Last Update: 10/26/20

Author: VDH Heart Disease Program

Coronary heart disease (CHD) is a disease in which a waxy substance called plaque builds up inside the coronary (heart) arteries. These arteries supply oxygen-rich blood to your heart muscle. When plaque builds up in the arteries (over many years), the condition is called atherosclerosis. Hardened plaque narrows the coronary arteries and reduces the flow of oxygen-rich blood to the heart. Hardened plaque can also harden or rupture (break open). If the plaque ruptures, a blood clot can form on its surface. A large blood clot can mostly or completely block blood flow through a coronary artery. Narrowed coronary arteries and reduced blood flow to the heart can lead to life-threatening complications including angina, heart attack, stroke, and heart failure.

If the flow of oxygen-rich blood to your heart muscle is reduced or blocked, angina or a heart attack can occur. Angina is chest pain or discomfort. It may feel like pressure or squeezing in your chest. The pain also can occur in your shoulders, arms, neck, jaw, or back. Angina pain may even feel like indigestion. It is important to note that women can experience very different symptoms when having a heart attack. As with men, women's most common heart attack symptom is chest pain or discomfort. But women are somewhat more likely than men to experience some of the other common symptoms, particularly shortness of breath, nausea/vomiting, and back or jaw pain. Learn about the warning signs of heart attack in women. A heart attack occurs if the flow of oxygen-rich blood to a section of heart muscle is cut off. If blood flow isn’t restored quickly, the section of heart muscle begins to die. Without quick treatment, a heart attack can lead to serious health problems or death.

Over time, CHD can weaken the heart muscle and lead to heart failure and arrhythmias. Heart failure is a condition in which your heart can't pump enough blood to meet your body’s needs. Arrhythmias are problems with the rate or rhythm of the heartbeat and can lead to sudden cardiac arrest, where the heart stops beating.

In 2014 there were 105.4 CHD deaths for every 100,000 adult Vermonters. While this rate is above the Healthy Vermonters 2020 goal of 89.4 CHD deaths per 100,000 adult Vermonters the trend over the past decade has been steadily falling, moving towards achieving that goal. CHD is currently the second cause of death (COD) for Vermonters after cancer.

This indicator is important because it is the second leading cause of death for Vermonters (leading cause of death in the nation) and is the common cause of heart disease. More importantly, is preventable and/ or treatable with appropriate evidence based lifestyle changes, medicines, and medical procedures. According to the National Heart, Lung and Blood Institute, CHD starts when certain factors damage the inner layers of the coronary arteries.

The major risk factors for CHD are:

• Unhealthy blood cholesterol levels. This includes high LDL cholesterol (sometimes called “bad” cholesterol) and low HDL cholesterol (sometimes called “good” cholesterol).
• High blood pressure. Blood pressure is considered high if it stays at or above 140/90 mmHg over time. If you have diabetes or chronic kidney disease, high blood pressure is defined as 130/80 mmHg or higher. (The mmHg is millimeters of mercury—the units used to measure blood pressure.)
• Smoking. Smoking can damage and tighten blood vessels, lead to unhealthy cholesterol levels, and raise blood pressure. Smoking also can limit how much oxygen reaches the body's tissues.
• Insulin resistance. This condition occurs if the body can't use its own insulin properly. Insulin is a hormone that helps move blood sugar into cells where it's used for energy. Insulin resistance may lead to diabetes.
• Diabetes. With this disease, the body's blood sugar level is too high because the body doesn't make enough insulin or doesn't use its insulin properly.
• Overweight or obesity. The terms “overweight” and “obesity” refer to body weight that’s greater than what is considered healthy for a certain height.
• Metabolic syndrome. Metabolic syndrome is the name for a group of risk factors that raises your risk for CHD and other health problems, such as diabetes and stroke.
• Lack of physical activity. Being physically inactive can worsen other risk factors for CHD, such as unhealthy blood cholesterol levels, high blood pressure, diabetes, and overweight or obesity.
• Unhealthy diet. An unhealthy diet can raise your risk for CHD. Foods that are high in saturated and trans fats, cholesterol, sodium (salt), and sugar can worsen other risk factors for CHD.
• Older age. Genetic or lifestyle factors cause plaque to build up in your arteries as you age. By the time you're middle-aged or older, enough plaque has built up to cause signs or symptoms. In men, the risk for CHD increases after age 45. In women, the risk for CHD increases after age 55.
• Family history of early heart disease. Your risk increases if your father or a brother was diagnosed with CHD before 55 years of age, or if your mother or a sister was diagnosed with CHD before 65 years of age.

