Arizona
Cardiovascular
Disease
State Plan

“Coming together is a beginning, staying
together is progress, and working together
is success.”
- Henry Ford

1

Acknowledgements
TRUST Commission
We would like to thank the Advisory Council of the Tobacco Revenue Use,
Spending and Tracking (TRUST) Commission for supporting the development
of the Cardiovascular Disease Prevention Plan for the State of Arizona.
Authors
Primary Authors
Nicole Olmstead, M.P.H.
Arizona Department of Health Services
Andrew Weiler
American Heart Association, Pacific Mountain Affiliate.
Reviewers
Renea Cunnien, Ph.D
Arizona Department of Health Services
Timothy Flood, M.D.
Arizona Department of Health Services
Susan Leo M.P.H.
Arizona Department of Health Services
Cristi Kauffman
Arizona Department of Health Services
Sharon Sass, R.D.
Arizona Department of Health Services
Marie Tymrak, R.D., M.P.H.
Arizona Department of Health Services
Veronica Vensor, M.P.H.
Arizona Department of Health Services

Contributors
We would like to thank everyone who contributed to the development of the
Cardiovascular Disease Prevention Plan for the State of Arizona through the
community forum.

2

Table of Contents
Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
Vision and Mission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6-9
Burden of Cardiovascular Disease in Arizona . . . . . . . . . . . . . . . . . . . . . . .10
Estimated Prevalence of Cardiovascular Disease in Arizona . . . . . .11
Cardiovascular Disease Mortality in Arizona . . . . . . . . . . . . . . . . . . .11-12
County Burden of Cardiovascular Disease in Arizona . . . . . . . . . . .12-14
Major Modifiable Risk Factor Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
Smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
Physical Inactivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15-16
High Cholesterol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16-17
High Blood Pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18-19
Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20-21
Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22
Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22-24
Non-Modifiable Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25
Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25
Gender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25-26
Heredity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26
Race . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26-28
Lack of Access to Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29-30
Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31-36
Addressing Cardiovascular Disease Disparities In Arizona . . . . . . . . . . . . .37
Implementation Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38
Next Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39
Appendix A – Description of Existing Programs . . . . . . . . . . . . . . . . . . . . .40-41
Appendix B – Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42
Appendix C – Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43-51
Appendix D – References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51-57

3

Executive Summary
Cardiovascular disease (CVD) is the leading cause




of death in Arizona. Cardiovascular disease, which

Reduce the number of stroke deaths in
Arizona by 20 percent by the year 2010.

includes heart disease and stroke, accounts for



more than 30 percent of the deaths in Arizona in

Decrease the number of Arizonans diagnosed
with Cardiovascular Disease by 20 percent by

2003 and CVD claimed more than 138,000 lives
over the past ten years.1 In addition to the lives

the year 2020.

lost as a result of cardiovascular disease,




approximately 4,195 per 100,000 people living in

Increase the proportion of adults aged 20
years and older that are aware of the early

Arizona are living with heart disease and 2,457 per

warning signs and symptoms of a heart attack

100,000 people are living with cerebrovascular

and the importance of seeking immediate

disease, the disease that leads to a stroke. As the

medical attention.

number of people living with CVD continues to rise,
and the state’s population continues to age, the




Increase the proportion of adults who are

health and economic burden of cardiovascular

aware of the early warning signs and

disease will greatly impact the population’s health

symptoms of a stroke and the importance of

status.

seeking immediate medical attention.

The Cardiovascular Disease Prevention Plan for




Establish a surveillance system to accurately

the State of Arizona outlines a comprehensive

identify the true burden of Cardiovascular

approach to reducing the burden of cardiovascular

Disease in the state of Arizona.

disease through the most efficient, cost-effective,



and evidence-based strategies available. This plan

Establish a core team, comprised of

supports current efforts in primary prevention and

physicians, hospital groups, public health

proposes new primary prevention activities that are

professionals and community members, that

specific to cardiovascular disease. The majority of

will advise the Arizona Department of Health

the plan addresses secondary prevention efforts

Services (ADHS) Cardiovascular Risk

and controlling risk factors in those who already

Reduction Program on the activities necessary

have cardiovascular disease.

to meet the long-term state plan objectives.

The long-term objectives to address

This release of the Cardiovascular Disease

cardiovascular disease in Arizona are:

Prevention Plan for the State of Arizona is the




Reduce the number of coronary deaths in

first step to significantly reducing heart disease

Arizona by 25 percent, by the year 2010, in

and stroke mortality and morbidity in Arizona.

conjunction with the American Heart

Achieving the objectives set forth in this plan

Association’s impact goal and achieving the

will take a coordinated effort from many

Healthy People 2010 goal.

organizations. Using this plan to guide activities,
and working in coordination, can reduce the death
and disability from heart disease and stroke in
Arizona.
4

Vision:
Reduce death and disability
from Cardiovascular Disease in Arizona.

Mission:
The mission of the Arizona State Plan on Cardiovascular Disease
is to reduce the death and disability associated with
all cardiovascular diseases, particularly
heart disease and stroke, using the most efficient,
cost-effective and evidence-based strategies available.

5

Introduction
Cardiovascular disease (CVD) refers to conditions

Angina is chest pain or discomfort that occurs

and diseases of the heart and blood vessels,

when the heart is not getting enough blood or

including, but not limited to, coronary artery

oxygen. Heart attacks, also known as myocardial

disease (CAD), heart attack, stroke, high blood

infarctions (MI), occur when the blood supply to the

pressure, congestive heart failure and congenital

heart is decreased or stopped. The result of a

heart diseases. CVD has been the leading cause

heart attack is death of at least part of the heart

of death every year since the early 1900s. Despite

tissue; the severity of the MI is determined by the

the increase in scientific knowledge and health

location and size of the blockage. CAD is the most

awareness that has occurred since that time, CVD

common form of heart disease and is the leading

continues to be the most prevalent health problem

cause of death in both men and women. If a

in the U.S., surpassing other diseases such as

person has CAD over an extended period of time,

diabetes and all forms of cancer combined.

it can weaken the heart muscle and contribute to

According to the Centers for Disease Control and

arrhythmias, or changes in the normal heart beat

Prevention

pattern, and heart failure.

(CDC),

approximately

950,000

Americans die from CVD each year, which is one
Congestive heart failure (CHF) is a condition

2

death every 33 seconds. Additionally

where blood output of the heart is significantly

approximately 31 million Americans, or one-fourth

reduced and is usually the result of an MI,

of the U.S. population, are currently living with

ischemia, cardiomyopathy, cardiomegaly, heart

some form of CVD.

muscle weakening, high blood pressure, a defect
The costs of heart disease and stroke continue to

in the muscular wall or valves, or other medical

increase annually. In 2004, the estimated cost of

conditions.

heart disease and stroke was $368 billion, which is

across the U.S. are living with CHF, and 550,000

an increase of $17 billion over the costs in 2003.

3

5

Approximately five million people

new cases are diagnosed each year.

CHF

The financial impact of treating CVD will not only

requires intensive follow-up between the patient

be affected by inflation, but also by the advent of

and the medical team. Preventing complications

new procedures and the growing population over

such as pulmonary and peripheral edema,

the age of 65 years old.

arrhythmia and electrolyte abnormalities can
significantly decrease the cost of treating CHF, as

Coronary artery disease (CAD) occurs when the

well as lessen the potential for disability

arteries that supply blood to the heart muscle

associated with this condition.

become hardened and narrow.

4

This hardening is

a result of plaque build-up on the inner walls of the
artery, a process that is called atherosclerosis.

When atherosclerosis affects the blood vessels in

5

and around the brain, ischemia can develop that

The narrowing restricts blood and oxygen flow to

could result in the death of brain tissue. This tissue

the heart. If the narrowing is severe enough,

death is often called a cerebrovascular accident,

angina or a heart attack can occur.

commonly known as a stroke.

6

4

An acute stroke can occur when a blood vessel

Accreditation of Health Organizations (JCAHO),

carrying oxygen and nutrients to the brain is either

will dramatically increase the effectiveness of the

blocked by a thrombus or embolus, or when the

“Chain of Survival” for stroke, and are an important

vessel dissects and causes intercranial bleeding

step in decreasing the death and disability

and significant disruption in the blood flow of the

of CVD.

6

brain. As with a heart attack, disruption of blood
flow causes part of the brain to be deprived of the

In the past 20 years, mortality from CVD has

nutrients and oxygen it needs and it begins to die.

declined; however, this decline slowed during the

Blocked arteries cause 88 percent of strokes;

1990s for heart disease and was static for stroke.

these would be classified as ischemic strokes. The

This is because more people are living with the

other type is a hemorrhagic stroke, where an

disease rather than dying from it. In fact, since

aneurysm or thin, weakened area of a blood vessel

1975, the number of people living with CHF has

ruptures. This is also known as “bleeding” stroke.

increased.

As part of the brain tissue dies from a lack of

Given that the leading risk factors for CVD,

oxygen, the area of the body it controls is affected.

smoking, physical inactivity, high cholesterol, high

Someone who has suffered from a stroke may be

blood pressure, diabetes and obesity, are

paralyzed, have language or vision problems, or

modifiable, it is surprising that it is the leading

die if the stroke affected the higher brain centers

cause of death in the U.S. and Arizona. The

that control breathing or movement of critical areas

contributing risk factors for CVD are poor nutrition

in the body. In the U.S., stroke is the third leading

and stress.

cause of death, and in the year 2000, accounted
for 167,661 deaths.

7

Poor nutrition, both in the form of

ingesting too many calories and by ingesting foods

There are approximately

that are high in fat and salt, contribute to many of

700,000 strokes each year, with 200,000 occurring

the major risk factors.

in patients who have suffered a prior stroke. It is

Other chronic diseases,

such as diabetes, arthritis, osteoporosis, and

alarming, given the high prevalence of stroke in

kidney disease, may have significant impact on the

our country that the general public is largely

development and treatment of heart disease and

unaware of the signs of stroke and that it is a

stroke.

medical emergency requiring immediate attention.
Treatments for acute coronary syndromes and

When classifying a risk factor as a major modifiable

stroke, which would dissolve a thrombus and stop

risk factor it is important to consider independence,

a stroke or heart attack from progressing, are

disproportionate

available and would minimize the damage to the

Independence means that smoking, or exposure to

brain or heart and the associated disability.

environmental tobacco smoke (ETS), physical

Unfortunately, these treatments are very

inactivity, high blood pressure, high cholesterol and

time-sensitive and need to be initiated within three

obesity are considered to cause heart disease and

hours of the stroke or heart attack. There is a great

stroke by independent mechanisms.

necessity in Arizona to develop the “Chain of
Survival” for stroke so that it is as proficient as the
chain for cardiac emergencies.

Primary stroke

centers, certified by the Joint Commission on the
7

risk,

and

dose

response.

