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

doi:10.1001/jamacardio.2018.0385

. 2018 May 1;3(5):375-389.

doi: 10.1001/jamacardio.2018.0385.

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

Global Burden of Cardiovascular Diseases Collaboration; Gregory A Roth^{1

2}, Catherine O Johnson¹, Kalkidan Hassen Abate³, Foad Abd-Allah⁴, Muktar Ahmed³, Khurshid Alam⁵, Tahiya Alam¹, Nelson Alvis-Guzman⁶, Hossein Ansari⁷, Johan Ärnlöv⁸, Tesfay Mehari Atey⁹, Ashish Awasthi¹⁰, Tadesse Awoke¹¹, Aleksandra Barac¹², Till Bärnighausen¹³, Neeraj Bedi¹⁴, Derrick Bennett¹⁵, Isabela Bensenor¹⁶, Sibhatu Biadgilign¹⁷, Carlos Castañeda-Orjuela¹⁸, Ferrán Catalá-López¹⁹, Kairat Davletov²⁰, Samath Dharmaratne²¹, Eric L Ding²², Manisha Dubey²³, Emerito Jose Aquino Faraon²⁴, Talha Farid²⁵, Maryam S Farvid²², Valery Feigin²⁶, João Fernandes²⁷, Joseph Frostad¹, Alemseged Gebru⁹, Johanna M Geleijnse²⁸, Philimon Nyakauru Gona²⁹, Max Griswold¹, Gessessew Bugssa Hailu⁹, Graeme J Hankey³⁰, Hamid Yimam Hassen³¹, Rasmus Havmoeller⁸, Simon Hay¹, Susan R Heckbert¹, Caleb Mackay Salpeter Irvine¹, Spencer Lewis James¹, Dube Jara³², Amir Kasaeian³³, Abdur Rahman Khan²⁵, Sahil Khera³⁴, Abdullah T Khoja³⁵, Jagdish Khubchandani³⁶, Daniel Kim³⁷, Dhaval Kolte³⁸, Dharmesh Lal³⁹, Anders Larsson⁴⁰, Shai Linn⁴¹, Paulo A Lotufo⁴², Hassan Magdy Abd El Razek⁴³, Mohsen Mazidi⁴⁴, Toni Meier⁴⁵, Walter Mendoza⁴⁶, George A Mensah⁴⁷, Atte Meretoja⁴⁸, Haftay Berhane Mezgebe⁹, Erkin Mirrakhimov⁴⁹, Shafiu Mohammed⁵⁰, Andrew Edward Moran⁵¹, Grant Nguyen¹, Minh Nguyen¹, Kanyin Liane Ong¹, Mayowa Owolabi⁵², Martin Pletcher¹, Farshad Pourmalek⁵³, Caroline A Purcell¹, Mostafa Qorbani⁵⁴, Mahfuzar Rahman⁵⁵, Rajesh Kumar Rai⁵⁶, Usha Ram²³, Marissa Bettay Reitsma¹, Andre M N Renzaho⁵⁷, Maria Jesus Rios-Blancas⁵⁸, Saeid Safiri⁵⁹, Joshua A Salomon¹³, Benn Sartorius⁶⁰, Sadaf Ghajarieh Sepanlou⁶¹, Masood Ali Shaikh⁶², Diego Silva⁶³, Saverio Stranges⁶⁴, Rafael Tabarés-Seisdedos¹⁹, Niguse Tadele Atnafu⁶⁵, J S Thakur⁶⁶, Roman Topor-Madry⁶⁷, Thomas Truelsen⁶⁸, E Murat Tuzcu⁶⁹, Stefanos Tyrovolas⁷⁰, Kingsley Nnanna Ukwaja⁷¹, Tommi Vasankari⁷², Vasiliy Vlassov⁷³, Stein Emil Vollset⁷⁴, Tolassa Wakayo³, Robert Weintraub⁷⁵, Charles Wolfe⁷⁶, Abdulhalik Workicho³, Gelin Xu⁷⁷, Simon Yadgir¹, Yuichiro Yano⁷⁸, Paul Yip⁷⁹, Naohiro Yonemoto⁸⁰, Mustafa Younis⁸¹, Chuanhua Yu⁸², Zoubida Zaidi⁸³, Maysaa El Sayed Zaki⁴³, Ben Zipkin¹, Ashkan Afshin¹, Emmanuela Gakidou¹, Stephen S Lim¹, Ali H Mokdad¹, Mohsen Naghavi¹, Theo Vos¹, Christopher J L Murray¹

