THE BURDEN OF HEART DISEASE AND STROKE IN THE BIG SKY STATE MMOONNTTAANNAA 22000077 ACKNOWLEDGEMENTS This report was prepared by the Cardiovascular Health and Diabetes Programs, Chronic Disease Prevention and Health Promotion Section, Public Health and Safety Division, Montana Department of Public Health and Human Services. The following individuals contributed and were involved in the development and prepa- ration of this report: Carrie S. Oser, MPH; Dorothy Gohdes, MD; Todd S. Harwell, MPH; Michael J. McNamara, MS; Crystelle Fogle, MBA, MS, RD and Steven D. Helgerson, MD, MPH. The authors would like to give special thanks to the following individuals and organizations for their technical support and contributions to this report: • Susan Cummings, BSN, CPHQ, Behavioral Risk Factor Surveillance System (BRFSS) Coordinator, Public Health and Safety Division • David Fulgham, PhD, Mortality Statistician, Office of Vital Statistics • Bruce Schwartz, MA, MPA, Research Specialist, Office of Vital Statistics • Billings Area Indian Health Service We acknowledge the following organizations for their continued support of the Cardiovascular Health Program: • American Heart Association • Centers for Disease Control and Prevention • Montana Cardiovascular Disease/Obesity Prevention Task Force • Montana Stroke Workgroup Front cover painting: Runoff by Mike Chapman Back cover photograph: Old Man of the Hills and Walling Reef, 2006 by Todd S. Harwell PREFACE This updated cardiovascular burden report is intended to complement Montana’s 2006-2010 Heart Disease and Stroke State Plan. The report provides a detailed view of heart disease, stroke and cardiovascular risk factors in Montana. Although the burden report identifies encouraging trends in cardiovascular disease mortality for our state, it also highlights the growing prevalence of cardiovascular risk factors in Montanans, particularly in American Indians. I EXECUTIVE SUMMARY Cardiovascular Disease Mortality in Montana In 2005, cardiovascular disease (CVD) remains the leading cause of death in Montana with the majority of these deaths (30%) due to heart disease and stroke. • Since 1979, cardiovascular disease age-adjusted mortality rates have fallen in the US and in Montana by almost 42% and 55%, respectively. • In 2005, heart disease and stroke were the second and fourth leading causes of death. In comparison, in 2000, heart disease and stroke were the first and third leading causes of death, respectively. • Significant health disparities exist in Montana’s largest minority group, Ameri- can Indians (AI). From 1990-2005, Montana American Indians experienced higher age-adjusted mortality rates from CVD than non-Indians in the state. Cardiovascular Risk Factors in Montana • Montana American Indians’ prevalence of diabetes increased from 12% in 1999 to 19% in 2005. During the same timeframe, this population’s preva- lence of high blood pressure rose from 26% to 37%. Montana American Indians’ prevalence of obesity was almost twice that of all Montanans and US adults from 1999 to 2005. • From 1990 to 2005, the prevalence of high blood pressure rose from 19% to 24% for Montana adults. During that period, the prevalence of high blood cholesterol among Montana adults rose from 25% to 33%. One out of five Montana adults was obese in 2005. Signs/Symptoms Awareness • From 2003 to 2005, older Montana BRFSS respondents increased their knowledge of four or more stroke and heart attack signs and symptoms. Discharge Data • Heart failure age-adjusted hospital discharge rates have increased from 2001 to 2005. • Among Montana residents, age-adjusted stroke and coronary heart disease hospital discharge rates decreased slightly from 2001 to 2005. II TABLE OF CONTENTS Acknowledgements Preface I Executive Summary II List of Figures IV, V Introduction 1 Montana Demographics 2 Leading Causes of Death in Montana 3 MORTALITY 4 Cardiovascular Disease 4 Heart Disease 6 Coronary Heart Disease 6 Heart Failure 9 Stroke 11 MODIFIABLE CARDIOVASCULAR RISK FACTORS 14 Diabetes 15 High Blood Pressure 15 High Blood Cholesterol 16 Blood Cholesterol Screening 16 Obesity 17 Current Tobacco Use 17 SELF-REPORTED CARDIOVASCULAR DISEASE 18 Heart Attack 18 Stroke 18 Number of Cardiovascular Risk Factors 19 KNOWLEDGE OF HEART ATTACK AND STROKE SIGNS/ SYMPTOMS AND NEED TO CALL 9-1-1 20 Heart Attack Signs and Symptoms 20 Stroke Signs and Symptoms 21 Discussion and Conclusion 22 Appendix A – Methods, Data Sources and Limitations 23 Appendix B – Montana Counties 26 References 27 LIST OF FIGURES PAGE Figure 1 Map of Montana Indian reservations and type of county, 2005 2 Figure 2 Leading causes of