Figure 19

Disproportionate risk refers to the observation that

has a strong family history of heart disease and/or

the presence of modifiable risk factors

stroke may decide, along with their medical team,

dramatically increases one’s risk for developing

that it is prudent to lower their blood pressure and

heart disease and stroke and that risk is increased

cholesterol levels to below what would be

exponentially when additional risk factors are

considered normal for individuals of the same age

present in an individual. Dose response means

without a family history.

that those individuals who are the least active, use
the most tobacco, have the highest blood pressure

Currently, the CDC provides funding for 32

and cholesterol levels and are the most overweight

programs across the U.S. to improve the

or obese are more likely to develop heart disease

cardiovascular health of Americans.

and/or stroke than their counterparts.

8

Figure 1,

The priorities of these programs are to:

based on Framingham Heart Study data, shows

10




Control high blood pressure;




Control high cholesterol;




Increase the awareness of the signs and

the increased risk of developing heart disease and
stroke when additional risk factors are present.
It is also important to consider the non-modifiable

symptom of heart disease and stroke and

risk factors for heart disease and stroke, such as

the importance of calling 911 when these

age, gender, and family history. These risk

signs and symptom occur;

factors, although non-modifiable, are useful in
assessing one’s risk for developing CVD,




Improve emergency response;




Improve quality of care; and




Eliminate disparities.

interpreting the thresholds for other modifiable risk
factors, and interpreting screening and
diagnostic tests for heart disease and stroke.
For example, an individual in his/her 40s and who
8

Addressing modifiable risk factors for heart

PA has been shown to increase the efficacy of

disease and stroke might have an effect on other

smoking cessation programs, reduce Body Mass

chronic diseases such as cancer, diabetes, arthritis

Index (BMI), waist circumference, waist to hip ratio

and depression. Also, interventions aimed at

and body fat percentage, lower total cholesterol,

modifying one modifiable risk factor may positively

lower blood pressure, and improve insulin

affect other risk factors and have a

sensitivity.

near-multiplicative reduction in the risk of

instead of as a group could still reduce heart

developing heart disease and/or stroke. Of those

disease and stroke significantly. According to the

that are modifiable, physical activity (PA), in

American Heart Association (AHA), if all major

particular, has the most significant effect on the

forms of heart disease and stroke were eliminated

other risk factors for heart disease and stroke.

the life expectancy of Americans would increase by

Addressing risk factors individually

almost 10 years.

9

Burden of Cardiovascular Disease in Arizona
Cardiovascular disease is a collection of diseases,

Almost any area of the body can be affected by

most of which affect the blood vessels of the

cardiovascular disease (CVD), because almost the

human body and restrict blood supply. Heart

entire body is dependent on blood flow to and from

disease, the leading cause of death in Americans,

the living tissues. When the disease process

is a broad term for any disease that affects the

affects an area other than the heart, it is called

heart muscle itself. Coronary Artery Disease (CAD)

peripheral vascular disease. The second largest

is the largest form of heart disease and is a

form of CVD and the largest peripheral vascular

condition that affects the blood flow to the heart.

disease is stroke; this is a disease process that

Generally arteriosclerosis and atherosclerosis

restricts blood flow to the brain. Restriction of blood

cause impairment in the function of the coronary

flow to the brain that is prolonged and causes

arteries and result in obstruction of blood to the

death of tissue is often called a cerebral vascular

heart. CAD is the largest cause of death for

accident or a stroke. It is similar to a heart attack,

American men and women and is the leading

which is caused by a significant obstruction of

cause of sudden cardiac arrest in America.

blood flow to the heart and where tissue death
occurs. Figure 2 represents all types of CVD in
Arizona. Clearly, the largest cause of CVD deaths
is ischemic heart disease.

Figure 2

10

Estimated Prevalence of
Cardiovascular Disease in Arizona

Cardiovascular Disease Mortality in
Arizona

The CDC and the American Heart Association

While disease prevalence is very important in

(AHA) have estimated that nearly 61 million

determining where prevention programs should be

Americans have at least one form of CVD. CAD

located, the most accurate data for CVD

has the largest prevalence in America, with 12

prevalence is mortality data. CVD is the leading

million people diagnosed.

2

The other component

cause of death, both nationally and in Arizona.

of CVD is stroke, which is estimated to have a

Nearly 950,000 Americans die from CVD each

prevalence of nearly 4 million Americans.

year, and CVD accounted for 40 percent of the
deaths in Arizona in 2002. Figure 3 shows the

The prevalence of CVD in Arizona is difficult to

leading causes of death in Arizona. The top four

estimate, due to a lack of available data. In order

leading causes of death in Arizona are heart

to calculate the rate, it is necessary to rely on

disease, cancer, stroke, and chronic lower

existing surveys such as the Behavioral Risk

respiratory disease.

Factor Surveillance Survey (BRFSS), a telephone
survey that is administered nationally on an

Arizona ranked 42nd in the U.S. and the District of

annual basis, or the National Health Interview

Columbia in deaths due to diseases of the heart,

Survey (NHIS), the most recent of which was
completed in 2001. The rates, unless otherwise

with an age adjusted rate of 204.5 per 100,000
11
Arizona ranked 46th across
population in 2001.

stated, reflect individuals age 20 years and older.

the U.S. and the District of Columbia in deaths due

Based on the NHIS, the prevalence of heart

to stroke with an age adjusted rate of 48.2 per

diseases in Arizona was estimated to be 4,195 per

100,000 population.

100,000 people and the prevalence of stroke in
Arizona was estimated to be 2,457 per 100,000
people.

Figure 3

11

Map 1

Morbidity and Mortality from CVD are related to a
number of modifiable risk factors, and many

County Burden of
Disease in Arizona

Cardiovascular

experts view CVD as largely preventable. Many of

The following maps of Arizona show where CVD

these risk factors can be addressed by

rates are highest and services should be

interventions aimed at improving unhealthy

concentrated. There are 15 counties in Arizona,

behaviors, such as a sedentary lifestyle, cigarette

and two primary population centers within those

smoking, and poor dietary habits. Risk factors like

counties.

tobacco use, physical inactivity and poor nutrition

Cochise, Gila, Graham, Greenlee, La Paz,

not only increase the likelihood of developing CVD,

Maricopa, Mohave, Navajo, Pima, Pinal, Santa

they also lead to high blood pressure and high

Cruz, Yavapai, and Yuma. The population centers

cholesterol. These conditions are also risk factors

are Phoenix, located in Maricopa County, with an

for developing heart disease and stroke. As shown

estimated population of 3,389,260, and Tucson,

in Figure 1 each additional risk factor

located in Pima County, with a population of

exponentially increases the risk of developing and

892,798.

dying from heart disease and stroke. Therefore, by

2003) in Arizona for heart disease is shown in Map

reducing the occurrence of the modifiable risk

1. The counties with the highest mortality rate are

factors that are responsible for CVD, it is possible

Gila, Mohave, and Yavapai. These three counties

to reduce the death and disability from CVD in

have mortality rates from heart disease of 392.0,

Arizona.

430.1 and 368.6 per 100,000 population,

The counties are: Apache, Coconino,

13

14

respectively.

12

The average mortality rate (2000-

15

Apache, Coconino and Santa Cruz counties have

Map 2 shows the average mortality rate across

the lowest rate mortality from heart disease, with

Arizona for stroke. Between 2000 and 2003, Gila

rates of 185.7, 129.7, and 202.5 per 100,000

and Yavapai counties have the highest rate of

respectively. Maricopa County and Pima County

mortality due to stroke with rates of 92.9 and 108.5

have moderate rates of mortality as a result of

per 100,000 respectively.

heart disease, compared to the other counties in

rates during the same time period occurred in

Arizona.

Apache and Coconino counties with rates of 35.9

The lowest mortality

and 35.0 per 100,000 population, respectively.
Maricopa County had a slightly lower rate at 60.8
per 100,000 population than Pima County with a
rate of 74.6 per 100,000

Map 2

13

Table 1

Table 1 shows the average count of

hospitalizations at Indian Health Services (IHS)

hospitalizations in non-federal hospitals across

facilities and Veterans Affairs (VA) hospitals would

Arizona for heart disease and stroke. It is

not be included in these numbers. In order to more

interesting to note that the northeast counties in

accurately portray the CVD hospitalization rate in

Arizona all have low counts for heart disease and

the northwest counties of Arizona, it would be

stroke hospitalizations. One theory is that the data

necessary to have access to that information.

used only captures hospitalizations in non-federal
facilities. Therefore, information regarding

14

Modifiable Risk Factor Analysis
Smoking
Cigarette smoking has significant evidence linking

Arizona ranks 23rd across the U.S. with 23 percent

it to an increased risk of developing CVD. People

of adults reporting current cigarette smoking in the

who smoke have a 70 percent increased risk of

2002 BRFSS.

developing CVD than a non-smoker.

16

17

According to the 2002 BRFSS 20

The length

percent of females and 26.9 percent of men report

of time a person smokes or how deeply they inhale

that they are currently smoking. Figure 4 shows

will also affect their risk of developing CVD.

the trend for smoking among adults in Arizona
between 1990 and 2002.

Figure 4

Physical Inactivity
Due to recent health marketing campaigns, the

The intensity of the activity significantly contributes

public is aware that there are positive benefits from

to a reduction in risk. Additionally, PA improves the

physical activity (PA), such as weight loss,

likelihood of surviving a heart attack.

improved energy and alertness.

PA, especially

aerobic exercise, plays a significant role in the

In the U.S. approximately 250,000 deaths per year

prevention of heart and blood vessel disease and

are attributable to lack of physical activity. PA

reduces the risk of developing CVD. However, the

prevents and helps treat many established

general public is unaware that lack of PA is causal

atherosclerotic risk factors, including elevated

in developing CVD. Bluntly put, physical inactivity

blood pressure, insulin resistance and glucose

is as bad for you as high cholesterol, high blood

intolerance, elevated triglyceride concentrations,

pressure and smoking.

low and high-density lipoprotein cholesterol
concentrations, and obesity.
15

According to the BRFSS, Arizona ranks 32nd

synthesized in adequate amounts by the liver.

across the U.S. with 22.6 percent of adults

Although it is essential for human life, cholesterol is

reporting no leisure time activity.

18

not an essential component of the typical

Figure 5 shows

the trend in Arizona and the U.S. No data was

American’s diet. Cholesterol is used to produce

collected in 1993, 1995, 1997 and 1999.

cell membranes, some hormones, as well as
participate in other crucial body functions.