Affiliations

¹ Institute for Health Metrics and Evaluation, University of Washington, Seattle.
² Division of Cardiology, Department of Medicine, University of Washington, Seattle.
³ Jimma University, Jimma, Ethiopia.
⁴ Cairo University, Giza, Egypt.
⁵ The University of Western Australia, Perth, Western Australia, Australia.
⁶ Universidad de Cartagena, Cartagena, Bolívar, Columbia.
⁷ Zahedan University of Medical Sciences, Zahedan, Iran.
⁸ Karolinska Institutet, Stockholm, Sweden.
⁹ Mekelle University, Mekelle, Ethiopia.
¹⁰ Indian Institute of Public Health Gandhinagar, Public Health Foundation of India, Gandhinagar, Gujarat, India.
¹¹ University of Gondar, Gondar, Ethiopia.
¹² University of Belgrade, Belgrade, Serbia.
¹³ Harvard University, Cambridge, Massachusetts.
¹⁴ Jazan University, Jizan, Saudi Arabia.
¹⁵ University of Oxford, Oxford, England.
¹⁶ University of São Paulo, São Paulo, São Paulo, Brazil.
¹⁷ Independent Public Health Consultant, Addis Abbaba, Ethiopia.
¹⁸ Observatorio Nacional de Salud, Instituto Nacional de Salud, Bogotá, DC, Colombia.
¹⁹ INCLIVA Health Research Institute, Centro de Investigación Biomédica en Red Salud Mental, University of Valencia, Valencia, Spain.
²⁰ Asfendiyarov Kazakh National Medical University, Almaty, Kazakhstan.
²¹ University of Peradeniya, Peradeniya, Sri Lanka.
²² Harvard T. H. Chan School of Public Health, Boston, Massachusetts.
²³ International Institute for Population Sciences, Mumbai, India.
²⁴ University of the Philippines Manila, Manila, Philippines.
²⁵ University of Louisville, Louisville, Kentucky.
²⁶ Auckland University of Technology, Auckland, New Zealand.
²⁷ Catholic University of Portugal, Lisbon, Portugal.
²⁸ Wageningen University, Wageningen, the Netherlands.
²⁹ University of Massachusetts Boston, Boston.
³⁰ School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia, Australia.
³¹ Mizan Tepi University, Tepi, Ethiopia.
³² Debre Markos University, Debre Markos, Ethiopia.
³³ Hematology, Oncology, and Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran.
³⁴ New York Medical College, Valhalla.
³⁵ Al Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia.
³⁶ Ball State University, Muncie, Indiana.
³⁷ Northeastern University, Boston, Massachusetts.
³⁸ Brown University, Providence, Rhode Island.
³⁹ Public Health Foundation of India, New Delhi, India.
⁴⁰ Department of Medical Sciences, Uppsala University, Uppsala, Sweden.
⁴¹ University of Haifa, Haifa, Israel.
⁴² Clinical Research Center, University Hospital, University of São Paulo, São Paulo, São Paulo, Brazil.
⁴³ Faculty of Medicine, Mansoura University, Mansoura, Egypt.
⁴⁴ State Key Laboratory of Molecular Developmental Biology, Institute of Genetics and Developmental Biology, Chinese Academy of Sciences, Chaoyang, Beijing.
⁴⁵ Martin Luther University of Halle-Wittenberg, Halle, Germany.
⁴⁶ United Nations Population Fund, New York, New York.
⁴⁷ National Institutes of Health, Bethesda, Maryland.
⁴⁸ University of Melbourne, Melbourne, Victoria, Australia.
⁴⁹ Kyrgyz State Medical Academy, Bishkek, Kyrgyzstan.
⁵⁰ Ahmadu Bello University, Zaria, Kaduna State, Nigeria.
⁵¹ Columbia University, New York, New York.
⁵² Department of Medicine, University of Ibadan, Ibadan, Oyo State, Nigeria.
⁵³ University of British Columbia, Vancouver, British Columbia, Canada.
⁵⁴ Noncommunicable Diseases Research Center, Alborz University of Medical Sciences, Hassan Abad, Karaj, Iran.
⁵⁵ BRAC, Dhaka, Bangladesh.
⁵⁶ Society for Health and Demographic Surveillance, West Bengal, India.
⁵⁷ Western Sydney University, Penrith, New South Wales, Australia.
⁵⁸ National Institute of Public Health, Wako, Japan.
⁵⁹ Maragheh University of Medical Sciences, East Azerbaijan Province, Iran.
⁶⁰ University of KwaZulu-Natal, Durban, South Africa.
⁶¹ Tehran University of Medical Sciences, Tehran, Iran.
⁶² Independent Consultant, Karachi, Pakistan.
⁶³ Federal University of Santa Catarina, Florianópolis, Santa Catarina, Brazil.
⁶⁴ Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada.
⁶⁵ Addis Ababa University, Addis Ababa, Ethiopia.
⁶⁶ Postgraduate Institute of Medical Education and Research, Chandigarh, India.
⁶⁷ Jagiellonian University Medical College, Krakow, Poland.
⁶⁸ University of Copenhagen, Copenhagen, Denmark.
⁶⁹ Cleveland Clinic, Cleveland, Ohio.
⁷⁰ Hospital Sant Joan de Déu Barcelona, Sant Joan de Déu Research Foundation, Centro de Investigación Biomédica en Red Salud Mental, Universitat de Barcelona, Barcelona, Spain.
⁷¹ Department of Internal Medicine, Federal Teaching Hospital, Abakaliki, Ebonyi State, Nigeria.
⁷² UKK Institute for Health Promotion Research, Tampere, Finland.
⁷³ National Research University Higher School of Economics, Moscow, Russia.
⁷⁴ Norwegian Institute of Public Health, Oslo, Norway.
⁷⁵ Royal Children's Hospital, Melbourne, Victoria, Australia.
⁷⁶ King's College London, London, England.
⁷⁷ Nanjing University School of Medicine, Nanjing, China.
⁷⁸ The University of Mississippi Medical Center, Jackson.
⁷⁹ University of Hong Kong, Pokfulam, Hong Kong.
⁸⁰ Kyoto University, Kyoto, Japan.
⁸¹ Jackson State University, Jackson, Mississippi.
⁸² Wuhan University, Wuhan, China.
⁸³ University Hospital of Setif, Setif, Algeria.

