Epidemiology of coronary heart disease
- Peter WF Wilson, MD
Peter WF Wilson, MD
- Professor of Medicine
- Emory University School of Medicine
- Pamela S Douglas, MD
Pamela S Douglas, MD
- Ursula Geller Professor of Research in Cardiovascular Diseases
- Duke University Medical Center
- Section Editors
- Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
- Editor-in-Chief — Cardiovascular Medicine
- Section Editor — Coronary Heart Disease
- Section Editor — Myopericardial Disease
- Professor of Medicine
- Mayo Medical School
- Patricia A Pellikka, MD, FACC, FAHA, FASE
Patricia A Pellikka, MD, FACC, FAHA, FASE
- Section Editor — Noninvasive Cardiac Imaging and Stress Testing
- Professor of Medicine
- Mayo Clinic College of Medicine
- Juan Carlos Kaski, MD, DM, DSc, FRCP, FESC, FACC, FAHA
Juan Carlos Kaski, MD, DM, DSc, FRCP, FESC, FACC, FAHA
- Section Editor — Coronary Heart Disease
- Professor of Cardiovascular Science
- Head, Cardiovascular Sciences Research Centre
- St. George's, University of London
Coronary heart disease (CHD) is a major cause of death and disability in developed countries. Although CHD mortality rates worldwide have declined over the past four decades, CHD remains responsible for about one-third or more of all deaths in individuals over age 35 [1-3]. It has been estimated that nearly one-half of all middle-aged men and one-third of middle-aged women in the United States will develop some manifestation of CHD .
Population-based epidemiologic data, such as that from the Framingham Heart Study, provide the best assessment of the risk factors that contribute to the development of coronary heart disease (CHD) and to the way it evolves, progresses, and terminates because these data are less encumbered by the unavoidable selection bias of clinical trials data. In addition, epidemiologic data provide critical information regarding targets for the primary and secondary prevention of CHD.
This topic will discuss the incidence, prevalence, trend in mortality, and general prognosis of CHD. The discussion of outcomes after myocardial infarction is found elsewhere. (See "Prognosis after myocardial infarction".)
The incidence, prevalence, and prognosis of non-coronary cardiovascular disease (CVD) such as cerebrovascular or peripheral artery disease are discussed elsewhere.
The terms incidence, prevalence, coronary heart disease, coronary artery disease, and cardiovascular disease, as used in this topic, are defined as follows:
- Rosamond W, Flegal K, Furie K, et al. Heart disease and stroke statistics--2008 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2008; 117:e25.
- Lloyd-Jones D, Adams RJ, Brown TM, et al. Executive summary: heart disease and stroke statistics--2010 update: a report from the American Heart Association. Circulation 2010; 121:948.
- Nichols M, Townsend N, Scarborough P, Rayner M. Cardiovascular disease in Europe 2014: epidemiological update. Eur Heart J 2014; 35:2950.
- Lloyd-Jones DM, Larson MG, Beiser A, Levy D. Lifetime risk of developing coronary heart disease. Lancet 1999; 353:89.
- GBD 2013 Mortality and Causes of Death Collaborators. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2015; 385:117.
- Towfighi A, Zheng L, Ovbiagele B. Sex-specific trends in midlife coronary heart disease risk and prevalence. Arch Intern Med 2009; 169:1762.
- Deedwania PC, Carbajal EV. Silent myocardial ischemia. A clinical perspective. Arch Intern Med 1991; 151:2373.
- Roger VL, Weston SA, Killian JM, et al. Time trends in the prevalence of atherosclerosis: a population-based autopsy study. Am J Med 2001; 110:267.
- Webber BJ, Seguin PG, Burnett DG, et al. Prevalence of and risk factors for autopsy-determined atherosclerosis among US service members, 2001-2011. JAMA 2012; 308:2577.
- Gordon T, Kannel WB, Hjortland MC, McNamara PM. Menopause and coronary heart disease. The Framingham Study. Ann Intern Med 1978; 89:157.
- Lerner DJ, Kannel WB. Patterns of coronary heart disease morbidity and mortality in the sexes: a 26-year follow-up of the Framingham population. Am Heart J 1986; 111:383.