death, Montana, 2005 3 Figure 3 Leading causes of death among Montana American Indians, 2005 3 Figure 4 Map of age-adjusted cardiovascular disease death rates, by county, 4 Montana, 1999-2005 Figure 5 Age-adjusted cardiovascular disease mortality rates for all Montanans 4 and the general US population, 1979-2005 Figure 6 Age-adjusted cardiovascular disease mortality for Montana and the 4 general US population, by gender, 1979-2005 Figure 7 Smoothed cardiovascular disease mortality rates, by race, 4 Montana, 1990-2005 Figure 8 Age-adjusted cardiovascular disease mortality rates for Montana, 5 by type of county, 1990-2005 Figure 9 Cardiovascular disease morality rates, by age and race, 5 Montana, 2000-2005 Figure 10 Leading causes of death, Montana, 2005 6 Figure 11 Map of age-adjusted coronary heart disease death rates, by county, 6 Montana 1999-2005 Figure 12 Age-adjusted coronary heart disease mortality rates for Montana 6 and the general US population, 1979-2005 Figure 13 Age-adjusted coronary heart disease mortality rates for Montana 6 and the general US population, by gender, 1979-2005 Figure 14 Smoothed coronary heart disease mortality rates, by race, 7 Montana, 1990-2005 Figure 15 Age-adjusted coronary heart disease mortality rates for Montana, 7 by type of county, 1990-2005 Figure 16 Coronary heart disease mortality rates, by age and race, 7 Montana, 2000-2005 Figure 17 Age-adjusted cardiovascular disease hospital discharge rates, 8 by type, Montana, 2001-2005 Figure 18 Age-specific coronary heart disease hospital discharge rates, 8 Montana, 2001-2005 Figure 19 Coronary heart disease hospital discharge rates, by gender and age, 8 Montana, 2005 Figure 20 Percentage of premature (less than 65 years) coronary heart disease 8 hospital discharges in Montana, by gender and type of county, 2005 Figure 21 Age-adjusted heart failure mortality rates for Montana and the general 9 US population, 1979-2005 Figure 22 Age-adjusted heart failure mortality rates for Montana and the general 9 US population, by gender, 1979-2005 Figure 23 Age-adjusted heart failure mortality rates for Montana, by type of county, 9 1990-2005 IV Figure 24 Age-specific heart failure hospital discharge rates, Montana 2001-2005 10 Figure 25 Heart failure hospital discharge rates, by gender and age, Montana, 2005 10 Figure 26 Percentage of premature (less than 65 years) heart failure hospital 10 discharges in Montana, by gender and type of county, 2005 Figure 27 Map of age-adjusted stroke death rates, by county, Montana 1999-2005 11 Figure 28 Leading causes of death, Montana, 2005 11 Figure 29 Age-adjusted stroke mortality rates for Montana and the general US 11 population, 1979-2005 Figure 30 Age-adjusted stroke mortality rates for Montana and the general US 11 population, by gender, 1979-2005 Figure 31 Smoothed stroke mortality rates, by race, Montana, 1990-2005 12 Figure 32 Age-adjusted stroke mortality rates for Montana, by type of county, 12 1990-2005 Figure 33 Stroke mortality rates, by age and race, Montana, 2000-2005 12 Figure 34 Age-specific stroke hospital discharge rates, Montana, 2001-2005 13 Figure 35 Stroke hospital discharge rates, by gender and age, Montana, 2005 13 Figure 36 Prevalence of diabetes for all Montanans, Montana American Indians 15 and the US, 1990 to 2005 Figure 37 Prevalence of high blood pressure for all Montanans, Montana American 15 Indians and the US, 1990-2005 Figure 38 Prevalence of high blood cholesterol for all Montanans, Montana 16 American Indians and the US, 1990 to 2005 Figure 39 Prevalence of cholesterol screening (in past 5 years) for all Montanans, 16 Montana American Indians and the US, overall and for those 45 years and older, 1990-2005 Figure 40 Prevalence of obesity for all Montanans, Montana American 17 Indians and the US, 1990 to 2005 Figure 41 Prevalence of current tobacco use for all Montanans, Montana 17 American Indians and the US, 1990-2005 Figure 42 Prevalence of Montana adults who reported having a heart attack or stroke, 18 by gender, 1999 to 2005 Figure 43 Prevalence of Montana American Indian adults who reported having a 18 heart attack or stroke, by gender, 1999 to 2005 Figure 44 Prevalence of Montana adults with self-reported cardiovascular risk factors, 19 by race, 1999 to 2005 Figure 45 Percentage responding correctly to questions about heart attack signs and 20 symptoms among Montana adults, by age, 2003 and 2005 Figure 46 Knowledge of heart attack signs and symptoms among Montana adults 65 20 years and older, 2003 and 2005 Figure 47 Knowledge of heart attack warning signs among adults 45 years and older 20 in Silver Bow and Flathead counties at baseline