PMID: 29641820
PMCID: PMC6145754
DOI: 10.1001/jamacardio.2018.0385

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

Global Burden of Cardiovascular Diseases Collaboration et al. JAMA Cardiol. 2018.

. 2018 May 1;3(5):375-389.

doi: 10.1001/jamacardio.2018.0385.

Authors

Affiliations

¹ Institute for Health Metrics and Evaluation, University of Washington, Seattle.
² Division of Cardiology, Department of Medicine, University of Washington, Seattle.
³ Jimma University, Jimma, Ethiopia.
⁴ Cairo University, Giza, Egypt.
⁵ The University of Western Australia, Perth, Western Australia, Australia.
⁶ Universidad de Cartagena, Cartagena, Bolívar, Columbia.
⁷ Zahedan University of Medical Sciences, Zahedan, Iran.
⁸ Karolinska Institutet, Stockholm, Sweden.
⁹ Mekelle University, Mekelle, Ethiopia.
¹⁰ Indian Institute of Public Health Gandhinagar, Public Health Foundation of India, Gandhinagar, Gujarat, India.
¹¹ University of Gondar, Gondar, Ethiopia.
¹² University of Belgrade, Belgrade, Serbia.
¹³ Harvard University, Cambridge, Massachusetts.
¹⁴ Jazan University, Jizan, Saudi Arabia.
¹⁵ University of Oxford, Oxford, England.
¹⁶ University of São Paulo, São Paulo, São Paulo, Brazil.
¹⁷ Independent Public Health Consultant, Addis Abbaba, Ethiopia.
¹⁸ Observatorio Nacional de Salud, Instituto Nacional de Salud, Bogotá, DC, Colombia.
¹⁹ INCLIVA Health Research Institute, Centro de Investigación Biomédica en Red Salud Mental, University of Valencia, Valencia, Spain.
²⁰ Asfendiyarov Kazakh National Medical University, Almaty, Kazakhstan.
²¹ University of Peradeniya, Peradeniya, Sri Lanka.
²² Harvard T. H. Chan School of Public Health, Boston, Massachusetts.
²³ International Institute for Population Sciences, Mumbai, India.
²⁴ University of the Philippines Manila, Manila, Philippines.
²⁵ University of Louisville, Louisville, Kentucky.
²⁶ Auckland University of Technology, Auckland, New Zealand.
²⁷ Catholic University of Portugal, Lisbon, Portugal.
²⁸ Wageningen University, Wageningen, the Netherlands.
²⁹ University of Massachusetts Boston, Boston.
³⁰ School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia, Australia.
³¹ Mizan Tepi University, Tepi, Ethiopia.
³² Debre Markos University, Debre Markos, Ethiopia.
³³ Hematology, Oncology, and Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran.
³⁴ New York Medical College, Valhalla.
³⁵ Al Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia.
³⁶ Ball State University, Muncie, Indiana.
³⁷ Northeastern University, Boston, Massachusetts.
³⁸ Brown University, Providence, Rhode Island.
³⁹ Public Health Foundation of India, New Delhi, India.
⁴⁰ Department of Medical Sciences, Uppsala University, Uppsala, Sweden.
⁴¹ University of Haifa, Haifa, Israel.
