Cardiovascular disease impact varies according to age, gender, other factors

Cardiovascular disease deaths have declined in the last 25 years, but the effect of America's No. 1 killer varies greatly based on gender, age, location and type, according to a study reported in Circulation: Journal of the American Heart Association.

Researchers in Minnesota found:

• Less improvement in cardiovascular disease (CVD) mortality among women and the elderly.
• A shift in the types of CVD deaths from coronary heart disease (CHD) to other forms of CVD.
• Out-of hospital deaths have not dropped as much as in-hospital deaths.

"The face of CVD death is changing," said Veronique Roger, M.D., M.P.H., senior author of the study and professor of medicine and epidemiology at the Mayo Clinic College of Medicine in Rochester, Minn. "Mortality trends should be examined according to age, gender and race as well as the types and location of CVD deaths."

Data conflicts on possible age and gender disparities in CVD mortality, and it is unclear whether the downward trend is consistent across hospitalized and non-hospitalized patients and among types of CVD deaths.

Researchers examined trends in CVD mortality in Olmsted County, Minn., between 1979 and 2003. They assessed variations in death rates by location of death -- in-hospital vs. out-of-hospital -- and by age, gender and specific CVD categories, such as CHD, heart failure, stroke or lymphatic vessel disorders.

The term CVD refers to any ailment of the heart or blood vessels and includes high blood pressure, CHD, heart failure, stroke and congenital defects. CHD refers to disease caused by atherosclerotic narrowing of arteries near or in the heart that often leads to a heart attack.

During the study, 6,378 CVD deaths were recorded in the county. Among the deaths, 57 percent were linked to CHD; 18 percent were from "non-CHD diseases of the heart," such as heart failure, pulmonary circulatory disease, and rheumatic fever; and 25 percent from "non-cardiac circulatory diseases" such as stroke, cerebrovascular diseases and diseases of the arteries, veins and lymphatic vessels. Cardiovascular deaths dropped 50 percent from 1979 - 2003, but researchers found great differences in specific aspects of the trend:

• Out-of-hospital deaths -- those occurring in emergency departments, private homes, public places, nursing or boarding care homes as well as those announced dead on arrival -- had a 1.8 percent annual decline, while in-hospital deaths (occurring in acute-care or long-term care facilities) had a 4.8 percent annual decline.
• Death rates among women declined 2.5 percent annually, while rates among men dropped 3.3 percent annually.
• Death rates for people under age 75 declined 3.9 percent annually. The rate among those ages 75 to 84 decreased 3.4 percent; and for those 85 and older, it dropped 1.5 percent.
• CHD deaths showed a marked annual decrease of 3.3 percent, while non-CHD diseases of the heart dropped 2.1 percent annually and non-cardiac circulatory diseases decreased 2.4 percent annually.

The disparities in the magnitude of the decline in CVD mortality represent opportunities for improved prevention and interventions, researchers said.

Previous studies have shown that women wait longer than men do to seek care after having a heart attack. Lack of awareness, ambiguous heart attack signs and symptoms, and social isolation may all contribute to the delays, Roger said.

"Also, women and older patients are less likely to participate in secondary prevention programs after a heart attack," Roger said. "Further reduction in CVD mortality will require strategies directed at elderly persons and women, for whom out-of-hospital cardiovascular death rates have only minimally changed."

She also said the lesser decline in non-CHD categories shows that the healthcare community should be increasingly prepared to address more than just acute coronary disease.

"As more people die from CVD out of the hospital, clinical and public health efforts should be directed at both primary and secondary prevention," Roger said. "Intervention in the very elderly with chronic CVD may sometimes revolve around end-of-life issues rather than acute care."

As the county population consisted primarily of whites, these findings will need to be examined in diverse populations.