During the late 1990s there was a sharp increase

Cholesterol is obtained in two ways: 1) it is made

in the percent of adults who engaged in no leisure

by the liver; and 2) it comes from animal products

time physical activity. However, since 1998, that

such as beef, poultry, eggs, fish, butter, cheese

trend has decreased.

and milk. Foods such as fruits and vegetables

In 2002, 22.6 percent of

Arizonans reported that they were sedentary.

do not have cholesterol in them. Individuals with

Given the number of health problems that can be

high cholesterol levels often have high levels of

encountered with sedentary habits, it is an

cholesterol synthesized by the liver or a high

encouraging trend to see that more people are

dietary cholesterol intake. It is important to know

being physically active.

that saturated fat in the diet has a more profound
effect on blood cholesterol levels than cholesterol

High Cholesterol

in the diet. It is thought that high dietary intake of

Cholesterol is a soft, fat-like, waxy substance
found in the bloodstream and in all body cells.

saturated fat signals the liver to increase

19

cholesterol production and may adversely affect

Cholesterol is essential for human life and is

the type of cholesterol synthesized by the liver.

Figure 5

16

Therefore, decreasing dietary saturated fat intake

Triglycerides are fatty substances found both in

may more substantially lower total cholesterol than

blood and adipose tissue in the body. They are

decreasing dietary cholesterol intake. A common

also a component of LDL cholesterol. They are

strategy to lower saturated fat intake is to move to

present in both plasma and form the plasma lipids,

a more plant-based diet, which reduces both

in relation to cholesterol.

saturated fat and cholesterol levels in the diet.

derived from other food sources such as

Triglycerides can be

carbohydrates and protein. Calories that are not
There are two forms of cholesterol in the blood.

turned into energy immediately are turned into

High-density lipoprotein cholesterol (HDL) is

triglycerides and transported to fat cells to be

considered “good” or protective cholesterol.

stored. They are released from fat cells and used

It helps to extract excess cholesterol from blood

for energy between meals. They are also a risk

vessel walls and transport it back to the liver for

factor for CVD. Current guidelines indicate that

elimination through the gastrointestinal tract.

triglyceride levels should not exceed 150mg/dL.

22

Current guidelines recommend that HDL

An estimated 105 million Americans have a total

cholesterol levels in the blood be above 40mg/dL

cholesterol level of 200mg/dl or higher, and over 80

for men and 50mg/dL for women.

20

Because fat

percent of those with high cholesterol do not have
23

and cholesterol do not dissolve into the blood, they

it under control.

must be carried through the body with lipoproteins.

have cholesterol levels of 240mg/dL or above.

Studies have shown that for every 1-mg/dL rise in

2003, 34.6 percent of Arizonans were at risk of

HDL cholesterol, the risk of developing CVD

having high cholesterol.

Nearly 37 million Americans
24

In

25

decreases by two to three percent.
Individuals with increased risk of high cholesterol
Low-density lipoprotein cholesterol (LDL) is the

are encouraged to begin therapeutic lifestyle

other form of cholesterol in the blood and is

changes (TLC). These changes include following

commonly referred to as “bad” cholesterol. LDL

the TLC diet, a low saturated fat, low cholesterol

cholesterol collects inside the walls of arteries and

diet, engaging in physical activity, and managing

contributes to the formation of plaque.

weight.

Current

26

The TLC diet recommends that

guidelines recommend an LDL cholesterol level of

saturated fat make up less than seven percent of

no more than 100mg/dL. The risk of developing

total caloric intake, and cholesterol intake is less

CVD increases exponentially as LDL levels rise.

21

than 200 milligrams per day. It also recommends

Additionally, even in a patient with a well controlled

that an intake of 10 to 25 grams per day of soluble

LDL cholesterol level below 100mg/dL, if HDL

fiber and an intake of two grams per day of plant

cholesterol levels are lower than the

stanols/sterols. If, after three months of TLC, LDL

recommended 40mg/dL risk of developing heart

cholesterol is still not within the desired range, drug

disease or stroke increases.

20

therapy with statins might be considered in
combination with TLC.

17

High Blood Pressure

For example, systolic blood pressure can increase

Blood pressure below 120/80 mmHg is necessary

two-fold in response to extreme stress such as

for efficient functioning of the cardiovascular

exercise.

27

system.

When the heart beats (a state called

However, the blood pressure of a

healthy adult should not remain elevated

systole), it pumps blood through the body and

chronically.

creates increased pressure in the arterial system.

the National Heart, Lung, and Blood Institute

This rise in pressure when measured at its peak is

(NHLBI) states that the blood pressure of typical

therefore called systolic blood pressure. This

adults should be below 120/80 mmHg.

pressure in the arteries is the result of two different

pressure that consistently stays between 121-

forces. The first force occurs as the blood pumps

139/81-89 mmHg is considered to be pre-hyper-

through the arteries and circulatory system.

27

The newest recommendations from

28

Blood

The

tension, a condition that often leads to high blood

second force occurs as the arteries resist the flow

pressure, and blood pressure above 140/90 mmHg

of the blood. The arteries of a healthy person are

is considered to be hypertension or high blood

elastic and muscular and stretch as the blood flows

pressure. The purpose of the new

through them. Blood pressure rises as the heart

“pre-hypertensive” category is to increase the

beats and decreases as the heart relaxes between

understanding of dose-response relationship

beats (a state called diastole). Blood pressure can

between CVD risk and elevated blood pressure.

change from minute to minute and can increase or
decrease as a natural response to changes in
posture, stress, exercise, or many other factors.
18

It is now recommended that individuals who have

This may cause hypertension, electrolyte

been classified as pre-hypertensive by three

abnormalities that can lead to life-threatening

consecutive measurements should begin the

arrhythmia, and in cases of extreme stenosis,

intervention to lower blood pressure to acceptable

cause ischemia leading to kidney failure and

levels prior to becoming truly hypertensive.

necrosis or infarct. The heart, brain, and kidneys
can adapt to high blood pressure for long periods

Major lifestyle modification is required for those

of time, which is why people can live so long with

who have high blood pressure and are good

the disease and not display any symptoms.

guidelines to reduce risk of developing high blood

However, these adaptations can cause long-term

pressure.

These modifications include weight

complications, such as problems with the heart

reduction in those individuals who are overweight

valves, cardiomyopathy or cardiomegaly, which

or obese, following the Dietary Approaches to Stop

can cause CHF or even a stroke.

Hypertension (DASH) diet, increased physical
activity and moderation of alcohol consumption.

Nearly 65 million Americans have high blood

These lifestyle modifications can reduce blood

pressure and another 45 million Americans are

pressure, increase drug therapies, and decrease

pre-hypertensive.

CVD risk.

28

Further, 70 percent of people

with high blood pressure do not have it under

Additionally, combining two or more of

control through medications, diet modifications, or

these modifications can achieve even better
results in decreasing blood pressure.

29

16

exercise.

Even a reduction of 12-13 mmHg in

blood pressure in those with hypertension can
High blood pressure is often called the “silent killer”

result in a reduction of heart attacks by 21 percent,

because a person can have it for years without

strokes by 37 percent, and total CVD deaths by 25

showing any signs or symptoms.

percent.

In primary or

28

In Arizona, 23.6 percent of Arizonans

essential hypertension, which accounts for 90-95

have been diagnosed by a physician as having

percent of the cases of high blood pressure, the

hypertension, an increase from 14.2 percent in

cause is unknown.

27

The leading cause of

1999. This is far above the Healthy People 2010

non-essential hypertension is renal artery stenosis.

goal of 16 percent or less reporting doctor–

Renal artery stenosis occurs when atherosclerotic

diagnosed hypertension and only slightly below the

lesions restrict the blood supply to the kidneys from

national average of 27.4 percent. Arizona ranks
40th across the U.S. and the District of Columbia

the renal artery.

for cases of high blood pressure.

19

30

Figure 631

Obesity

Figure 6 shows the increasing prevalence of

Arizona, like the rest of the U.S., is seeing an

obesity and overweight in Arizona and the U.S.

alarming increase in the rate of obesity. In 1991,

Health experts warn that if this trend in obesity and

11 percent of the Arizona population was

overweight does not change, eventually the entire

considered obese; however by 2000, this had

population of the U.S. will be either overweight or

increased to 18 percent of the state. The 2003

obese.

BRFSS indicated that nearly 57.1 percent of the
Obesity and overweight increase the risk of

Arizona population is considered overweight or
obese.

31

developing many chronic health problems,

In 2002, 54.8 percent of deaths in Arizona

were from diseases for which overweight and

including CVD. There are two ways of measuring

obesity are known to increase the risk. Overweight

overweight and obesity, Body Mass Index (BMI)

and obesity in Arizona is not just affecting adults.

and waist circumference. BMI is calculated using

According to the Pediatric Nutrition Surveillance

weight and height and is used because, for most

System 24 percent of low-income children between

people, it correlates with their amount of body fat.

the ages of two and five years old are overweight

A person is considered to be overweight if they
have a Body Mass Index (BMI) between 25.0kg/m2

or at risk of becoming overweight. In 2003, the

indicated that 24 percent of Arizona high school

and 29.9kg/m2 and is considered to be obese if
32
they have a BMI of 30kg/m2 or greater. Although

students are overweight or at risk of becoming

a BMI of 24.9kg/m2 does not meet the definition of

Youth Risk Behavioral Surveillance System

overweight, there is still an increased risk of

overweight.

developing CVD. In Arizona, according to the 2003
BRFSS, 20.1 percent of the respondents either
met or exceeded the BMI for obesity and 37
percent of the respondents were overweight.
20

25

One limitation of using BMI to determine

U.S. healthcare system.

overweight and obesity is that it does not directly

35

The national costs of

overweight and obesity accounted for 9.1 percent

measure body fat. Some people, like athletes,

of the total U.S. medical expenditures in 1998 and

may have a BMI that identifies them as overweight

may have reached as high as $92.6 billion in 2002.

even though they do not have any excess body fat.

In Arizona, between 1998 and 2000, the estimated

Another factor to consider in determining obesity is

costs of obesity and overweight were $752

waist circumference. According to the American

million.

36

Dietetic Association, a waist circumference of 40
inches in men and 35 inches in women is a good

In addition to the medical costs that can be

indicator of increased risk of CVD and other

attributed to obesity and overweight, it is important

chronic conditions.

31

Excess abdominal fat

to consider other economic costs incurred through

increases the risk of high blood pressure and high

activities such as dieting. Many individuals who

cholesterol, both risk factors for developing CVD.

are overweight or obese use diets to try and bring

Recent studies indicate such fat is also a strong

their weight down to a healthy level.

indicator of type 2 diabetes risks.

33

BMI does not

However,

often times these are popular diet trends and may

specifically indicate where fat is distributed and

work in the short term, but generally do not

persons with increased abdominal (visceral) fat are

emphasize the behavior changes required to

at particular risk of CVD because the fat is around

maintain a healthy weight. Nationally, 55 million

their major internal organs.

Americans attempt some kind of diet plan each

Visceral fat also

secretes more inflammatory agents that may

year, and only 5-10 percent of those achieve their

rupture plaques in arteries, leading to heart attack

goal. Across the U.S., $40 billion is spent in the

or stroke.

34

Currently, Arizona does not have waist

weight loss industry, and by 2006 this amount is

circumference data available.

expected to top $48 billion annually.

