Gindi  RM,  et al.  Use of low-dose aspirin as secondary prevention of atherosclerotic cardiovascular disease in US adults (from the National Health Interview Survey, 2012).  Am J Cardiol. 2015;115(7):895-900.PubMedArticle
18.
Gu  Q, Paulose-Ram  R, Burt  VL, Kit  BK.  Prescription Cholesterol-Lowering Medication Use in Adults 40 and Over: United States, 2003-2012. Hyattsville, MD: National Center for Health Statistics; 2014. NCHS Data Brief, No. 177.
19.
Mozaffarian  D, Benjamin  EJ, Go  AS,  et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee.  Heart disease and stroke statistics—2016 update: a report from the American Heart Association.  Circulation. 2016;133(4):e38-e360.PubMedArticle
20.
Huffman  MD, Capewell  S, Ning  H, Shay  CM, Ford  ES, Lloyd-Jones  DM.  Cardiovascular health behavior and health factor changes (1988-2008) and projections to 2020: results from the National Health and Nutrition Examination Surveys.  Circulation. 2012;125(21):2595-2602.PubMedArticle
21.
National Center for Health Statistics. Vital Statistics Rapid Release. Quarterly provisional estimates for selected causes of death: United States, 2014—quarter 3, 2015. http://www.cdc.gov/nchs/products/vsrr/mortality-dashboard.htm. Published February 24, 2016. Accessed March 4, 2016.
22.
Imes  CC, Burke  LE.  The obesity epidemic: the United States as a cautionary tale for the rest of the world.  Curr Epidemiol Rep. 2014;1(2):82-88.PubMedArticle
23.
Mainous  AG  III, Baker  R, Koopman  RJ,  et al.  Impact of the population at risk of diabetes on projections of diabetes burden in the United States: an epidemic on the way.  Diabetologia. 2007;50(5):934-940.PubMedArticle
24.
Flegal  KM, Carroll  MD, Ogden  CL, Johnson  CL.  Prevalence and trends in obesity among US adults, 1999-2000.  JAMA. 2002;288(14):1723-1727.PubMedArticle
25.
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.PubMedArticle
26.
CDC’s Division of Diabetes Translation. National Diabetes Surveillance System. Long-term trends in diabetes. http://www.cdc.gov/diabetes/statistics/slides/long_term_trends.pdf. Published October 2014. Accessed March 20, 2016.
27.
Centers for Disease Control and Prevention.  National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States, 2014. Atlanta, GA: US Dept of Health & Human Services; 2014.
28.
Marken  S. US uninsured rate 11.9% in fourth quarter of 2015. http://www.gallup.com/poll/188045/uninsured-rate-fourth-quarter-2015.aspx. Published January 7, 2016. Accessed March 20, 2016.
29.
Sidney  S, Rosamond  WD, Howard  VJ, Luepker  RV; National Forum for Heart Disease and Stroke Prevention.  The “heart disease and stroke statistics—2013 update” and the need for a national cardiovascular surveillance system.  Circulation. 2013;127(1):21-23.PubMedArticle
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