Coronary heart disease epidemiology in the 21st century.

Abstract

Knowledge of the determinants, distribution, and sequelae of coronary heart disease (CHD) in populations of the world's developed nations is extensive, is growing rapidly, and extends from the molecular level of individual persons to total societies. Lifestyle changes as well as public health and medical care advances in the prevention and treatment of CHD from the 1950s to the 1980s were accompanied by a 50 percent decline in CHD mortality in countries such as the United States (1). CHD nevertheless remains the leading cause of death in developed nations and is predicted to achieve that status worldwide within decades (2). The clinical manifestations, morbidity, and mortality of CHD are end-stage events triggered after decades of progression of asymptomatic, subclinical coronary atherosclerosis. The determinants of both the subclinical and clinical stages of the disease are numerous and varied, including risk factors for individual persons, group characteristics of entire populations, and environmental exposures. Broad, multilevel categories of CHD determinants and their interrelations are illustrated in figure 1. In this conceptualization, the determinants are categorized as follows: inherited genes and culture; biomedical, lifestyle, and psychosocial risk factors at the individual level; social, political, and economic factors at the group and aggregate levels; and social, medical care, physicochemical, and biologic exposures at the environmental level. Each interactively influences population levels of and trends in CHD over time. CHD susceptibility is transmitted intergenerationally, is conditioned environmentally, evolves and is manifest clinically over the time scale of each individual person's life, and is expressed in population rates of CHD during societies' histories.