37

Many

popular diet trends promise a quick solution but do
Not only does obesity and overweight have a

not emphasize that in order to lose weight, caloric

significant physical impact, the increased

intake needs to decrease and energy expenditure

economic costs have a considerable impact on the

needs to increase.

21

Diabetes

prevalence of DM in the Native American

Diabetes Mellitus (DM) was once considered a

populations and the large numbers of this group in

contributing risk factor for cardiovascular disease,

Arizona.

but recent data has indicated that diabetes is a
independent risk factor for CVD and the American

Nutrition

Heart Association has designated diabetes as a

Even though there is still more to learn about the

major modifiable risk factor for heart disease and

role specific nutrients or combinations of nutrients

stroke.

38

play in chronic diseases, dietary patterns are an

The National Cholesterol Education

important consideration in reducing the risk of

Program has declared that a person with diabetes
is to be treated like they have CVD as well.

39

developing CVD. The DASH diet, which
emphasizes increased consumption of fruits and

For many, the relationship between CVD and DM

vegetables, and low-fat food has been shown more

likely begins in the “pre-diabetic state” sometimes

effective than sodium restriction alone to reduce

referred to as metabolic syndrome. This syndrome

high blood pressure, a leading cause of CVD.

is characterized primarily by abdominal fat,

Consumption of lean meats, including limiting red

low-levels of HDL, high levels of triglycerides and

meat, and emphasis on low-fat dairy products is

high blood pressure.

40

also an important step in reducing CVD risk by

Secondary characteristics

45

include elevated liver enzymes and

reducing fat intake.

hyperinsulinemia. One third to one half of the

recommended for all people, not just those with

people with metabolic syndrome will eventually

diagnosed heart disease. A heart healthy diet is

develop diabetes, but cardiovascular disease can

described as limited saturated fat intake (less than

occur prior to diabetes due to the presence of high

10 percent of total daily calories), limited

blood lipids and the other risk factors present.

41

A heart healthy diet is

cholesterol intake (less than 300 mg/dL), and

Men with metabolic syndrome have four times the

limited intake of trans-fatty acids combined with the

risk of developing fatal CAD and two times the risk

consumption of fruit and vegetables as mentioned

of developing any kind of CVD, even after

above.

22

adjustments for age, LDL-cholesterol, smoking and
Current dietary guidelines emphasize eating fruits

family history.

and vegetables and keeping fat intake between 20
Those with metabolic syndrome have five to nine

and 35 percent of total daily caloric intake. The

times the risk of developing diabetes, which

Dietary Guidelines are reviewed and updated

increases the risk of dying from CVD by two to four

every five years in a joint effort by the U.S.

42,43,44

times.

CVD is the major cause of morbidity in

Department of Health and Human Services

patients with diabetes and outcomes for patients

(DHHS) and the U.S. Department of Agriculture

with both DM and CVD are far worse than those

(USDA). These two organizations identified the

with only CVD and no DM present.

38

According to

need to emphasize energy balance, the

the AHA diabetes committee, nearly two-thirds of

consequences of a sedentary lifestyle, and certain

people with DM will eventually die of heart or blood

food choices in the sixth edition of the Dietary

3

vessel disease. It is important to keep DM in mind

Guidelines.

as a risk factor for CVD in Arizona given the high
22

The key recommendations in the 2005 Dietary
Guidelines are:






46

Achieve physical fitness by including
cardiovascular conditioning, stretching

Consume a variety of nutrient dense foods

exercises for flexibility and resistance

and beverages within and among the basic

exercise or calisthenics for muscle

food groups while choosing foods that limit

strength and endurance.

the intake of saturated and trans fats,



cholesterol, added sugars, salt and alcohol.

Consume a sufficient amount of fruits and
vegetables while staying within energy




Meet recommended intakes within energy

needs. Two cups of fruit and 2½ cups of

needs by adopting a balanced eating

vegetables per day are recommended for a

pattern, such as the USDA Food Guide

reference 2,000-calorie intake, with higher

or the DASH Eating Plan.

or lower amounts depending on the
calorie level.




To maintain body weight in a healthy range,
balance calories from foods and beverages




with calories expended.

Choose a variety of fruits and vegetables
each day. In particular, select from all five
vegetable subgroups (dark green, orange,




To prevent gradual weight gain over time,

legumes, starchy vegetables, and other

make small decreases in food and

vegetables) several times a week.

beverage calories and increase
physical activity.




Consume 3 or more ounce-equivalents of
whole-grain products per day, with the rest




Engage in regular physical activity and

of the recommended grains coming from

reduce sedentary activities to promote

enriched or whole-grain products. In

health, psychological well-being and

general, at least half the grains should

a healthy body weight.

come from whole grains.

23




Consume 3 cups per day of fat-free or
low-fat milk or equivalent milk products.




Consume less than 10 percent of calories
from saturated fatty acids and less than
300 mg/day of cholesterol, and keep trans
fatty acid consumption as low as possible.




Keep total fat intake between 20 to 35

Those with diagnosed CVD should seek Medical

percent of calories, with most fats coming

Nutrition Therapy (MNT) from a registered dietitian.

from sources of polyunsaturated and

Based in the individual’s particular size, food

monounsaturated fatty acids, such as fish,
nuts, and vegetable oils.



Americans are encouraged to get the energy they
need while maintaining a healthy weight and being
physically active at least 30 minutes a day, most
days of the week. Alcohol, for those who drink, is
recommended in moderation only; no more than 2
drinks per day for men and 1 drink per day for
46
women. A consumer friendly resource with more
details can be found at http://www.mypyramid.gov.

preferences, available food, and other factors the
MNT may include vitamins, supplements, changes

When selecting and preparing meat,

in cooking styles, guidance for eating outside the

poultry, dry beans, and milk or milk

home, and access to additional food resources. A

products, make choices that are lean,

dietary prescription and behavior modification

low fat, or fat-free.

programs are key to reducing the damage and
disability that can result from CVD. Communities




Limit intake of fats and oils high in saturated
and/or trans fatty acids, and choose

that provide a variety of healthy food choices and
opportunities for physical activities in safe and

products low in such fats and oils.

convenient environments are essential for
preventing CVD and making the lifestyle
modifications for those at risk possible.

24

Non-modifiable Risk Factor Analysis
Age

Gender

Many risk factors for developing CVD can be

Gender is an important non-modifiable risk factor

modified by various interventions. However, four

for the development of cardiovascular disease.

risk factors cannot be affected by any kind of

However, heart disease and stroke are still the

interventions. Age is a risk factor for

number one cause of death among men and

cardiovascular disease because, generally,

women. In Arizona, the age adjusted mortality rate

atherosclerotic lesions are the result of a

for heart disease in 2003 for males was 246.6 per

progressive process that develops over years. As

100,000 population and 157.1 per 100,000

a person ages, their aortic system stiffens, thus

population for females. The age adjusted mortality

increasing the blood pressure and risk for a cardiac

rate for stroke in males was 42.9 per 100,000

47

According to the NHLBI, approximately 72

population and 43.8 per 100,000 for females. This

percent of the people who suffer a stroke are age

shows that men are more likely to die from heart

65 years and older and the incidence of stroke

disease, while women are more likely to die from a

more than doubles in each successive decade

stroke.

event.

after the age of 55. In Arizona, the mortality rate for
Death and disability associated with

stroke and heart disease were higher in the older

cardiovascular disease can be reduced

age group of 65 years and older. This data is most

significantly by increasing the awareness that

useful in interpreting signs and symptoms of

women develop CVD. During a study conducted in

diagnostic test data in those age 40 years or older.

1997 by the American Heart Association, more

Recent studies of children show the beginnings of

than 50 percent of the women interviewed felt that

the streaky patterns in the inner lining of the artery.

cancer was a greater threat to them than

This indicates that prevention of MI and stroke in
adults in their 6th and 7th decade of life may begin
in their childhood.

48

cardiovascular disease.

However, women are

twice as likely to die within a year of having a heart

Preventing the beginning

attack. This is due partly to not recognizing the

injury to the arterial wall would have the most

signs and symptoms of a heart attack and

profound effect of reducing cardiovascular

assuming that they exhibit the same behaviors as

diseases.

men do when they are having a heart attack.

49

Risk factors such as smoking status, physical

The American Academy of Cardiologists (AAC)

activity level, cholesterol values, blood pressure

and the AHA released a position paper regarding

and level and distribution of adiposity can have a

the acute treatment of atypical symptoms that may

profound effect on the rate of progression of CVD

indicate that an acute coronary episode is

once arterial insult has occurred. In extreme cases

happening. When compared to the typical

of risk factor modification, atherosclerotic lesions

symptoms a man might have, women seem

can be held stagnant and in some cases, even

to complain more of gastro intestinal symptoms.

reversed.

49

By controlling risk factors as a person

Complaints of this nature may lead the patient

ages, the risk of death or disability from CVD

and/or the clinician to consider less lethal

declines.

conditions.
25

Additionally, women take longer to present to the

However, while the individual may not be able to

Emergency Room with symptoms, not only

change the fact that they make higher levels of

because of the atypical symptoms that they

blood cholesterol, they can mitigate the effect of

present with but possibly due to a higher

their high cholesterol with comprehensive lifestyle

threshold of pain. Once at the hospital, many of

modifications.

50

the diagnostic procedures used are not as
accurate for women or they require specialized

Race

knowledge on how to modify the interpretation for

Nationally, cardiovascular disease is the leading

a woman. Women also tend to delay treatment in

cause of death and disability. When looking at the

order to complete other tasks.

heart disease component of CVD using a racial

49

and ethnic breakdown, heart disease is the leading
A broad-based intervention is necessary in Arizona

cause of death for American Indians and Alaska

to reduce the death and disability associated with

Natives, African Americans, Hispanics and White,

CVD in women by increasing the awareness that

Non-Hispanics.

CVD is the number one medical threat to their

death for Asians and Pacific Islanders, accounting

lives. Public awareness of the signs and

for 26.4 percent of all deaths, with heart disease

symptoms of a heart attack in both men and

accounting for 25.4 percent of all deaths.

women and the need to seek immediate medical

highest mortality rate for heart disease nationally,

attention is a crucial element of reducing death and

among racial and ethnic groups is among White,

disability from CVD in Arizona.

Non-Hispanics, at 263 per 100,000 population and

Cancer is the leading cause of

51

The

African Americans have the second highest
Heredity

mortality rate for heart disease at 210 per 100,000

The third non-modifiable risk factor for CVD is

population. Figure 7 shows a comparison of

heredity. Individuals who have a family history of

mortality rates for heart disease in Arizona among

CVD are likely to develop it themselves.

the racial and ethnic groups.

Figure 7

26

Figure 8

Figure 8 shows the hospitalization rates for

The other component of CVD addressed in this

heart disease in Arizona. Heart disease was
projected to cost the U.S. $238.6 billion,

plan is stroke, and independent of heart disease,it
is the 3rd leading cause of death in the U.S. and

nationwide, in medication, health care services and

accounted for about one out of every 14 deaths in

lost productivity.