⁴² Clinical Research Center, University Hospital, University of São Paulo, São Paulo, São Paulo, Brazil.
⁴³ Faculty of Medicine, Mansoura University, Mansoura, Egypt.
⁴⁴ State Key Laboratory of Molecular Developmental Biology, Institute of Genetics and Developmental Biology, Chinese Academy of Sciences, Chaoyang, Beijing.
⁴⁵ Martin Luther University of Halle-Wittenberg, Halle, Germany.
⁴⁶ United Nations Population Fund, New York, New York.
⁴⁷ National Institutes of Health, Bethesda, Maryland.
⁴⁸ University of Melbourne, Melbourne, Victoria, Australia.
⁴⁹ Kyrgyz State Medical Academy, Bishkek, Kyrgyzstan.
⁵⁰ Ahmadu Bello University, Zaria, Kaduna State, Nigeria.
⁵¹ Columbia University, New York, New York.
⁵² Department of Medicine, University of Ibadan, Ibadan, Oyo State, Nigeria.
⁵³ University of British Columbia, Vancouver, British Columbia, Canada.
⁵⁴ Noncommunicable Diseases Research Center, Alborz University of Medical Sciences, Hassan Abad, Karaj, Iran.
⁵⁵ BRAC, Dhaka, Bangladesh.
⁵⁶ Society for Health and Demographic Surveillance, West Bengal, India.
⁵⁷ Western Sydney University, Penrith, New South Wales, Australia.
⁵⁸ National Institute of Public Health, Wako, Japan.
⁵⁹ Maragheh University of Medical Sciences, East Azerbaijan Province, Iran.
⁶⁰ University of KwaZulu-Natal, Durban, South Africa.
⁶¹ Tehran University of Medical Sciences, Tehran, Iran.
⁶² Independent Consultant, Karachi, Pakistan.
⁶³ Federal University of Santa Catarina, Florianópolis, Santa Catarina, Brazil.
⁶⁴ Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada.
⁶⁵ Addis Ababa University, Addis Ababa, Ethiopia.
⁶⁶ Postgraduate Institute of Medical Education and Research, Chandigarh, India.
⁶⁷ Jagiellonian University Medical College, Krakow, Poland.
⁶⁸ University of Copenhagen, Copenhagen, Denmark.
⁶⁹ Cleveland Clinic, Cleveland, Ohio.
⁷⁰ Hospital Sant Joan de Déu Barcelona, Sant Joan de Déu Research Foundation, Centro de Investigación Biomédica en Red Salud Mental, Universitat de Barcelona, Barcelona, Spain.
⁷¹ Department of Internal Medicine, Federal Teaching Hospital, Abakaliki, Ebonyi State, Nigeria.
⁷² UKK Institute for Health Promotion Research, Tampere, Finland.
⁷³ National Research University Higher School of Economics, Moscow, Russia.
⁷⁴ Norwegian Institute of Public Health, Oslo, Norway.
⁷⁵ Royal Children's Hospital, Melbourne, Victoria, Australia.
⁷⁶ King's College London, London, England.
⁷⁷ Nanjing University School of Medicine, Nanjing, China.
⁷⁸ The University of Mississippi Medical Center, Jackson.
⁷⁹ University of Hong Kong, Pokfulam, Hong Kong.
⁸⁰ Kyoto University, Kyoto, Japan.
⁸¹ Jackson State University, Jackson, Mississippi.
⁸² Wuhan University, Wuhan, China.
⁸³ University Hospital of Setif, Setif, Algeria.

