(posted 10/04/04)

CVD Statistics (American Heart Association - 2001)

• Morbidity - 64 million Americans have one or more CVD.
• ____ million - high blood pressure (hypertension)
• ____ million - coronary heart disease (CHD)
• ____ million - stroke
• Mortality - 0.9 million annually (38.5% of all deaths)
• total cancer - 1/2 million, accidents - 100,000, AIDS-related - 14,000
• CHD and stroke cost the nation $368 billion annually

• Single leading cause of death in the U.S.A.
• ____________ deaths per year
• Every year, around 1.2 million Americans have a new or recurrent heart attack.
• Approximately ________ of them will die. Of these, 2/3 die at an ER or before reaching the hospital.

• The transport system of the body
• Arteries and veins carry blood to and from body tissues and organs.
• Coronary arteries supply blood to the ______________, providing it with oxygen.
• _______________ - loss of arterial elasticity
• _______________ - formation of plaques of cholesterol and other lipids (fats)

• Stroke-- Occurs when arteriosclerosis and atherosclerosis damage the arteries that deliver blood to the brain.
• Hypertension (high blood pressure)
• _____________ and secondary hypertension
• Symptomless
• Treatment - medication, decrease sodium intake, exercise, weight control
• Strains the heart and arteries - causes arteriosclerosis and atherosclerosis
• Coronary heart disease (CHD)
• ___________ - crushing pain in the chest
• Myocardial infarction (heart attack)

• Any predictor (not necessarily a _______)

• Age
• Family history
• Gender (More prevalent in ________)
• Ethnic background
• African Americans are at increased risk - evidence for both a physiological and social explanation
• ____________ (Affects serum cholesterol levels)

• Hypertension (Most important factor, Many people unaware they have it)
• Serum (________) cholesterol level
• High-density lipoprotein - _______ cholesterol
• Low-density lipoprotein - _______ cholesterol
• Ratio between the two is important. Improved by: exercise, decreasing saturated fat intake, moderate alcohol consumption.
• May not be important for people over the age of 65-70

• Smoking
• Smokers are around ______ times as likely to die from CHD as non- smokers.
• _______ constricts coronary arteries
• Physical inactivity
• Inactive people _______ as likely to develop CHD
• Diet
• Low intake of saturated fats is good
• Possible benefits of vitamin E, antioxidants, and fiber.
• Obesity may be related to CHD

• Anxiety level, occupation, income, marital status, education
• ___________ behavior pattern
• Originated in the 1950s
• Characterized by: ___________, competitiveness, time urgency, extreme ambition.
• Jenkins Activity Survey, Structured Interview
• Hostility
• Cook-Medley Hostility Scale (1954)
• __________
• Unpleasant emotion accompanied by physiological arousal, usually lasting for a relatively short duration.

• Cook-Medley Hostility Scale (1954)
• Originally used in the Minnesota Multiphasic Personality Inventory (MMPI).
• Measures ____________________, resentment, frequent anger, cynical mistrust of others.
• Sample items:
• People often disappoint me
• It is safer to trust nobody
• No one cares much what happens to me
• Strangers look at me critically
• Someone has it in for me

• Barefoot et al. (1983)
• Sample = 255 doctors (including 19 deceased)
• Completed the MMPI as medical students (1954-1959)
• Follow-up in 1981 19 people dead (CHD a factor for 4 people). 11 people had experienced either an MI or angina.
• Median split CHD incidence _____ times higher in people scoring above the median (high hostility).
• Classification of people into quartiles based on hostility scores was related to CHD incidence.
• Hostility and CHD Incidence
• 
• Results unchanged after controlling for age, smoking, and family history.
• Unexpected result: Hostility scores predicted mortality from _________ as well as they predicted CHD
• 20 Year Survival by Hostility Score
• 
• Conclusions
• Hostility seems to play an important role in the pathogenesis and course of _______.
• Evidence that hostility may affect one's ability to survive other diseases.
• Anger and Cardiovascular Reactivity