51

7

the U.S. in 2000. Stroke mortality rates are
substantially higher for African Americans than for

The highest rate of hospitalizations in Arizona was

White, Non-Hispanics with rates of 87 per 100,000

for White Non-Hispanics at 1601.1 per 100,000

population of African American males versus 59

population in 2003. The second highest rate of

per 100,000 for White Non-Hispanic males and 78

hospitalizations was among African Americans at

per 100,000 population of African American women

1480.7 per 100,000. The lowest rate of

versus 58 per 100,000 for White Non-Hispanic

hospitalizations occurred in Asians, at 279.6

women. All other racial/ethnic groups have

per 100,000 population, significantly lower than

significantly lower mortality rates, compared to

that

African Americans.

of

White

Americans.

Non-Hispanics

and

African

The hospitalization rate for Native

Americas in Figure 8 is likely artificially low
because the state database for hospitalizations
does not capture events at Indian Health Service
facilities.

27

7

In Arizona, the highest mortality rate associated

contrary to the national trend. Figure 9 shows a

with stroke occurs in the White Non-Hispanic

comparison of racial and ethnic groups for stroke

group, with a rate of 70.2 per 100,000 population,

mortality.

Figure 9

African Americans in Arizona have the second

hospitalization rate for stroke with a rate of 351.6

highest mortality from stroke, with a rate of 54.2 per

per 100,000 population. Asians have the lowest

100,000. Figure 10 compares the hospitalization

hospitalization rates for stroke with a rate of 106.8

rates for stroke in Arizona among the five leading

per 100,000 population. While there are few cost

racial and ethnic groups.

estimates for stroke, in 1998, Medicare spent $3.6
billion on stroke survivors discharged from

White, Non-Hispanics in Arizona continue to have

short-stay hospitals. This is not adjusted to

the highest rates for hospitalization due to stroke

reflect additional costs incurred after discharge,

with a rate of 390.1 per 100,000 population.

medications the patient is put on, or lost

African Americans have the second highest

productivity.

Figure 10

28

Lack of Access to Care
Many Arizona residents do not have access to the

There are five counties, Apache, Gila, Graham,

specialty care needed to treat their cardiovascular

Greenlee, and Navajo, within the state of Arizona

disease. According to the U.S. Census

that do not have any type of cardiologist to serve

projections, the population of Arizona in 2003 was

the residents. Map 3 shows the location of the

estimated to be 5,580,811.

13

Nearly 77 percent of

cardiologists within the state of Arizona.

The

this population lives in either Maricopa or Pima

majority of them are concentrated in the Phoenix

counties, so it is understandable that physicians

and Tucson metropolitan areas.

would want to live where the people live.
Alarmingly, that leaves 23 percent of the residents

Having access to a specialty medical provider, a

of Arizona without the specialty care that they

primary care physician, and having medical

desperately need.

insurance are all leading indicators of health.

Map 3

29

Part of the Healthy People 2010 National

attract physicians; hence they tend to be located in

Objectives, as well as the Healthy Arizona 2010

the metropolitan areas. While 77 percent of the

Objectives, is to increase the number of persons

population lives in the metropolitan areas of the

with health insurance.

According to the 2002

state, the other 23 percent of the residents live in

BRFSS, 16.1 percent of the population in Arizona

very rural locations, sometimes many hundreds of

did not have any form of health insurance.

52

This

miles away from the nearest specialist. As a result

is a small decrease from the 2000 BRFSS, which

of living far away from the nearest provider, it is

indicated that 17.1 percent of the population in

quite possible for a person suffering from a stroke

Arizona did not have health insurance. High rates

or heart attack to miss the window of opportunity

of uninsured individuals are startling, as those

for effective treatment, thereby significantly

people tend to be less healthy and are more likely

worsening their chances for a survival or reduced

to report poor health status overall. They are also

disability. Transportation protocols for emergency

more likely to delay seeking medical care and

services (ambulances) and use of technologies,

forego medically necessary care for serious health

like telemedicine, are imperative in a state with as

conditions.

much distance between rural areas and
metropolitan areas as is found in Arizona.

There are several other barriers that prevent
Arizonans from seeking necessary medical care.

The Arizona State Plan to address heart disease

Physical distance from care and lack of

and stroke focuses on secondary prevention in

transportation are also significant barriers that are

adults age 20 years and older but not to the

difficult to overcome. Arizona is the sixth largest

exclusion of primary prevention and other age

landmass in the U.S., and the rural and frontier

groups.

areas of the state often are not locations that

30

Objectives
This is the target population for two

reducing the amount of food a person is

reasons:

eating. By doing this, the individual might




Many of the programs aimed at children,

lose weight, thus addressing the obesity

(e.g. smoking prevention and cessation,

epidemic, may reduce the risk of

removing foods with minimal nutritional

developing type 2 diabetes mellitus, and

value from vending machines in schools,

reduce the risk of developing heart

encouraging physical activity in schools

disease and stroke. In an effort to

and during leisure time) are currently being

maximize existing resources and avoid

implemented by other programs within and

duplication, especially in light of limited

outside the Arizona Department of Health

resources in heart disease and stroke

Services. In an effort to ensure that

prevention efforts, we focused on

consistent messages are being used and

interventions that are specifically aimed at

to reduce duplication, the state plan for

heart disease and stroke and hope to

heart disease and stroke does not focus

capitalize on other initiatives to address

on this age group, but does support efforts

primary prevention of CVD.

being done by other entities.
During the development of the state plan to



Secondary prevention is the focus of this

reduce heart disease and stroke, the team has

plan because there are many existing

used the socio-ecological model to base

primary preventions that impact more than

interventions upon. These strategies will be

one chronic disease. For example, a

implemented using population-based approaches.

portion control campaign would emphasize

31

Behavior can be influenced at multiple levels:

Cardiovascular Disease State Plan Long Term

individuals, interpersonal, organization,

Objectives:

community and public policy. This model was

1. Reduce the number of coronary deaths in

chosen as the basis for the objectives because it

Arizona by 25 percent, by the year 2010, in

combines individual behavior with social and

conjunction with the American Heart

physical environments. Figure 11 depicts the

Association’s impact goal and achieving the

interrelationships between the various levels of

Healthy People 2010 goal at the same time.

the socio-ecological model.
2. Reduce the number of stroke deaths in
The strategies that are suggested in this plan

Arizona by 20 percent by the year 2010.

recognize that individuals have the responsibility
3. Decrease the number of Arizonans

for self-regulation of their behaviors to achieve

diagnosed with Cardiovascular Disease

positive changes. However, it also recognizes the

by 20 percent by the year 2020.

influence of outside environmental forces such as
worksites, schools, and community organizations

4. Increase the proportion of adults aged 20

to promote and maintain healthy lifestyles.

years and older that are aware of the early
warning signs and symptoms of a heart

A major portion of this plan will focus on changes

attack and the importance of seeking

within the healthcare system in order to improve

immediate medical attention.

and encourage compliance with heart disease and
stroke. It will also promote awareness regarding

5. Increase the proportion of adults who are

the signs and symptoms of heart attacks and

aware of the early warning signs and

strokes.

symptoms of a stroke and the importance
of seeking immediate medical attention.

Figure 11

32

2. Implement primary interventions that are

6. Establish a surveillance system to
accurately identify the true burden

specific to reducing the death and disability

of Cardiovascular Disease in the state

from cardiovascular disease.

of Arizona.

a. Increase the number of Arizonans
that know their cholesterol values.

7. Establish a core team, comprised of

b. Increase the number of physicians that

physicians, hospital groups, public health

are following the recommended

professionals and community members,

guidelines for cholesterol screening and

that will advise the Arizona Department

treatment.

of Health Services Cardiovascular Risk

c. Increase the number of Arizonans

Reduction Program on the activities

that know their blood pressure value.

necessary to meet the long-term state

d. Increase the number of physicians that

plan objectives.

are following the recommended
guidelines for blood pressure

Cardiovascular Disease State Plan Primary

screening and treatment.

Prevention Objectives:

e. Increase the number being referred to

1. Support existing efforts to improve related

the appropriate professionals to receive

risk factors for cardiovascular disease.

medical nutrition therapy and a formal

(Please see appendix A for a description

exercise prescription to treat high

of the programs.)

cholesterol and high blood pressure.

a. Physical Activity Efforts:

f. Follow the Barbershop Hypertension

i. Promoting Lifetime Activity in Youths

Screening Program as a model for

ii. Walk Everyday, Live Longer Arizona

identifying hypertension in African

(W.E.L.L. AZ)

Americans and other groups as a way

iii. Active Arizona

to reduce disparities in the screening

b. Obesity Prevention:

process.

i. To promote and enable the citizens of
Arizona to eat smart.

3. Implement primary interventions that are

ii. To promote and enable active

specific to those who are at increased risk

lifestyles in Arizona residents.

of developing cardiovascular disease due to

c. Smoking Cessation:

other complicating diseases.

i. Arizona Smoker’s Helpline
Cardiovascular Disease State Plan Secondary

ii. Media Campaigns:

Prevention Objectives:

1. Ashes to Ashes

1. Individual Interventions:

2. Inhale Life

a. Increase the number of those diagnosed

iii. Community and School Activities

with heart disease and stroke that

d. Improved Nutrition:
i. 5-A-Day

participate in cardiac rehabilitation

ii. Arizona Nutrition Network

and other formal, multidisciplinary
approaches to secondary prevention of
the heart disease and stroke.
33

location in the state.

b. Increase the number of those diagnosed

2. Promote telemedicine and

with heart disease and stroke that

transportation agreements

adhere to their prescribed medications.

between rural healthcare agencies

c. Increase the number of Arizonans
diagnosed with hypertension who

and Primary Stroke Centers in

adhere to their medications,

Arizona.
ii. Increase the number of hospitals

medical nutrition therapy and formal

participating in the American Heart

exercise program.

Associations program “Get With The

d. Increase the number of Arizonans
diagnosed with hyperlipidemia/

Guidelines” CAD, Stroke and CHF

dyslipidemia who adhere to their

programs.
b. Healthcare Providers:

medications, medical nutrition therapy

i. Increase the number of healthcare

and formal exercise prescription.

providers who are appropriately
2. Community Interventions:

utilizing evidence-based secondary

a. Increase the availability of automated

prevention guidelines for heart

external defibrillators (AED) in public

disease and stroke.

places where Emergency Medical

ii. Increase the number of healthcare

Service availability may be delayed.

providers who are appropriately

b. Increase the number of sites willing to

utilizing resources for lifestyle

participate in the American Heart

interventions including medical

Association Public Access to

nutrition therapy (MNT) and allied

Defibrillators Program.

health professionals such as

c. Increase the number of communities

registered dietitians and exercise

offering heart healthy activities and

specialists.

programs.

iii. Increase the number of healthcare
providers who refer Arizonans to

3. Education Interventions:

congestive heart failure

a. Increase the number of Emergency

multidisciplinary treatment programs.

