The Burden of Cardiovascular Diseases Among US States, 1990-2016

Global Burden of Cardiovascular Diseases Collaboration, Gregory A Roth, Catherine O Johnson, Kalkidan Hassen Abate, Foad Abd-Allah, Muktar Ahmed, Khurshid Alam, Tahiya Alam, Nelson Alvis-Guzman, Hossein Ansari, Johan Ärnlöv, Tesfay Mehari Atey, Ashish Awasthi, Tadesse Awoke, Aleksandra Barac, Till Bärnighausen, Neeraj Bedi, Derrick Bennett, Isabela Bensenor, Sibhatu Biadgilign, Carlos Castañeda-Orjuela, Ferrán Catalá-López, Kairat Davletov, Samath Dharmaratne, Eric L Ding, Manisha Dubey, Emerito Jose Aquino Faraon, Talha Farid, Maryam S Farvid, Valery Feigin, João Fernandes, Joseph Frostad, Alemseged Gebru, Johanna M Geleijnse, Philimon Nyakauru Gona, Max Griswold, Gessessew Bugssa Hailu, Graeme J Hankey, Hamid Yimam Hassen, Rasmus Havmoeller, Simon Hay, Susan R Heckbert, Caleb Mackay Salpeter Irvine, Spencer Lewis James, Dube Jara, Amir Kasaeian, Abdur Rahman Khan, Sahil Khera, Abdullah T Khoja, Jagdish Khubchandani, Daniel Kim, Dhaval Kolte, Dharmesh Lal, Anders Larsson, Shai Linn, Paulo A Lotufo, Hassan Magdy Abd El Razek, Mohsen Mazidi, Toni Meier, Walter Mendoza, George A Mensah, Atte Meretoja, Haftay Berhane Mezgebe, Erkin Mirrakhimov, Shafiu Mohammed, Andrew Edward Moran, Grant Nguyen, Minh Nguyen, Kanyin Liane Ong, Mayowa Owolabi, Martin Pletcher, Farshad Pourmalek, Caroline A Purcell, Mostafa Qorbani, Mahfuzar Rahman, Rajesh Kumar Rai, Usha Ram, Marissa Bettay Reitsma, Andre M N Renzaho, Maria Jesus Rios-Blancas, Saeid Safiri, Joshua A Salomon, Benn Sartorius, Sadaf Ghajarieh Sepanlou, Masood Ali Shaikh, Diego Silva, Saverio Stranges, Rafael Tabarés-Seisdedos, Niguse Tadele Atnafu, J S Thakur, Roman Topor-Madry, Thomas Truelsen, E Murat Tuzcu, Stefanos Tyrovolas, Kingsley Nnanna Ukwaja, Tommi Vasankari, Vasiliy Vlassov, Stein Emil Vollset, Tolassa Wakayo, Robert Weintraub, Charles Wolfe, Abdulhalik Workicho, Gelin Xu, Simon Yadgir, Yuichiro Yano, Paul Yip, Naohiro Yonemoto, Mustafa Younis, Chuanhua Yu, Zoubida Zaidi, Maysaa El Sayed Zaki, Ben Zipkin, Ashkan Afshin, Emmanuela Gakidou, Stephen S Lim, Ali H Mokdad, Mohsen Naghavi, Theo Vos, Christopher J L Murray, Global Burden of Cardiovascular Diseases Collaboration, Gregory A Roth, Catherine O Johnson, Kalkidan Hassen Abate, Foad Abd-Allah, Muktar Ahmed, Khurshid Alam, Tahiya Alam, Nelson Alvis-Guzman, Hossein Ansari, Johan Ärnlöv, Tesfay Mehari Atey, Ashish Awasthi, Tadesse Awoke, Aleksandra Barac, Till Bärnighausen, Neeraj Bedi, Derrick Bennett, Isabela Bensenor, Sibhatu Biadgilign, Carlos Castañeda-Orjuela, Ferrán Catalá-López, Kairat Davletov, Samath Dharmaratne, Eric L Ding, Manisha Dubey, Emerito Jose Aquino Faraon, Talha Farid, Maryam S Farvid, Valery Feigin, João Fernandes, Joseph Frostad, Alemseged Gebru, Johanna M Geleijnse, Philimon Nyakauru Gona, Max Griswold, Gessessew Bugssa Hailu, Graeme J Hankey, Hamid Yimam Hassen, Rasmus Havmoeller, Simon Hay, Susan R Heckbert, Caleb Mackay Salpeter Irvine, Spencer Lewis James, Dube Jara, Amir Kasaeian, Abdur Rahman Khan, Sahil Khera, Abdullah T Khoja, Jagdish Khubchandani, Daniel Kim, Dhaval Kolte, Dharmesh Lal, Anders Larsson, Shai Linn, Paulo A Lotufo, Hassan Magdy Abd El Razek, Mohsen Mazidi, Toni Meier, Walter Mendoza, George A Mensah, Atte Meretoja, Haftay Berhane Mezgebe, Erkin Mirrakhimov, Shafiu Mohammed, Andrew Edward Moran, Grant Nguyen, Minh Nguyen, Kanyin Liane Ong, Mayowa Owolabi, Martin Pletcher, Farshad Pourmalek, Caroline A Purcell, Mostafa Qorbani, Mahfuzar Rahman, Rajesh Kumar Rai, Usha Ram, Marissa Bettay Reitsma, Andre M N Renzaho, Maria Jesus Rios-Blancas, Saeid Safiri, Joshua A Salomon, Benn Sartorius, Sadaf Ghajarieh Sepanlou, Masood Ali Shaikh, Diego Silva, Saverio Stranges, Rafael Tabarés-Seisdedos, Niguse Tadele Atnafu, J S Thakur, Roman Topor-Madry, Thomas Truelsen, E Murat Tuzcu, Stefanos Tyrovolas, Kingsley Nnanna Ukwaja, Tommi Vasankari, Vasiliy Vlassov, Stein Emil Vollset, Tolassa Wakayo, Robert Weintraub, Charles Wolfe, Abdulhalik Workicho, Gelin Xu, Simon Yadgir, Yuichiro Yano, Paul Yip, Naohiro Yonemoto, Mustafa Younis, Chuanhua Yu, Zoubida Zaidi, Maysaa El Sayed Zaki, Ben Zipkin, Ashkan Afshin, Emmanuela Gakidou, Stephen S Lim, Ali H Mokdad, Mohsen Naghavi, Theo Vos, Christopher J L Murray