- Kannel WB. Prevalence and clinical aspects of unrecognized myocardial infarction and sudden unexpected death. Circulation 1987; 75:II4.
- Go AS, Iribarren C, Chandra M, et al. Statin and beta-blocker therapy and the initial presentation of coronary heart disease. Ann Intern Med 2006; 144:229.
- Ergin A, Muntner P, Sherwin R, He J. Secular trends in cardiovascular disease mortality, incidence, and case fatality rates in adults in the United States. Am J Med 2004; 117:219.
- Arciero TJ, Jacobsen SJ, Reeder GS, et al. Temporal trends in the incidence of coronary disease. Am J Med 2004; 117:228.
- Yusuf S, Reddy S, Ounpuu S, Anand S. Global burden of cardiovascular diseases: Part II: variations in cardiovascular disease by specific ethnic groups and geographic regions and prevention strategies. Circulation 2001; 104:2855.
- Lopez AD, Mathers CD, Ezzati M, et al. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet 2006; 367:1747.
- Yusuf S, Reddy S, Ounpuu S, Anand S. Global burden of cardiovascular diseases: part I: general considerations, the epidemiologic transition, risk factors, and impact of urbanization. Circulation 2001; 104:2746.
- Goyal A, Yusuf S. The burden of cardiovascular disease in the Indian subcontinent. Indian J Med Res 2006; 124:235.
- Critchley J, Liu J, Zhao D, et al. Explaining the increase in coronary heart disease mortality in Beijing between 1984 and 1999. Circulation 2004; 110:1236.
- Rodríguez T, Malvezzi M, Chatenoud L, et al. Trends in mortality from coronary heart and cerebrovascular diseases in the Americas: 1970-2000. Heart 2006; 92:453.
- Beaglehole R, Reddy S, Leeder SR. Poverty and human development: the global implications of cardiovascular disease. Circulation 2007; 116:1871.
- Furman MI, Dauerman HL, Goldberg RJ, et al. Twenty-two year (1975 to 1997) trends in the incidence, in-hospital and long-term case fatality rates from initial Q-wave and non-Q-wave myocardial infarction: a multi-hospital, community-wide perspective. J Am Coll Cardiol 2001; 37:1571.
- Rogers WJ, Frederick PD, Stoehr E, et al. Trends in presenting characteristics and hospital mortality among patients with ST elevation and non-ST elevation myocardial infarction in the National Registry of Myocardial Infarction from 1990 to 2006. Am Heart J 2008; 156:1026.
- Chen J, Normand SL, Wang Y, et al. Recent declines in hospitalizations for acute myocardial infarction for Medicare fee-for-service beneficiaries: progress and continuing challenges. Circulation 2010; 121:1322.
- Hardoon SL, Whincup PH, Lennon LT, et al. How much of the recent decline in the incidence of myocardial infarction in British men can be explained by changes in cardiovascular risk factors? Evidence from a prospective population-based study. Circulation 2008; 117:598.
- Roger VL, Weston SA, Gerber Y, et al. Trends in incidence, severity, and outcome of hospitalized myocardial infarction. Circulation 2010; 121:863.
- Parikh NI, Gona P, Larson MG, et al. Long-term trends in myocardial infarction incidence and case fatality in the National Heart, Lung, and Blood Institute's Framingham Heart study. Circulation 2009; 119:1203.
- Kuulasmaa K, Tunstall-Pedoe H, Dobson A, et al. Estimation of contribution of changes in classic risk factors to trends in coronary-event rates across the WHO MONICA Project populations. Lancet 2000; 355:675.
- McGovern PG, Pankow JS, Shahar E, et al. Recent trends in acute coronary heart disease--mortality, morbidity, medical care, and risk factors. The Minnesota Heart Survey Investigators. N Engl J Med 1996; 334:884.
- Capewell S, Morrison CE, McMurray JJ. Contribution of modern cardiovascular treatment and risk factor changes to the decline in coronary heart disease mortality in Scotland between 1975 and 1994. Heart 1999; 81:380.