and follow-up, 2005 Figure 48 Percentage responding correctly to questions about stroke signs and 21 symptoms among Montana adults, by age, 2003 and 2005 Figure 49 Knowledge of stroke signs and symptoms among Montana adults 65 years 21 and older, 2003 and 2005 Figure 50 Knowledge of stroke warning signs among adults 45 years and older in 21 Cascade and Yellowstone counties at baseline and follow-up, 2004 and 2005 V INTRODUCTION Cardiovascular disease (CVD) is the leading cause of death in Montana. Many Montanans have experienced a heart attack, heart failure or stroke, and many others are at risk for serious but preventable cardiovascular disease. Public health efforts to reduce the burden of cardiovascular disease are growing in the state. The approaches include: • promoting public awareness of risk factors and symptoms of heart attack and stroke and the need to use 911 • coordinating care to reduce risk factors for both primary prevention and prevention of recurrent events • working with physician offices to improve hypertension and lipid control Surveillance related to cardiovascular disease in Montana gives the framework for the comprehensive Cardiovascular Health Program and provides informa- tion for all Montanans about progress in controlling the risk factors and reduc- ing the morbidity and mortality in Montana. This document updates the 2003 Burden of Cardiovascular Disease in Montana and contains updated data from a variety of sources. Policy makers, health care providers, emergency response personnel, health department workers and many other individuals can use the information contained in this update to guide activities and assess progress in reducing cardiovascular disease in Montana communities. 1 MONTANA DEMOGRAPHICS Montana is the fourth largest state in the United States but has a relatively small population. In 2005, the estimated total population of Montana was 935,670 with a population density of approximately 6.4 persons per square mile. The median age was 40.2 years, 50% were women and 13% of Mon- tana residents were 65 years of age or older. Of the 56 counties in Montana, 48 were defined as “frontier” (non-metropolitan counties without a city of 10,000). The remaining eight counties were defined as “small urban” counties with over 60% of the states’ population residing in these counties. Over 90% of Montana’s population is white with approximately 6% of the population being American Indian – Montana’s largest ethnic population. (Figure 1) Over 62% of the population lives in one of eight counties. These counties, defined as “small urban,” range in population from 16,304 to 136,691. A small urban county is a non-metropolitan county with a city of > 10,000 population or a county in metropolitan areas with less than one million population. (1) In contrast, the remaining 48 counties in Montana are defined as “frontier,” meaning a non-met- ropolitan county without a city of 10,000 or more population. (1) In 2005, population estimates in the frontier counties ranged from 470 to 39,940 with seven of these counties having fewer than 1,500 residents and 45 of these counties having a population density of six or fewer persons per square mile. (2) This report compares trends in mortality between frontier and small urban counties. Another important feature of Montana’s population is the economic characteristics of the state. In 2005, the median household income for Montana was almost 15% less than the US, ($39,301 compared to $46,242) (2) although the median household income for Montana American Indians was only $25,696 compared to $40,354 for the white population. In terms of wages, in 2003, eight of the top 10 poorest counties in America were located in Montana’s frontier counties. (3) In 2005, the Behavioral Risk Factor Surveillance System (BRFSS) found that 22% of all Montanans reported hav- ing no health care coverage, and this rate of uninsured Montanans has increased steadily from 15% in 2000. Unfortunately, the rate of uninsured Montana adults is seven percentage points higher than the comparable national figure of 15%. (4) Uninsured adult Montanans were likely to be younger and report lower income and less education than adults with health care coverage (data not shown). [Note: The terms “small urban” and “frontier” are used in this document as general descriptors only.] Figure 1. Map of Montana Indian reservations and type of county, 2005 Blackfeet Rocky Boy's FortPeck Fort Belknap Flathead Northern Cheyenne Crow Legend Indianreservation Smallurbancounty Frontiercounty Data source: Montana Department of Public Health and Human Services, Office of Vital Statistics 2