PMID: 29641820
PMCID: PMC6145754
DOI: 10.1001/jamacardio.2018.0385

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.

PubMed Disclaimer

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 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 (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) per 100 000 Persons for Cardiovascular Disease (CVD) Causes by Age in 2016**

**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 per 100 000 Persons in 2016 in Both Sexes**

**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 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.

See this image and copyright information in PMC

Comment in

Geographic Variation in Cardiovascular Disease Burden: Clues and Questions.
Rosamond WD. Rosamond WD. JAMA Cardiol. 2018 May 1;3(5):366-368. doi: 10.1001/jamacardio.2018.0387. JAMA Cardiol. 2018. PMID: 29641821 No abstract available.
Maturing Methods for Cardiovascular Disease and Stroke Surveillance in the United States.
Huffman MD. Huffman MD. JAMA Cardiol. 2018 May 1;3(5):390. doi: 10.1001/jamacardio.2018.0812. JAMA Cardiol. 2018. PMID: 29641822 No abstract available.

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References

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[1] GBD 2016 Causes of Death Collaborators Global, regional, and national age-sex specific mortality for 264 causes of death, 1980-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2017;390(10100):1151-1210. - PMC - PubMed

[2] GBD 2016 Causes of Death Collaborators Global, regional, and national age-sex specific mortality for 264 causes of death, 1980-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2017;390(10100):1151-1210. - PMC - PubMed

[3] Case A, Deaton A. Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. Proc Natl Acad Sci U S A. 2015;112(49):15078-15083. - PMC - PubMed

[4] Case A, Deaton A. Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. Proc Natl Acad Sci U S A. 2015;112(49):15078-15083. - PMC - PubMed

[5] Sidney S, Quesenberry CP Jr, Jaffe MG, et al. . Recent trends in cardiovascular mortality in the United States and public health goals. JAMA Cardiol. 2016;1(5):594-599. - PubMed

[6] Sidney S, Quesenberry CP Jr, Jaffe MG, et al. . Recent trends in cardiovascular mortality in the United States and public health goals. JAMA Cardiol. 2016;1(5):594-599. - PubMed

[7] O’Flaherty M, Buchan I, Capewell S. Contributions of treatment and lifestyle to declining CVD mortality: why have CVD mortality rates declined so much since the 1960s? Heart. 2013;99(3):159-162. - PubMed

[8] O’Flaherty M, Buchan I, Capewell S. Contributions of treatment and lifestyle to declining CVD mortality: why have CVD mortality rates declined so much since the 1960s? Heart. 2013;99(3):159-162. - PubMed

[9] Ford ES, Ajani UA, Croft JB, et al. . Explaining the decrease in US deaths from coronary disease, 1980-2000. N Engl J Med. 2007;356(23):2388-2398. - PubMed

[10] Ford ES, Ajani UA, Croft JB, et al. . Explaining the decrease in US deaths from coronary disease, 1980-2000. N Engl J Med. 2007;356(23):2388-2398. - PubMed

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

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

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