As noted above, CHD can lead to heart attack or stroke, aneurysm, heart failure, and sudden cardiac arrest. The measure for Coronary Heart Disease Death Rate per 100,000 (the number, per 100,000 adults, who die of coronary heart disease each year) is a Healthy Vermonters 2020 performance indicator. The Department of Health receives grant funds from the CDC to coordinate activities and partnerships that support strategies to reduce risk factors for heart disease across the state. These Health Department programs are managed in the Division of Health Promotion and Chronic Disease Prevention, and include the following programs: Tobacco Control Program, Physical Activity and Nutrition Program, heart health side of the Ladies First Program, and a coordinated chronic disease grant which focuses on school health, diabetes, obesity, and hypertension – all of which support strategies that play an important role in reducing heart disease.

• Vermont Blueprint for Health and its statewide network of Community Health Teams
• AARP
• Primary Care Providers (no link available – these are individual practices)
• Community Health Centers
• Million Hearts ^®
• Association of State and Territorial Leaders (ASTHO)
• American Heart Association of Vermont

Reducing the modifiable risk factors (listed above) can help prevent coronary heart disease. Evidence based strategies include maintaining a healthy weight, not smoking, limiting alcohol, and eating a healthy diet rich in fruits, vegetables, and fiber and low in fats and sugars. Several programs housed within the Department of Health’s Division of Health Promotion and Chronic Disease Prevention and Division of Alcohol and Drug Abuse Prevention support activities that promote those strategies.

National organizations including the Centers for Disease Control and Prevention (CDC), Million Hearts, American Diabetes Association, and the American Heart Association recommend a number of evidence-based interventions to help adults with hypertension reduce and control their blood pressure. These include:

• Working with a health care team
• Making lifestyle changes (healthy diet, being active, not smoking and limiting alcohol).
• Using self-measured Blood Pressure techniques
• Using self-management programs such as the Stanford Healthier Living Workshop – Diabetes (HLWD), Chronic Disease Self-Management (CDSMP) and the National Diabetes Prevention Program
• Working to promote use of evidence based treatment protocols among Primary Care Providers
• Promoting evidence based resources such as the DASH Eating Plan and the Healthy Eating and Lifestyle Resource Center

The Vermont Department of Health is funded by the CDC to work on prevention activities that reduce heart disease through a grant called Improving the Health of Americans Through Prevention and Management of Diabetes and Heart Disease and Stroke ( CDC-RFA-DP18-1815). Our strategy is to work with providers, clinics and community partners to create healthy environments, promote best practices, and support Vermonters to make healthy choices that will prevent or help reduce the likelihood of developing coronary heart disease.

Although a self-management program specifically focused on heart disease is not currently available, programs such as the Chronic Disease Self-Management (CDSMP) and the National Diabetes Prevention Program help teach people with or at risk for heart disease to manage lifestyle and behaviors that will lead to better blood pressure control, weight loss, lower cholesterol, and other lifestyle factors that lower the risk for heart disease. These programs are available across the state to all qualifying Vermonters at no cost. The CDSMP is called “Healthier Living Workshop” in Vermont and is offered throughout the state. The program specifically addresses arthritis, diabetes, lung and heart disease, but teaches skills useful for managing a variety of chronic diseases. This program was developed at Stanford University and helps individuals develop skills to cope with their condition, improve energy levels, manage pain, and learn to make the best choices for their condition and lifestyle. It covers topics such as: techniques to deal with problems associated with chronic disease, appropriate exercise, appropriate use of medications, communicating effectively with family, friends, and health professionals, nutrition, and how to evaluate new treatments. Participants who took CDSMP demonstrated significant improvements in exercise, ability to do social and household activities, less depression, fear and frustration or worry about their health, reduction in symptoms like pain, and increased confidence in their ability to manage their condition. Other strategies include the development and distribution of treatment guidelines and consumer resources for clinical management and self-management of blood sugar and blood pressure.

An important first step is to make an appointment with your primary care provider to have your heart health assessed. Your provider can help identify ways to maintain a healthy heart, or develop a plan that could include lifestyle changes and possibly medications, to help lower your risk factors.

Recommendations from health care providers are among the most influential factors in convincing people to be physically active and join a self-management program. The American Heart Association also has an online heart health assessment tool called My Life Check – Life’s Simple 7 where people can take the assessment online, see their heart health score, and receive a seven step list related to lifestyle behaviors that can help people stay healthy or take steps to reduce risk factors linked to heart disease.

