Cardiovascular disease: Leading cause of death Content Points: The need for more effective therapy to reduce cardiovascular risk is underscored in current epidemiological data that identify cardiovascular disease as a continuing public health problem. In 1998, cardiovascular disease (CVD) claimed the lives of 445 692 men and 503 927 women, accounting for 40.6% of all deaths.1 Heart disease has been the leading cause of death in this country since 1921.2 The most recent statistics from the American Heart Association show that CVD is responsible for more deaths than the next four leading causes of death combined.

A public health crisis: 60 A public health crisis: 60.8 million Americans have 1 or more CV diseases Content Points: 60.8 million Americans have one or more cardiovascular diseases.1 According to National Health and Nutrition Examination Survey (NHANES) data, 50 million Americans have hypertension. 12.4 million Americans have coronary heart disease, including 7.3 million who have had a myocardial infarction (MI) and 6.4 million with angina pectoris. 4.5 million have survived a stroke. 4.7 million have congestive heart failure.

Over 1 million Americans will have a heart attack this year Content Points: Coronary heart disease is the single largest killer of all Americans.1 An estimated 1.1 million heart attacks occur each year. Approximately 650 000 are first attacks and 450 000 are recurrent attacks. Men have more heart attacks than women in the number at every age. Among women aged 65 and older, the number of heart attacks increases five-fold compared with middle-aged women.

A public health crisis: Stroke prevalence is on the rise Content Points: The prevalence of stroke is increasing. Between 1971-1975 and 1991-1994 the prevalence of stroke increased in each of the groups shown, males and female, blacks and whites.2 The most striking increases in stroke prevalence have occurred in blacks and women.

Stroke morbidity and mortality Content Points: Stroke accounts for 1 in 15 deaths in the US each year, of which 47% occur outside of the hospital.1 People under age 65 suffer 20% of all strokes and half of these people die within 8 years. Stroke is also the leading cause of serious, long-term disability. 15% to 30% of stroke survivors are permanently disabled.

A public health crisis: CHF hospitalizations have tripled in 25 years Content Points: As shown here, between 1971 and 1996, the rate of hospitalizations for congestive heart failure (CHF) tripled.2 This increase is particularly striking in people aged 65 and older.

A public health crisis: Increasing prevalence of diabetes Content Points: Diabetes is a major cause of morbidity and mortality in the US.3 From 1990 to 1998, the prevalence of diabetes rose 33%, from 4.9% to 6.5%, with the highest increase, 76%, in people aged 30-39. Body mass index and obesity are major risk factors for diabetes; the risk of diabetes increases 9% with every kilogram increase in weight. Because the prevalence of diabetes is highly correlated with obesity, the rising prevalence of obesity portends that diabetes will become an even greater problem.

The global burden of cardiovascular disease Content Points: Cardiovascular disease is a hidden global epidemic.4 57% of the deaths due to coronary disease worldwide occurred in developing countries. Heart disease is the leading cause of death worldwide, and second leading cause of death in developing countries, after infectious diseases, specifically of the respiratory tract. A health transition sweeping the developing world is behind these changes. According to UN figures, the number of older people (≥ 60 years) in less developed countries will increase from 171 million in 1998 to 1594 million in 2050. Changes in underlying health habits, such as increases in smoking, dietary changes leading to increases in cholesterol, and rises in blood pressure levels are also contributing to the global epidemic of CVD. Also contributing to this global epidemic is that improvements in medical care have tended to focus on treatment rather than prevention.

CVD deaths worldwide: 1990 to 2020 Content Points: This slide shows the most important causes of death with the projected changes in ranking from 1990 to 2020.5 Ischemic heart disease and cerebrovascular disease are projected to remain the first and second causes of death worldwide.

Atherosclerotic changes in fetal development: Influence of maternal hypercholesterolemia Content Points: Pathophysiological events occurring during fetal development are increasingly recognized as influencing atherosclerosis throughout childhood and adolescence. Work by Napoli and colleagues described atherogenesis in early human development.6,7 In the first systematic assessment of fatty streak development in fetal aortas, Napoli and colleagues showed that maternal hyper-cholesterolemia during pregnancy markedly increases fatty streak formation in human fetal arteries.6 For this study, they obtained fetuses from spontaneous abortions and premature infants that died within 12 hours; fetal age was 6.2 ± 1.3 months. A comparison of fetal aortas from mothers who were normo-cholesterolemic (n = 22), hypercholesterolemic (n = 33), and hypercholesterolemic only during pregnancy (n = 27) showed that fetal aortas from hypercholesterolemic mothers and mothers with temporary hypercholesterolemia contained significantly more and larger lesions than aortas from normocholesterolemic mothers (P < 0.00005). Fetal plasma cholesterol levels correlated with maternal cholesterol levels in fetuses younger than 6 months, decreased with increasing fetal age, and showed no correlation with material lipid levels after 6 months gestation.

Progression of atherosclerosis in childhood: Influence of maternal hypercholesterolemia Content Points: Napoli and colleagues studied the influence of maternal hypercholesterolemia on early atherosclerotic lesions in childhood in the Fate of Early Lesions in Childhood (FELIC) study.7 They hypothesized that fetal lesions would regress in infancy when cholesterol concentrations were low. They found that although fetal fatty streaks partially regress under normocholesterolemic conditions, progression of atherosclerosis in children of hypercholesterolemic mothers is much faster than in children of normocholesterolemic mothers. The largest fatty streaks in the aortic arch of children younger than 3 years of hypercholesterolemic mothers were 64% smaller than those previously found in corresponding fetuses (P < 0.0001), showing that human fatty streaks formed during fetal development can regress. Lesion size in the aortic arch and abdominal aorta increased linearly with age. But the progression was strikingly faster in children of hypercholesterolemic mothers than in those of normocholesterolemic mothers (P < 0.0001).