Medical Technician training programs in

iv. Increase the number of healthcare

the state of Arizona that include a stroke

providers who refer Arizonans to

training module in their curriculum.

multidisciplinary cardiac rehabilitation
4. Healthcare:

programs.

a. Hospitals/Healthcare Facilities:

v. Increase the number of healthcare

i. Ensure that an adequate number of

providers who refer Arizonans to

Primary Stroke Centers in Arizona

multidisciplinary diabetes treatment

meet the nationally recognized

programs and who screen diabetics

guidelines.

for cardiovascular disease and refer

1. Have at least one Primary Stroke

them to the appropriate professional.

Center within two hours of any
34

physical activity during the workday.

vi. Have cultural competence training

vi Increase the number of employers

available for providers as needed.

who provide incentives to employees

c. First Responders

for engaging in healthy behaviors,

i. Increase the number of first
responders with access to

especially those that would reduce

defibrillation capabilities in rural

sedentary lifestyles, tobacco usages,

locations.

hypertension, high cholesterol and/or
obesity rates.

ii. Implement protocols under which

vii. Increase awareness of community

paramedic/EMT units may bypass a
hospital in order to transport a stroke

programs that would assist

victim to a Primary Stroke Center,

employers, especially small

thereby increasing their chance of

employers, in providing employee

survival and with less severe

wellness benefits/programs.

disabilities.
6. Policy/Environmental:
a. Pursue funding sources, both at the

5 Worksite:

federal and state level to establish and

a. Increase employers’ awareness of heart
disease and stroke risk factors and the

provide ongoing support for a heart

impact that heart disease and stroke

disease and stroke program in Arizona.
b. Increase support and awareness of the

have on their workforce.

Stop Stroke Act.

b. Increase awareness that wellness

c. Pursue the possibility of making cardiac

efforts, especially those aimed at
reducing heart disease and stroke, can

rehabilitation available to those

reduce health care insurance claims and

diagnosed with any form of

associated costs.

cardiovascular disease and not waiting

i. Establish a baseline level of

until they have suffered an attack.
d. Work in conjunction with other programs

cardiovascular disease-related costs.

to support issues such as:

ii. Provide wellness programs for
employers and strategies to create a

i. Smoke-free environments

healthier work environment for their

ii. Physical Education in schools.

employees.

iii. Healthier food choices available
in schools.

iii. Increase the number of employers
that offer healthier food selections in

7. Social Marketing Campaigns:

vending machines and cafeterias.

a. Increase the number of people who are

iv. Increase the number of employers

aware of and can recognize the signs

that offer screening programs for their

and symptoms of a stroke and know the

employees and providing referrals to

next step that needs to be taken.

appropriate care.

i. Utilize existing stroke education

v. Increase the number of employers

materials provided by the American

that allow employees to engage in

Heart Association.
35

b. Increase the number of people who are

a. Utilize the resources of the American

aware of and can recognize the signs

Heart Association’s Cultural Health

and symptoms of a heart attack or

Initiatives department as well as the

myocardial infarction (MI).

American Heart Association’s culturally
appropriate literature in relevant

c. Increase the number of women who are

populations where disparities exist.

aware of the symptoms of a heart attack,
which are very different than the signs of

Cardiovascular Disease State Plan Surveillance

a heart attack for men.

Objectives:

d. Increase the number of people who are

1. Continue to utilize the Behavioral Risk

aware of the signs and symptoms of

Factor Surveillance Survey, including the

sudden cardiac arrest.

new modules.

e. Increase the number of Arizonans that
utilize the American Heart Association’s

2. Continue to utilize the data that can be

Halle Heart Center as a resource to

obtained via existing data sources such as

provide prevention education programs

mortality data, hospital discharge data, and

to adults as well as children.

emergency room data.

f. Ensure that messages are culturally
3. Encourage managed care organizations to

appropriate to the populations being

develop new data systems that more

targeted.

accurately capture the prevalence and

g. Provide materials such as videos and
brochures in physician’s offices to make

management of heart disease and stroke

patients aware of cardiovascular disease

in Arizona.

and its effects.

4. Utilize and support the American Heart
Associations Get With the Guidelines

Cardiovascular Disease State Plan Health

modules for coronary artery disease, stroke,

Disparities Objectives:

and congestive heart failure as a

1. Provide health related information that will

surveillance tool as well as an intervention

reduce the incidence of heart disease and

tool.

stroke in culturally sensitive and relevant
modalities, which will reduce disparities in
individual access and ability to use the
current health systems.

36

Addressing Cardiovascular Disease Disparities
in the Native American Population in Arizona
There are populations within Arizona that require

Another population that presents unique

unique modifications when designing interventions

challenges is the border populations. The

to reduce disease.

One such population is the

communities located along the Southern Arizona

Native American population. Arizona has one of

U.S. – Mexico border serve as a gateway between

the largest Native American populations in the

the U.S. and Mexico.

U.S., comprising approximately five percent of the

largely dependent on agriculture as their main

population.

53

There are 21 separate sovereign

economic source.

These communities are

The population in this area

Native American nations located on 24

tends to have a higher poverty rate, higher

reservations throughout Arizona.

numbers of under insured and uninsured, and

This presents

unique challenges, not only because the tribes are

typically have higher rates of chronic diseases.

sovereign nations subject to their own

Language differences can also create barriers to

governmental structure, but also because these

medical care in these populations. Similar to the

tribes have geographic barriers, traditions, and

Native American needs, the populations in the

history that must be considered. Statewide

border communities need infrastructure building to

meetings held in 2001 to determine the healthcare

successfully implement programs to combat CVD.

needs and concerns of Native Americans across
the state indicated that the greatest need is for

In order to effectively address CVD among the

improved infrastructure, especially around data

disparate populations in Arizona, it will be

collection, while always remembering that data

important to include them in the planning process

collected from the tribes ultimately belongs to the

and to develop interventions with their input so

54

They indicated that not only were

they will be more likely to be implemented.

interventions or services needed, but infrastructure

Additionally, traditional techniques that are unique

was also needed. Primarily, they wanted to be able

to each population are very important and should

to adapt an intervention to fit their specific needs

be included in program planning. Ideally members

and cultural beliefs.

need to be present during the planning process as

tribes.

well as be a part of the implementation team. By
partnering with each population, it will be possible
to develop interventions that are culturally
appropriate and more effective than they would
have been without community input.

37

Implementation Plan
The development of this plan was intended to

professional providers groups and interested

provide guidelines for organizations to use when

stakeholders. The coalition will make

choosing an area in the state of Arizona to conduct

recommendations on where interventions are

CVD interventions. A CVD coalition will be formed

needed and what interventions would best suit that

to guide interventions in the state of Arizona and

populations needs. While funding will be pursued

will consist of public health agencies, both at the

both at the federal level and the state level, many

state and county level, community leaders, tribal

of the objectives in this plan can only be achieved

representatives, non-profit organizations,

by coordinated efforts of interested stakeholders.

38

Next Steps
Cardiovascular disease is the leading cause of

interventions developed not only in the state and

death in the U.S. and in Arizona. It is also one of

local health departments, but also in the

the most preventable chronic diseases. Modifiable

communities and organizations that conduct

risk factors, namely tobacco use, physical

activities in and around cardiovascular disease.

inactivity, high cholesterol, high blood pressure,

The objectives set down in this plan are not

overweight and obesity, diabetes, and poor

mandates; they are simply guides for where the

nutrition, are most effectively addressed through

most benefit could be gained from interventions.

primary and secondary interventions.

This plan

Through collaboration and partnership between

serves as a guide for reaching the state objectives

organizations, a larger impact can be made and

and the Healthy People 2010 objectives in Arizona.

death and disability from cardiovascular disease

This plan can be used to guide the actions and

can be reduced.

39

Appendix A
Promoting Lifetime Activity in Youths
A 12-week teacher directed, behavior change program reaching 160 schools, 24,000 students,
8,200 parents and 900 teachers. The program was developed with consultation from the County
Health Department program staff and Arizona State University (ASU) faculty. Promoting Lifetime
Activity In Youths is targeted to grades four through eight and is designed to intervene when the
decline in adolescent physical activity first begins. Evaluation data from the first 5 years of
Promoting Lifetime Activity In Youths indicated that the attitudes of students participating in the
program are more positive about physical activity and the number of students reporting that they
are not physically active has decreased.
Walk Everyday, Live Longer Arizona (W.E.L.L. AZ)
The WELL AZ program is a physical activity program for adults who would like to increase their
daily physical activity. A pedometer is used in WELL AZ as a motivation and feedback tool for
participants. WELL AZ is designed to be delivered by a single facilitator. The program is four
weeks long and consists of facilitated group meetings once a week combined with individual goal
setting and self-monitoring, using the pedometer for feedback. Participants are to set a goal and
monitor their activity using the pedometer.
Active Arizona
In 2000, Active Arizona (a statewide working group of Healthy Arizona 2010 Initiative) was formed
and includes more than 30 different individuals and organizations. Focus groups were held to
obtain information about why Arizonans were not getting the recommended amount of physical
activity. The information gathered was used to develop a media campaign entitled “Feeling Great:
It Happens When You Move!” This group collaborates with the Action for Healthy Kids Arizona
State Team to increase the number of schools in Arizona that provide opportunities for daily
physical activity during the school day, including during before and after school programs.
5-A-Day
The ADHS nutrition programs have incorporated the 5-a-Day message into their public health and
education programs. Since the start of this program in 1991, the BRFSS data indicates that adults
are reporting an increase of 20 percent in eating 5 or more servings of fruits and vegetables a day.

Arizona Nutrition Network (AzNN)
This public and private partnership began in 1996 to bring people and programs together to
deliver common nutrition messages to the low-income populations using social marketing
approaches. The mission of the AzNN is to shape food consumption in a positive way, promote
health and reduce disease among people living in Arizona.

