August6, 1999 / 48(30);649-656
Achievements in Public Health, 1900-1999: Dec
in Deaths from Heart Disease and Stroke -- Uni
Heart disease has been the leading cause of death in the United States since 1921, and stroke has b
third leading cause since 1938 (1); together they account for approximately 40% of all deaths. Since
adjusted death rates from cardiovascular disease (CVD) have declined 60%, representing one of the
important public health achievements of the 20th century. This report summarizes the temporal trend
advances in the understanding of risk factors for CVD, development of prevention interventions to red
risks, and improvements in therapy for persons who develop CVD.
Decline in CVD Death Rates
Age-adjusted death rates per 100,000 persons (standardized to the 1940 U.S. population) for diseas
heart (i.e., coronary heart disease, hypertensive heart disease, and rheumatic heart disease) have de
from a peak of 307.4 in 1950 to 134.6 in 1996, an overall decline of 56% (1) (
rates for coronary heart disease (the major form of CVD contributing to mortality) continued to increa
1960s, then declined. In 1996, 621,000 fewer deaths occurred from coronary heart disease than wou
been expected had the rate remained at its 1963 peak (1).
Age-adjusted death rates for stroke have declined steadily since the beginning of the century. Since
stroke rates have declined 70%, from 88.8 in 1950 to 26.5 in 1996. Total age-adjusted CVD death ra
declined 60% since 1950 and accounted for approximately 73% of the decline in all causes of deaths
same period (1).
Intensive investigation into the CVD epidemic largely began in the 1940s following World War II, altho
causal hypotheses about CVD and recognition of geographic differences in disease rates occurred e
Landmark epidemiologic investigations, including the cross-country comparisons of Ancel Keys (5) (
and the Framingham Heart Study (6), established the major risk factors of high blood cholesterol, hig
pressure, and smoking and dietary factors (particularly dietary cholesterol, fat, and sodium). The risk
concept--that particular biologic, lifestyle, and social conditions were associated with increased risk fo
-developed out of CVD epidemiology (3,4). In addition to the major risk factors (i.e., high blood press
blood cholesterol, and smoking), other important factors include socioeconomic status, obesity, and p
inactivity (7). Striking regional differences were noted particularly for stroke mortality, with the highes
observed in the southeastern United States (1). Cross-national and cross-cultural studies highlighted
importance of social, cultural, and environmental factors in the development of CVD.
Coronary heart disease and stroke, the two major causes of CVD-related mortality, are not influenced