By focusing on the health and well-being of all Vermonters through quality health systems, physical activity, nutrition and tobacco prevention and cessation intervention – the most effective ways to prevent or reduce the risk of developing heart disease – we can help to address the most significant risk factors and ensure better quality of life for those at risk for heart disease.

BRFSS

Vermont tracks the risk behaviors of its adult residents using a telephone survey, the Behavioral Risk Factor Surveillance System (BRFSS), for landlines and cellular phones leverage through funding from the Centers for Disease Control and Prevention (CDC). The inclusion of cellular phones began in 2009; this was done to ensure the survey contained an accurate representative sample of adult Vermonters as cell phone use as the primary household phone was increasing significantly. The sample of respondents is then weighted, using standardized methodology developed by the CDC, to achieve population level estimates. In 2011 this weighting methodology was changed due to the fact that cell phones became the predominant make-up of the entire sample. This new system of raking allows for the incorporation of other variables not traditionally used in the weighting process, most importantly, telephone source.

Behavioral Risk Factor Surveillance System -- BRFSS

Vermont tracks risk behaviors and chronic disease using a telephone survey of adults called the Behavioral Risk Factor Surveillance Survey (BRFSS). Since 1990, Vermont, along with the 49 other states, Washington D.C. and U.S. territories, has participated in the BRFSS with the Centers for Disease Control and Prevention. The CDC provides the Vermont Department of Health with funding each year to carry out the survey. Several thousand Vermonters are randomly and anonymously selected and called annually, on both landlines and cell phones. An adult (18 or older) is asked a uniform set of questions. The results are weighted to represent the adult population of the state.

Note that beginning in 2011 the CDC implemented changes to the BRFSS weighting methodology in order to more accurately represent the adult population.While this makes calculations more representative of the population, the changes in methodology also limit the ability to compare results from 2011 forward with those from previous years.The Vermont Department of Health recommends that comparisons between BRFSS data from 2011 forward and earlier years be made with caution.Statistical differences may be due to methodological changes, rather than changes in opinion or behavior.

YRBS

The Youth Risk Behavior Survey (YRBS) is a paper survey taken by Vermont middle and school students every other year as a collaboration between the Department of Health’s Division of Alcohol and Drug Abuse Program and the Agency of Education’s Coordinated School Health Programs. It measures the prevalence of behaviors that contribute to the leading causes of death, disease, and injury among Vermont Youth. Data is weighted so as to generate population level estimates for all Vermont Middle and High Schools.

Youth Risk Behavior Survey -- YRBS

The Youth Risk Behavior Survey (YRBS) is a paper survey administered in Vermont middle and high schools every two years since 1993. The survey is sponsored by the Department of Health's Division of Alcohol and Drug Abuse Programs, and the Department of Education's Coordinated School Health Programs and the CDC. The YRBS measures the prevalence of behaviors that contribute to the leading causes of death, disease, and injury among youth. Vermont surveys over 30,000 students at each administration. Weighted data is compiled to generate a representative state sample, and local data is used by schools, supervisory unions, health programs and other local organizations. The YRBS is completed in over 40 other states and there is a national weighted sample for comparison.

VITAL STASTICS

The Vermont vital statistics system monitors vital events (births, deaths, marriages and civil unions, divorces and dissolutions, etc.). Death certificates are often completed by the funeral directors who obtain all necessary information from the family. However, a physician is required to complete and certify the cause of death in the Electronic Death Registration System (EDRS).Mortality rates are calculated based on the ICD-10 code for the underlying cause of death listed on death records received by Vital Records. Only Vermont residents are included in these calculations.Rates were calculated by comparing the number of deaths in a given time period to the overall population of Vermont in the same time period.

WHEN A MEASURE IS AGE ADJUSTED

Age adjustment is used for comparison of regions with varying age breakdowns.In order to remain consistent with the methods of comparison at a national level, some statistics in Vermont are age adjusted.In cases where age adjustment was noted as being part of the statistical analysis, the estimates were adjusted based on the proportional age breakdowns of the U.S. population in 2000. For more detailed information on age adjustment see Healthy People 2010 Statistical Notes.

Methods

Prevalence and percentages are calculated by using descriptive statistical procedures using software such as SPSS, SAS, and/or SUDAAN.These statistics describe the proportion of individuals with a given trait in the population during a specified period of time.

Discharge rates are calculated using the Vermont Uniform Hospital Discharge data set.We look at all hospital and ED discharge among Vermont residents who utilized services at regional hospitals (including hospitals in bordering states).We compared the number of discharges in a given time period to the Vermont population in the same time period to calculate discharge rates.