40

The AzNN is funded through the U.S. Department of Agriculture, Food Stamp Nutrition Education
Program (FSNEP) with activities limited to the food stamp eligible persons. It is the only FSNEP
in Arizona and links social marketing efforts with community education programs utilizing common
behavior change messages and materials based on formative research conducted with
low-income individuals.
Arizona Smoker’s Helpline
The Arizona Smokers’ Helpline is a free telephone-based counseling, information, and referral
system for Arizona residents who want to quit using tobacco products. The Helpline is a project
under the Division of Health Promotion Sciences in the University of Arizona College of Public
Health in Tucson, Arizona.
Tobacco Media Campaigns
Ashes to Ashes
A media campaign focused on the African American population in Arizona.
This campaign uses very strong language and powerful images to relay its
message. The campaign also conveys a sense of urgency in quitting tobacco
products and not passing the legacy of using them down to future generations.
Inhale Life/Be Tobacco Free
This is an integrated campaign that speaks to all demographics and ethnic groups, and
the disparate populations statewide, across all messages. The messages fall into two
categories: 1) Prevention/Positive lifestyle and 2) Cessation and Secondhand Smoke.
School Based Tobacco Efforts
The Tobacco Education and Prevention Program provides intensive prevention interventions with
curricula in target schools reaching fourth through eight grade students. One-time prevention
interventions in these same grades are done through guest speakers and the Phoenix Suns
Gorilla. These interventions contain an education message on the harms of using tobacco.
Community Tobacco Efforts
Healthy Kids Arizona
This is an annual health fair for youth at a school district in Maricopa County. Activities
include health screenings (vision, dental, diabetes, asthma, scoliosis), physical activity,
and information for parents on a variety of health and health related issues.
Local Project Events/Health Fairs
County tobacco programs participate in community health fairs to provide information on
the danger of tobacco use and secondhand smoke.

41

Appendix B
Abbreviations
ACC

American College of Cardiology

ADA

American Dietetic Association/American Diabetes Association based on context

ADHS

Arizona Department of Health Services

AEDs

Automated External Defibrillators

AHA

American Heart Association

ASA

American Stroke Association

BMI

Body Mass Index

BRFSS

Behavioral Risk Factor Surveillance Survey

CAD

Coronary Artery Disease

CDC

Centers for Disease Control

CHF

Congestive Heart Failure

COPD

Chronic Obstructive Pulmonary Disease

CVA

Cerebral Vascular Accident

CVD

Cardiovascular Disease

DM

Diabetes Mellitus

EMS

Emergency Medical System

GWTG

Get With the Guidelines

HDL

High-Density Lipoproteins

HLP

Hyperlipidemia

HTN

Hypertension

LDL

Low-Density Lipoproteins

MI

Myocardial Infarction

MmHg

Millimeters of Mercury

MNT

Medical Nutrition Therapy

NHIS

National Health Interview Survey

NHLBI

National Heart, Blood & Lung Institute on the National Institutes of Health

PA

Physical Activity

PSC

Primary Stroke Centers

PVD

Peripheral Vascular Disease

SCA

Sudden Cardiac Arrest

SCD

Sudden Cardiac Death

VLDL

Very Low-Density Lipoproteins

42

Appendix C Glossary
Abdominal fat (visceral fat)

Aorta

Body fat stored in the large cavity of the trunk often

Largest artery in the body, originating at the left

around organs and is associated with increased

ventricle and descending through the thorax

risk of CVD.

and abdomen.

Acute coronary syndromes

Arrhythmia (dysrhythmia)

Rapid onset of an emergent situation related to

Any disturbance or abnormality in the heart’s

disease of the coronary vascular system. Often

normal rhythmic pattern.

56

referring to obstruction of the coronary arteries
Arterial insult

over a short period of time and related to thrombus.

Damage or ulceration to the lumen or interior of an

When treated with antithrombolytics during

artery caused by a variety of mechanisms some of

catherization there is often no detectable

which are unknown.

residual disease.

Arteries

Adoposity

Blood vessels that carry blood away from the

The level and amount of body fat stored in an area

heart. All arteries, with the exception of the

of the body or the entire body.

Pulmonary Artery, carry oxygen and other nutrients
Age-adjusted mortality

from the heart to the body cells.

The number of deaths occurring per 100,000
Arteriosclerosis

population per year, calculated in accordance with

Arteri/o refers to the artery and sclerosis means

a standard age structure to minimize the effect of

“hardening”.Hardening of the arteries.

age differences when rates are compared between
populations or over time.

55

Atherosclerosis
Hardening of fatty plaque deposited on the artery

Aneurysm

56

wall. A pathological condition affecting the

Ballooning of a weakened portion of an

medium-sized and larger arteries, especially those

arterial wall.

that supply the heart (coronary arteries), the brain
Angina

(the carotid and cerebral arteries), and the lower

Chest pain caused by ischemia of the heart muscle

extremities (the peripheral arteries), as well as the

and is referred to the chest, arm, neck, jaw and/

aorta; underlies the occurrence of heart attacks,

or back.

many strokes, peripheral arterial disease, and
dissection or rupture of the aorta.

43

55

Atherosclerotic cascade

Blood pressure

The chain of events that begins with an insult or

The pressure, measured in millimeters of mercury

injury to the arterial wall and ends in stenosis of

(mmHg), exerted against the artery walls. Also

the artery.

considered to be the force required by the heart to
move blood through the vascular system.

Automated external defibrillators
A device used by a health professional or trained

Diastolic blood pressure

lay-rescuer that defibrillates or shocks the heart in

The measurement of pressure in the

the hope that an organized condution of the

arterial system during the resting phase of

electrical impulse will be restored and effective

the cardiac cycle when the coronary

mechanical function of the heart will resume. This

arteries fill and perfusion of the

device is automated so that it may be used with

myocardium takes place. Diastole refers

minimal training and available to the public in

to the resting of the heart

contrast to a standard defibrillator, which is used
Systolic blood pressure

by healthcare professionals trained in the

The measurement of pressure in the

American Heart Association’s Advanced Cardiac

arterial system during the contraction of

Life Support Certification.

the heart when blood is forced out of the
left ventricle into the arterial system.

Baby boomers
Those Americans born between 1946 and 1964, a

Body fat percentage

period where the birthrate increased significantly

The percentage of bodyweight that is predicted to

when compared with the period before and after.

be comprised of body fat. This excludes

This increase in population of this age group poses

fat-free or lean body mass that would

significant impact on CVD rates as well as stress

consist of muscle, organs and bone etc.

on the healthcare system as baby boomers move
through the lifespan.

Body Mass Index
A height to weight ratio field measurement which is

Behavioral Risk Factor Surveillance Survey

correlated to an increased risk for CVDs. BMI is in
units of kg/m2 and is derived by taking the

(BRFSS)
A telephone survey that is administered

bodyweight of an individual in kilograms and

nationally on an annual basis, and asks

dividing it by the height of that individual in meters

standardized questions aimed at assessing the

squared. Absolute values are used to interpret BMI

prevalence of risk factors for a variety of diseases

in adults and CDC’s published growth charts for

and threats to health and quality of life and to

age and gender are used to interpret BMI in

measure changes in the population’s risk.

children.
Cardiomegaly
Enlargement of the heart measured by increased
mass and thickness of the septum and walls of
the myocardium.

44

Cardiomyopathy

Congenital heart diseases
56

Literally means disease of the heart muscle and

Heart abnormalities present at birth.

56

results in dilation of one or more chambers of the
Congestive Heart Failure (also called heart

heart.

failure)
Cardiovascular Disease

Impairment of the pumping function of the heart as

May refer to any of the disorders that can affect the

the result of heart disease; heart failure often

circulatory system, but often means coronary heart

causes physical disability and increased risk for

disease (CHD), heart failure and stroke taken

other CVD events.

together.

55

55

Inability of the heart to pump

enough blood through the arterial system to supply
the tissues and organs.

Cerebral vascular accident (see stroke)

56

CHF is diagnosed by

measuring the percentage of blood in a chamber of

Interruption of blood supply to the brain caused by

the heart that is pumped out during systole (see left

a cerebral thrombosis, cerebral embolism, or

ventricular ejection fraction or LVEF).

cerebral hemorrhage. The patient may experience
mild to severe paralysis, also called stroke or brain

Coronary arteries

attack.

The arteries that supply blood to the heart muscle
and whose narrowing or occlusion constitutes

Chain of survival

coronary artery disease (CAD) and can precipitate

The steps that need to occur during a cardiac
event to improve possible outcome.

a heart attack.

57

55

1. Prompt activation of 9-1-1.

Coronary Heart Disease

2. Early cardiopulmonary

Heart disease caused by impaired circulation in

resuscitation (CPR)

one or more coronary arteries; often manifests as

3. Rapid defibrillation

chest pain (angina) or heart attack (myocardial

4. Timely advance life support.

infarction).

55

Cholesterol (see hyperlipidemia)

Defibrillation (cardiac defibrillation)

A steroid alcohol present in animal cells and body

Application of an electric shock to the myocardium

fluids, importing in physiological processes, and

through the chest wall to restore normal cardiac

implicated experimentally as a factor in

rhythm.

arteriosclerosis.

56

58

Diabetes mellitus (Diabetes)
Chronic obstructive pulmonary disease

A metabolic disorder resulting from insufficient

(COPD)

production or utilization of insulin, commonly

A group of disorders that are almost always a result

leading to cardiovascular complications.

55

of smoking that obstructs bronchial flow. One or
Diastole

more of the following in varying degrees are

The relaxation phase of the cardiac cycle.

present in COPD: emphysema, chronic bronchitis,
bronchospasm, and bronchiolitis.

56

45

Dyslipidemia

Exercise

An abnormal lipid profile without necessarily

A subclass of physical activity that is planned,

having high blood cholesterol. For example

structured, and repetitive bodily movement done to

individuals with low HDL cholesterol and a high

improve or maintain one or more component of

HDL to total cholesterol ratio but borderline total

physical fitness.

59

cholesterol values.
Heart disease (disease of the heart)

High-density lipoproteins

Any affliction that impairs the structure of function

Lipoprotein of blood plasma that is

of the heart (e.g., atherosclerotic and hypertensive

composed of high proportion of protein

diseases, congenital heart disease, rheumatic

with little triglyceride and cholesterol and

heart disease, and cardiomyopathies).

that is associated with decreased
probability of developing atherosclerosis.

55

58

Heart Valves
Low-density lipoproteins

Structure of the heart that directs the flow of blood

Lipoprotein of blood plasma that is

from chamber to chamber and to the lungs and the

composed of a moderate proportion of

aorta.

protein with little triglyceride and high

Tricuspid valve

proportion of cholesterol and that is

Located between the right atrium and right

associated with increased probability of

ventricle.

developing atherosclerosis.

56

58

Mitral valve
Electrolyte

A bicuspid valve between the left atrium

A substance (acid, base or salt that when dissolved

and the left ventricle.

56

in a suitable solvent becomes a suitable conductor.
Pulmonary valve

Electrolytes are necessary for many physiological

A semilunar valve located between the

processes especially muscle contraction and

right ventricle and the pulmonary artery.

electrical conduction. Electrolyte abnormalities can

56

be lethal and are a common complication related

Aortic valve

to CHF.

A semilunar valve located between the left
ventricle and the aorta.

Embolus

56

Blood clot or foreign material, such as air or fat,

Hemorrhagic stroke

that enters the bloodstream and moves until it

Also called a bleeding stroke. Sudden interruption

lodges at another point in the circulation.
(compare to Thrombus)

56

of blood flow to the brain caused by disruption of

58

blood flow due to loss of integrity and bleeding
from the artery. Common causes are dissecting
aneurysm and trauma.