Abstract

Importance: Cardiovascular disease (CVD) is the leading cause of death in the United States, but regional variation within the United States is large. Comparable and consistent state-level measures of total CVD burden and risk factors have not been produced previously.

Objective: To quantify and describe levels and trends of lost health due to CVD within the United States from 1990 to 2016 as well as risk factors driving these changes.

Design, setting, and participants: Using the Global Burden of Disease methodology, cardiovascular disease mortality, nonfatal health outcomes, and associated risk factors were analyzed by age group, sex, and year from 1990 to 2016 for all residents in the United States using standardized approaches for data processing and statistical modeling. Burden of disease was estimated for 10 groupings of CVD, and comparative risk analysis was performed. Data were analyzed from August 2016 to July 2017.

Exposures: Residing in the United States.

Main outcomes and measures: Cardiovascular disease disability-adjusted life-years (DALYs).

Results: Between 1990 and 2016, age-standardized CVD DALYs for all states decreased. Several states had large rises in their relative rank ordering for total CVD DALYs among states, including Arkansas, Oklahoma, Alabama, Kentucky, Missouri, Indiana, Kansas, Alaska, and Iowa. The rate of decline varied widely across states, and CVD burden increased for a small number of states in the most recent years. Cardiovascular disease DALYs remained twice as large among men compared with women. Ischemic heart disease was the leading cause of CVD DALYs in all states, but the second most common varied by state. Trends were driven by 12 groups of risk factors, with the largest attributable CVD burden due to dietary risk exposures followed by high systolic blood pressure, high body mass index, high total cholesterol level, high fasting plasma glucose level, tobacco smoking, and low levels of physical activity. Increases in risk-deleted CVD DALY rates between 2006 and 2016 in 16 states suggest additional unmeasured risks beyond these traditional factors.

Conclusions and relevance: Large disparities in total burden of CVD persist between US states despite marked improvements in CVD burden. Differences in CVD burden are largely attributable to modifiable risk exposures.

Conflict of interest statement

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Hankey has received personal fees from Bayer and Medscape outside the submitted work. Dr Lotufo has received personal fees from AbbVie Brazil and Amgen Brazil as well as grants from Fundação Vale, Brazil. Dr Mendoza currently works for the Peru Country Office of the United Nations Population Fund, which does not necessarily endorse this study. No other disclosures were reported.

Figures

Figure 1.. Scatterplot of Age-Standardized Cardiovascular Disease…
Figure 1.. Scatterplot of Age-Standardized Cardiovascular Disease Disability-Adjusted Life-Years (DALYs) per 100 000 Persons and Sociodemographic Index (SDI) in 1990 and 2016
To provide a consistent comparison by socioeconomic status, an SDI was estimated by state using equally weighted age-sex-state-year–specific geometric means of income per capita, educational attainment, and total fertility rate.
Figure 2.. Maps of Age-Standardized Disability-Adjusted Life-Year…
Figure 2.. Maps of Age-Standardized Disability-Adjusted Life-Year (DALY) Rate and Percentage Change in DALY Rate for All Cardiovascular Diseases (CVDs) by Sex
A, Percentage change in age-standardized DALY rate of CVD for men between 1990 and 2016. B, Percentage change in age-standardized DALY rate of CVD for women between 1990 and 2016. C, Age-standardized DALYs from CVD per 100 000 persons in 2016 for men. D, Age-standardized DALYs from CVD per 100 000 persons in 2016 for women.
Figure 3.. Percentage of Disability-Adjusted Life-Years (DALYs)…
Figure 3.. Percentage of Disability-Adjusted Life-Years (DALYs) per 100 000 Persons for Cardiovascular Disease (CVD) Causes by Age in 2016
Figure 4.. Age-Standardized Cardiovascular Disease (CVD) Disability-Adjusted…
Figure 4.. Age-Standardized Cardiovascular Disease (CVD) Disability-Adjusted Life-Years (DALYs) per 100 000 Persons by US State in 2016
Figure 5.. Age-Standardized Prevalence of Heart Failure…
Figure 5.. Age-Standardized Prevalence of Heart Failure per 100 000 Persons in 2016 in Both Sexes
Figure 6.. Age-Standardized Cardiovascular Disease (CVD) Disability-Adjusted…
Figure 6.. Age-Standardized Cardiovascular Disease (CVD) Disability-Adjusted Life-Years (DALYs) per 100 000 Persons Attributable to Risk Factors in 2016
Figure 7.. US State Drivers of Change…
Figure 7.. US State Drivers of Change in Cardiovascular Disease (CVD) Disability-Adjusted Life-Years (DALYs) From 2006 to 2016
Drivers explored in this analysis include population growth, population aging, trends in exposure to all risks included in the Global Burden of Disease 2016 Study, and all other unmeasured factors combined. Results are shown for all CVD DALYs by state. The circle on the bar graph indicates the total percentage change.

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