- Capewell S, Beaglehole R, Seddon M, McMurray J. Explanation for the decline in coronary heart disease mortality rates in Auckland, New Zealand, between 1982 and 1993. Circulation 2000; 102:1511.
- Cooper R, Cutler J, Desvigne-Nickens P, et al. Trends and disparities in coronary heart disease, stroke, and other cardiovascular diseases in the United States: findings of the national conference on cardiovascular disease prevention. Circulation 2000; 102:3137.
- McGovern PG, Jacobs DR Jr, Shahar E, et al. Trends in acute coronary heart disease mortality, morbidity, and medical care from 1985 through 1997: the Minnesota heart survey. Circulation 2001; 104:19.
- Rosamond WD, Chambless LE, Folsom AR, et al. Trends in the incidence of myocardial infarction and in mortality due to coronary heart disease, 1987 to 1994. N Engl J Med 1998; 339:861.
- Ford ES, Ajani UA, Croft JB, et al. Explaining the decrease in U.S. deaths from coronary disease, 1980-2000. N Engl J Med 2007; 356:2388.
- Tu JV, Nardi L, Fang J, et al. National trends in rates of death and hospital admissions related to acute myocardial infarction, heart failure and stroke 1994-2004. CMAJ 2009; 180:1304.
- Preis SR, Hwang SJ, Coady S, et al. Trends in all-cause and cardiovascular disease mortality among women and men with and without diabetes mellitus in the Framingham Heart Study, 1950 to 2005. Circulation 2009; 119:1728.
- Fox CS, Evans JC, Larson MG, et al. Temporal trends in coronary heart disease mortality and sudden cardiac death from 1950 to 1999: the Framingham Heart Study. Circulation 2004; 110:522.
- Fox CS, Coady S, Sorlie PD, et al. Increasing cardiovascular disease burden due to diabetes mellitus: the Framingham Heart Study. Circulation 2007; 115:1544.
- Levi F, Lucchini F, Negri E, La Vecchia C. Trends in mortality from cardiovascular and cerebrovascular diseases in Europe and other areas of the world. Heart 2002; 88:119.
- Reddy KS. Cardiovascular disease in non-Western countries. N Engl J Med 2004; 350:2438.
- Okrainec K, Banerjee DK, Eisenberg MJ. Coronary artery disease in the developing world. Am Heart J 2004; 148:7.
- Sheifer SE, Manolio TA, Gersh BJ. Unrecognized myocardial infarction. Ann Intern Med 2001; 135:801.
- Kannel WB, Cupples LA, Gagnon DR. Incidence, precursors and prognosis of unrecognized myocardial infarction. Adv Cardiol 1990; 37:202.
- Kannel WB. Lipids, diabetes, and coronary heart disease: insights from the Framingham Study. Am Heart J 1985; 110:1100.
- Sigurdsson E, Thorgeirsson G, Sigvaldason H, Sigfusson N. Unrecognized myocardial infarction: epidemiology, clinical characteristics, and the prognostic role of angina pectoris. The Reykjavik Study. Ann Intern Med 1995; 122:96.
- Jónsdóttir LS, Sigfusson N, Sigvaldason H, Thorgeirsson G. Incidence and prevalence of recognised and unrecognised myocardial infarction in women. The Reykjavik Study. Eur Heart J 1998; 19:1011.
- de Torbal A, Boersma E, Kors JA, et al. Incidence of recognized and unrecognized myocardial infarction in men and women aged 55 and older: the Rotterdam Study. Eur Heart J 2006; 27:729.
- Davidoff R, Goldman AP, Diamond TH, et al. The natural history of the Q wave in inferoposterior myocardial infarction. S Afr Med J 1982; 61:611.
- Richter A, Herlitz J, Hjalmarson A. QRS complex recovery during one year after acute myocardial infarction. Clin Cardiol 1987; 10:16.
- Kannel WB, Abbott RD. A prognostic comparison of asymptomatic left ventricular hypertrophy and unrecognized myocardial infarction: the Framingham Study. Am Heart J 1986; 111:391.