46

High Blood Pressure (see hypertension)

Ischemia

A condition in which the pressure in the arterial

Deficiency of blood

circulation is greater than desired; associated with

demand of tissue exceeds oxygen supply so there

increased risk for heart disease, stroke, chronic

is a deficit. Prolonged ischemia will lead to

kidney disease, and other conditions; blood

necrosis of tissue.

56;

a condition where the oxygen

pressure is considered “high” if systolic pressure
Ischemic heart disease (see coronary arter

(measured at the peak of contraction of the heart)

disease)

is >140 mmHg or if diastolic pressure (measured at

Heart disease caused by ischemia generally due to

the fullest relaxation of the heart) is >90 mmHg.

coronary artery disease.
Hyperlipedemia
Ischemic stroke

A high blood concentration of a family of lipid or

Stroke caused by ischemia mainly due to

“fatty” molecular compounds obtained directly from

atherosclerosis in the carotid, vertebral, cerebral

the diet or produced in the body form fatty dietary

arteries and/or thrombus or embolism.

components; a necessary factor in development of
Atherosclerosis; total cholesterol concentrations is

Kidney disease (chronic kidney failure/see

classified as high if it is >200mg/dl.

renal artery disease)
Conditions that affect the kidney or function of the

Hypertensive disease

kidney and can lead to CVDs, electrolyte imba

Diseases caused by prolonged or chronic hig

ances, hypertension and other adverse

blood pressure including cerebral vascular

physiological consequences. A common cause of

disease chronic kidney disease, and heart

kidney disease is atherosclerosis in the renal

diseases including coronary artery disease,

artery.

valvular heart disease, cardiomyopathies and
cardiomegalies.

Left Ventricular Ejection Fraction (LVEF see
congestive heart failure)

Intracranial bleeding (see hemorrhagic stroke)

The percentage of blood in the left ventricle at the

A condition where the integrity of the cerebral

end of diastole that is ejected from the left

arteries is compromised causing bleeding into the

ventricle after systole. The LVEF is an index for

intracranial space; sometimes causing an increase

diagnosing CHF and stratifying the risk associated

in pressure in the cranium. Individuals who take

with CHF.

anticoagulant medication or other medication that
slows the clotting time of blood are at increased

Lesion (see plaque)

risk of intracranial bleeding.

An abnormal change in structure of an artery due
to injury or disease.

47

Major-modifiable risk factors for CAD

Metabolic syndrome

Attributes or characteristics of a person’s lifestyle,

A collection of physiological markers that are

which predisposes them to develop coronary artery

thought to be precursors to type II diabetes and

disease. Major modifiable risk factors have met

CVD and may be a link between the two diseases.

criterion of disproportionate risk, dose response,

These physiological markers are: abdominal fat,

independence, and proposed mechanism and

low-levels of high-density lipoprotein, high levels of

among others

triglyceride, and high blood pressure, secondary
findings may include elevated liver enzymes and

Disproportionate risk

hyperinsulinemia.

A disproportionate increase in developing
CVDs related to a single risk factor; a

Morbidity

relative risk of 1.3 is often considered as a

The extent of illness, injury or disability in a defined

threshold for disproportionate risk.

population.

Dose Response

Mortality

A relationship that between the presence

Rate of death expressed as the number of deaths

of a risk factor and its deleterious effect;

occurring in a population of given size within a

i.e. a person who smokes the longest or

specified time interval (e.g. 265 annual deaths from

the most would also have more significant

heart disease per 100,000 U.S. Hispanic women,

CVD and/or diffuse CVD.

1991-1995).

Independence

Myocardial infarction (see heart attack)

A given risk factor independently causes

An acute event in which the heart muscle is

CVD through proposed mechanisms

damaged because of a lack of blood flow from the

rather than mediating its effect through

coronary arteries, typically accompanied by chest

other conditions; in addition independent

pain and other warning signs but sometimes

risk factors can also mediate the risk for

occurring with no recognized symptoms (i.e. silent

developing CVD through other risk factors.

heart attack)

55

For example physical inactivity in and of
National Health Interview Survey (NHIS)

itself causes CVD but may also worsen

A cross-sectional household interview survey,

CVD risk by negatively modifying the non

administered by the National Center for Health

exerciser’s cholesterol profile.

Statistics (NCHS), which is a principal source of
Medical nutrition therapy

information on the health of the U.S. civilian

A comprehensive, evidence-based assessment

population.

involving patients who are at risk and who are
Non-modifiable risk factors

likely to benefit from therapy based on nutrition

Risk factors that are not amenable to modification

practice guidelines. MNT is generally provided by

by an individual such as increased age, family

a registered dietician and became a reimbursable

history, gender and ethnicity.

benefit by Medicare in January 2002.

48

Obesity

Pre-hypertensive

Often defined in terms of body mass index (BMI),

A range of blood pressure from 120/80mmHg to

which is calculated as bodyweight in kilograms

139/89 mmHg that signifies the importance of an

(1kg=2.2lbs) divided by height in meters

individual to start lifestyle modifications that may

(1M=39.37 inches) squared; a BMI of > 30.0 kg/m2

prevent developing high blood pressure.

is considered “obese.”

55

Prevalence
Overweight

The frequency of a particular condition within a

Often defined in terms of body mass index (BMI),

defined population at a designated time (i.e. 12.6

which is calculated as bodyweight in kilograms

million Americans living with heart disease in 1999

(1kg=2.2lbs) divided by height in meters

or 36.4% of African American men aged 20-74

(1M=39.37 inches) squared; a BMI of 25-29.9
kg/m2 is considered overweight. In children, the

years found to have hypertension in a survey
conducted in 1988-1994.

CDC defines overweight as BMI greater than the
95th percentile value for the same age and gender
group.

55

Primary (essential) hypertension
Hypertension with an unknown cause representing

55

approximately 95% of diagnosed cases of
Peripheral edema

hypertension.

A puffing, swelling of tissue in the extremities
Primary prevention of CVDs

(usually the lower extremities) from the

Interventions, including the detection and control of

accumulation of fluid in the extra-cellular space;

risk factors, designed to prevent the first

often a consequence of CHF.

occurrence of heart attack, heart failure, or stroke
Peripheral vascular disease

among people with identifiable risk factors.

55

Mainly atherosclerosis of the extremities;
Primary stroke centers

especially important in lower extremities; also
called peripheral vascular disease.

Key elements of primary stroke center include

55

acute stroke teams, stroke units, written care
Physical Activity (see exercise)

protocols, and an integrated emergency response

Bodily movement that is produced by the

system. Important support services include

contraction of skeletal muscle and that

availability and interpretation of computed

substantially increases energy expenditure.

59

tomography scans 24 hours everyday and rapid
laboratory testing. Administrative support, strong

Plaque

leadership, and continuing education are also

The characteristic manifestation of atherosclerosis

important elements for stroke centers. Adoption of

located in the arterial wall and extending into the

these recommendations may increase the use of

lumen or channel of the artery; plaque can disturb

appropriate diagnostic and therapeutic modalities

or restrict blood flow and is prone to fissure or

and reduce peristroke complications.

rupture, thus precipitating formation of a blood clot
that can cause an acute coronary event.

55

49

Primordial prevention of CVD

Secondary hypertension (see renal

Interventions targeting people without (known) risk

artery disease)

factors or CVD (including the maintenance or

Approximately 5% of the diagnosed cases of

restoration of favorable social and environmental

hypertension where the cause can be identified;

conditions and the promotion of healthy behavioral
patterns) to prevent development of risk factors.55

atherosclerosis in the renal artery is the leading

Population-wide approach:

Secondary prevention of CVDs

Intervention strategy that targets the population as

A set of interventions aimed at survivors of acute

a whole without regard to the risk levels of various

CVD events (i.e. heart attack, heart failure, stroke)

subgroups; distinguished form and complementary

or others with known CVD in which long-term case

to the high-risk approach.

cause of secondary hypertension.

55

management is used to reduce disability and risk
for subsequent CVD events.

56

Pulmonary edema
56

Abnormal accumulation of fluid in the lungs and a

Silent Ischemia (see silent myocardial

common complication of CHF or chronic kidney

infarction)

disease.

Ischemia of the heart muscle that does not result in
angina.

Pulmonary heart disease
Impaired function of the right ventricle resulting in

Stenosis

poor perfusion into the lungs and insufficient

A narrowing or constriction of the diameter of a

oxygenation.

bodily passage or oriface commonly in CVD to

56

be found in an artery or heart valve.
Renal artery disease
Arteriosclerosis in either of the renal arteries that

STOP Stroke Act

branches off the abdominal aorta to each kidney.

Legislation aimed at ensuring that stroke is more

This is the largest known cause of hypertension

widely recognized by the public and treated more

called secondary or non-essential hypertension.

effectively by healthcare professionals. STOP
stands for stroke treatment and ongoing

Rheumatic heart disease

prevention.

Damage to the heart muscle or heart valves
caused by one or more episodes of rheumatic

Stroke

56

fever. Rheumatic fever is an inflammatory

Sudden interruption of blood supply to the brain

disease, usually occurring in children and often

caused by an obstruction or the rupture of a blood

following an upper respiratory tract streptococcal

vessel.

infection.

56

50

55

Sudden cardiac arrest

Thrombus

An acute emergency where the heart no longer

A clot formed within a blood vessel and remaining

provides cardiac output at a level which supports

attached to its place of origin (compare

the victims life; mainly caused by arrhythmia which

Embolus).

59

can be best treated by rapid defibrillation of the
Vascular disease

heart.

Diseases which effect the arteries including but not
Sudden cardiac death

limited to aneurisms, atherosclerosis, and

The result of sudden cardiac arrest with

arteriosclerosis and is the underlying mechanism

unsuccessful resuscitation.

in major forms of cardiovascular disease effecting
the brain, heart, kidneys and extremities.

Systole
The contraction phase of the cardiac cycle where

Veins

blood is moved through the arterial system and

Blood vessels that carry blood from the capillaries

arterial pressure rises.

toward the heart and have thinner walls than the
arteries and often valves at interval to prevent

Telemedicine

reflux of the blood which flows in a steady stream

An attempt to overcome geographical barriers to

and is in most cases dark-colored due to the

care by using video-conferencing, high speed data

presence of reduced hemoglobin.

transmission, telemetry and other communication
technology to provide consults, clinical and

Waist to Hip Ratio

diagnostic data and allow urban facilities to tap into

The circumference of the waist divided by the hips;

rural resources.

an index of risk related to body fat which is
sensitive to body fat patterning; the pattern of body
fat distribution is recognized as in important
predictor of the health risks of obesity.

51

59

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58

This Publication was supported by funds from the Tobbacco Tax
Funds generated as a result of Proposition 303 passed in
November of 2003.

Arizona
Cardiovascular Disease
State Plan
Arizona Department of Health Services
Division of Public Health
Office of Chronic Disease Prevention and Nutrition Services
www.azdhs.gov