• CVDs are the leading cause of death in the U.S.A.
• Various types of risk factors increase the chances of developing CHD
• Inherent
• Physiological
• Behavioral
• Psychosocial
• These risk factors do not act independently
• e.g. synergistic nature of a combination of hypertension and smoking or serum cholesterol

• 2 puzzling phenomena
• Hypertension is more prevalent among _____________ than among ___________
• _____________ and ___________with CHD receive by- pass surgery less frequently than ___________ and _______

• ____% of African Americans have HBP (compared to ___% of Americans overall)
• HBP accounts for 20% of all deaths among AA (compared to only ___% for whites)
• In contrast, rural ______ _________ has among the lowest rates of hypertension
• Makes a _______ explanation seem implausible

Why these differences?

• Study participants in all countries had similar ethnic backgrounds
• Americans were more likely to
• Be overweight
• __________ less
• Eat more ________
• BMI = kg/m² Measure of overweight
• Health risks increase when BMI > 25

Factors other than diet

• Hypertension more prevalent in ________ areas
• Suggests role of stress
• African Americans face a unique type of stress: ___________________

• In the US, blacks and women with CHD are treated less aggressively E.g., receive less ______________
• Not clear whether blacks and women are under-treated or whites and men are _____________
• Possible reasons for this difference
• Patient preferences
• Differences in character of disease
• Maybe blacks and women have _____________________
• Differences in ________________
• Maybe blacks and women are more likely to have other health conditions that place them at high surgical risk

BACKGROUND: Epidemiologic studies have reported differences in the use of cardiovascular procedures according to the race and sex of the patient. Whether the differences stem from differences in the recommendations of physicians remains uncertain. METHODS: We developed a computerized survey instrument to assess physicians' recommendations for managing chest pain. Actors portrayed patients with particular characteristics in scripted interviews about their symptoms. A total of 720 physicians at two national meetings of organizations of primary care physicians participated in the survey. Each physician viewed a recorded interview and was given other data about a hypothetical patient. He or she then made recommendations about that patient's care. We used multivariate logistic-regression analysis to assess the effects of the race and sex of the patients on treatment recommendations, while controlling for the physicians' assessment of the probability of coronary artery disease as well as for the age of the patient, the level of coronary risk, the type of chest pain, and the results of an exercise stress test. RESULTS: The physicians' mean (+/-SD) estimates of the probability of coronary artery disease were lower for women (probability, 64.1+/-19.3 percent, vs. 69.2+/-18.2 percent for men; P<0.001), younger patients (63.8+/-19.5 percent for patients who were 55 years old, vs. 69.5+/-17.9 percent for patients who were 70 years old; P<0.001), and patients with nonanginal pain (58.3+/-19.0 percent, vs. 64.4+/-18.3 percent for patients with possible angina and 77.1+/-14.0 percent for those with definite angina; P=0.001). Logistic-regression analysis indicated that women (odds ratio, 0.60; 95 percent confidence interval, 0.4 to 0.9; P=0.02) and blacks (odds ratio, 0.60; 95 percent confidence interval, 0.4 to 0.9; P=0.02) were less likely to be referred for cardiac catheterization than men and whites, respectively. Analysis of race-sex interactions showed that black women were significantly less likely to be referred for catheterization than white men (odds ratio, 0.4; 95 percent confidence interval, 0.2 to 0.7; P=0.004). CONCLUSIONS: Our findings suggest that the race and sex of a patient independently influence how physicians manage chest pain.

• 720 physicians watched a video of a patient presentation
• Patient was
• Black or white
• _____ or ______
• Age 55 or 70
• High or low coronary risk factors
• Chest pain was definitely/possibly/not _________
• All 48 combinations Each physician saw only 1
• Physicians asked to
• Classify chest pain (angina or not)
• Rate probability of _________
• Review thallium stress test results
• Rate updated probability of CHD
• Recommend (or not) referral for __________   ________________
• Recommendation for cardiac cath less likely in
• _______ (OR = 0.60)
• _______ (OR = 0.60)
• _______ patients (OR = 0.62)
• __________________ were least likely to be referred (OR = 0.20), compared to _______________.
• Can't be explained by disease severity, co- morbidities, or patient preferences These factors were all controlled