- Levy D, Salomon M, D'Agostino RB, et al. Prognostic implications of baseline electrocardiographic features and their serial changes in subjects with left ventricular hypertrophy. Circulation 1994; 90:1786.
- Levy D, Garrison RJ, Savage DD, et al. Prognostic implications of echocardiographically determined left ventricular mass in the Framingham Heart Study. N Engl J Med 1990; 322:1561.
- Verdecchia P, Carini G, Circo A, et al. Left ventricular mass and cardiovascular morbidity in essential hypertension: the MAVI study. J Am Coll Cardiol 2001; 38:1829.
- Kors JA, de Bruyne MC, Hoes AW, et al. T axis as an indicator of risk of cardiac events in elderly people. Lancet 1998; 352:601.
- Rautaharju PM, Nelson JC, Kronmal RA, et al. Usefulness of T-axis deviation as an independent risk indicator for incident cardiac events in older men and women free from coronary heart disease (the Cardiovascular Health Study). Am J Cardiol 2001; 88:118.
- Kannel WB, Dannenberg AL, Abbott RD. Unrecognized myocardial infarction and hypertension: the Framingham Study. Am Heart J 1985; 109:581.
- Shlipak MG, Elmouchi DA, Herrington DM, et al. The incidence of unrecognized myocardial infarction in women with coronary heart disease. Ann Intern Med 2001; 134:1043.
- Orencia A, Bailey K, Yawn BP, Kottke TE. Effect of gender on long-term outcome of angina pectoris and myocardial infarction/sudden unexpected death. JAMA 1993; 269:2392.
- Hemingway H, McCallum A, Shipley M, et al. Incidence and prognostic implications of stable angina pectoris among women and men. JAMA 2006; 295:1404.
- LaCroix AZ, Guralnik JM, Curb JD, et al. Chest pain and coronary heart disease mortality among older men and women in three communities. Circulation 1990; 81:437.
- Maddox TM, Stanislawski MA, Grunwald GK, et al. Nonobstructive coronary artery disease and risk of myocardial infarction. JAMA 2014; 312:1754.
- Chow BJ, Small G, Yam Y, et al. Incremental prognostic value of cardiac computed tomography in coronary artery disease using CONFIRM: COroNary computed tomography angiography evaluation for clinical outcomes: an InteRnational Multicenter registry. Circ Cardiovasc Imaging 2011; 4:463.
- Maddox TM, Reid KJ, Spertus JA, et al. Angina at 1 year after myocardial infarction: prevalence and associated findings. Arch Intern Med 2008; 168:1310.
- White HD, Barbash GI, Modan M, et al. After correcting for worse baseline characteristics, women treated with thrombolytic therapy for acute myocardial infarction have the same mortality and morbidity as men except for a higher incidence of hemorrhagic stroke. The Investigators of the International Tissue Plasminogen Activator/Streptokinase Mortality Study. Circulation 1993; 88:2097.
- Maynard C, Litwin PE, Martin JS, Weaver WD. Gender differences in the treatment and outcome of acute myocardial infarction. Results from the Myocardial Infarction Triage and Intervention Registry. Arch Intern Med 1992; 152:972.
- Hochman JS, McCabe CH, Stone PH, et al. Outcome and profile of women and men presenting with acute coronary syndromes: a report from TIMI IIIB. TIMI Investigators. Thrombolysis in Myocardial Infarction. J Am Coll Cardiol 1997; 30:141.
- Chang WC, Kaul P, Westerhout CM, et al. Impact of sex on long-term mortality from acute myocardial infarction vs unstable angina. Arch Intern Med 2003; 163:2476.
- Hochman JS, Tamis JE, Thompson TD, et al. Sex, clinical presentation, and outcome in patients with acute coronary syndromes. Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndromes IIb Investigators. N Engl J Med 1999; 341:226.
- Roger VL, Farkouh ME, Weston SA, et al. Sex differences in evaluation and outcome of unstable angina. JAMA 2000; 283:646.
- Kannel WB, Thomas HE Jr. Sudden coronary death: the Framingham Study. Ann N Y Acad Sci 1982; 382:3.
- Zheng ZJ, Croft JB, Giles WH, Mensah GA. Sudden cardiac death in the United States, 1989 to 1998. Circulation 2001; 104:2158.
- Byrne R, Constant O, Smyth Y, et al. Multiple source surveillance incidence and aetiology of out-of-hospital sudden cardiac death in a rural population in the West of Ireland. Eur Heart J 2008; 29:1418.
- Andréoletti L, Ventéo L, Douche-Aourik F, et al. Active Coxsackieviral B infection is associated with disruption of dystrophin in endomyocardial tissue of patients who died suddenly of acute myocardial infarction. J Am Coll Cardiol 2007; 50:2207.
- Kannel WB, Doyle JT, McNamara PM, et al. Precursors of sudden coronary death. Factors related to the incidence of sudden death. Circulation 1975; 51:606.
- Gillum RF. Sudden coronary death in the United States: 1980-1985. Circulation 1989; 79:756.
- Kannel WB, Wilson PW, D'Agostino RB, Cobb J. Sudden coronary death in women. Am Heart J 1998; 136:205.
- Berger CJ, Murabito JM, Evans JC, et al. Prognosis after first myocardial infarction. Comparison of Q-wave and non-Q-wave myocardial infarction in the Framingham Heart Study. JAMA 1992; 268:1545.
- Kannel WB, Cupples LA, D'Agostino RB. Sudden death risk in overt coronary heart disease: the Framingham Study. Am Heart J 1987; 113:799.
- Marchioli R, Barzi F, Bomba E, et al. Early protection against sudden death by n-3 polyunsaturated fatty acids after myocardial infarction: time-course analysis of the results of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI)-Prevenzione. Circulation 2002; 105:1897.
- Torp-Pedersen C, Køber L. Effect of ACE inhibitor trandolapril on life expectancy of patients with reduced left-ventricular function after acute myocardial infarction. TRACE Study Group. Trandolapril Cardiac Evaluation. Lancet 1999; 354:9.
- Myerburg RJ, Kessler KM, Castellanos A. Sudden cardiac death. Structure, function, and time-dependence of risk. Circulation 1992; 85:I2.
- Chugh SS, Uy-Evanado A, Teodorescu C, et al. Women have a lower prevalence of structural heart disease as a precursor to sudden cardiac arrest: The Ore-SUDS (Oregon Sudden Unexpected Death Study). J Am Coll Cardiol 2009; 54:2006.
- Kim C, Fahrenbruch CE, Cobb LA, Eisenberg MS. Out-of-hospital cardiac arrest in men and women. Circulation 2001; 104:2699.
- Cupples LA, Gagnon DR, Wong ND, et al. Preexisting cardiovascular conditions and long-term prognosis after initial myocardial infarction: the Framingham Study. Am Heart J 1993; 125:863.
- Choudhri AH, Cleland JG, Rowlands PC, et al. Unsuspected renal artery stenosis in peripheral vascular disease. BMJ 1990; 301:1197.
- Bucher HC, Griffith LE, Guyatt GH. Effect of HMGcoA reductase inhibitors on stroke. A meta-analysis of randomized, controlled trials. Ann Intern Med 1998; 128:89.
- Crouse JR 3rd, Byington RP, Hoen HM, Furberg CD. Reductase inhibitor monotherapy and stroke prevention. Arch Intern Med 1997; 157:1305.
- SOURCES OF EPIDEMIOLOGIC DATA
- Temporal trends
- International trends
- Myocardial infarction
- - STEMI versus NSTEMI
- CHD MORTALITY
- - Possible explanations
- International data
- SILENT MYOCARDIAL ISCHEMIA AND INFARCTION
- Unrecognized MI
- - ECG findings
- - Risk factors
- - Prognosis after unrecognized MI
- Angina in men versus women
- Non-obstructive CHD
- Myocardial infarction
- - Non-ST elevation ACS
- SUDDEN CARDIAC DEATH
- Impact of sex
- NON-CORONARY CARDIOVASCULAR DISEASE
- INFORMATION FOR PATIENTS