hearT DISEASE AND STROKE IN RURAL
by Miguel Zuniga, D’Arcie Anderson, and Kristie
Alexander
Approximately 61
million individuals in the United States are afflicted with some form of
cardiovascular disease, which includes both heart disease and stroke and
contributes to an estimated four of every 10 deaths in the United States.8
Compounding the problem is the staggering percentage of the population with
high cholesterol, hypertension, and obesity¾all risk factors for heart disease and
stroke.30 While there has been a 50 percent reduction in coronary
heart disease and stroke in the past 30 years,3 mostly attributable to advances in therapy
and technology, disparities among certain subgroups have become more
exaggerated.4 Among these vulnerable subgroups include
rural populations,5, 6 particularly those in the South and
Appalachian region.4
Given that heart
disease and stroke are the first and third leading causes of death in the
United States,1 addressing this health concern is pivotal
to improving the nation’s health. Specifically, the goal of the Healthy People
2010 heart disease and stroke objective is to “improve cardiovascular health
and quality of life through the prevention, detection, and treatment of risk
factors; early identification and treatment of heart attacks and strokes; and
prevention of recurrent cardiovascular events.”2
The Healthy People
20102 objectives addressed in this section are as
follows:
The following
definitions are pertinent to the discussion of heart disease and stroke:
- Coronary heart
disease (CHD) occurs when
there is a decreased flow of blood to the heart muscle, resulting in damage and/or
death of the deoxygenated heart muscle.2
- Acute myocardial infarction (AMI, commonly called a “heart attack”)
“occurs when a coronary artery becomes completely blocked, usually by a blood
clot (thrombus), resulting in lack of blood flow to the heart muscle and
therefore loss of needed oxygen.”2
- Stroke occurs when the brain does not receive an
adequate supply of blood due to the rupture of blood vessels or the presence of
blood clots.2 There are two main types of strokes:
ischemic (blockage) and hemorrhagic (bleeding). Ischemic strokes are the most
common, and account for approximately 88 percent of all strokes.31
identified by people living in rural areas as a
high priority health issue for them
According to the Rural Healthy People 2010 survey,
heart disease and stroke ranked second across the four groups of state and
local respondents in the frequency of priority nominations received. This focus
area was nominated by an average of 41 percent of the respondents.7
Respondents from rural hospitals and rural health centers and clinics were more
likely than respondents from local public health offices or state health
organizations to rate this topic area as a high priority. State agency
respondents were least likely to rate heart disease and stroke as a priority.
The differences in nomination rates were statistically significant. The
Heart
disease and stroke are respectively the first and third leading causes of death
in the United States1 and cost the United States
almost $298 billion annually.8 In 1999, cardiovascular disease
contributed to one out of every 2.5 deaths, (958,775 individuals).30
Stroke affects more
than 600,000 individuals every year. The associated cost for treatment and
rehabilitative services for stroke victims in the
Although
heart disease is sometimes considered a disease mostly affecting men, half of
all cardiovascular disease deaths occur in women.8 Women are almost
twice as likely to die from heart disease than to die from cancer.39
According to the Center for Disease Control and Preventions’ National Health
and Nutrition Examination Survey (NHANES) III (1988-94), during early
adulthood, men have higher rates of cardiovascular disease than women, but this
difference lessens during later years—equaling each other at the ages of 65-74
and surpassing men at the age of 75 years.30 The highest rates of
heart disease deaths among women occur in Northeastern large urban areas
followed by the South’s most rural counties.9 For men, the highest
heart disease-related deaths occur in the South’s most rural counties.9
For women and men, the lowest death rates from heart disease occur in the West.9
As noted earlier, the incidence of heart disease and stroke has declined
significantly over the past three decades;3 however, the decline has not been uniform
across all subgroups. According to 1995 data, the death rate for
African-American males from cardiovascular disease is 42 percent higher than
white males, and the rate for African-American females is 65 percent higher
than white females.2 Other vulnerable populations to heart
disease and stroke include older African Americans,2 Hispanic
Americans,3 individuals of lower socioeconomic status,11
and as noted in the preceding, rural populations,5, 6 particularly those in the South and
Appalachian region.4, 12 This trend, as summarized by Wing,11 suggests
that coronary heart disease has shifted from a disease of the privileged to one
of the disadvantaged.
According to
self-reported data in the 1996 National Health Interview Survey, heart disease
was 1.34 times more prevalent in non-metropolitan statistical areas (non-MSAs)
(98.8 per 1,000 individuals) when compared to metropolitan statistical areas
(72.6 per 1,000 individuals). Cerebrovascular disease was reportedly 1.45 times
higher in non-MSAs than in MSAs (15.1 per 1,000 individuals and 10.4 per 1,000
individuals, respectively). Hypertension was also higher in rural than urban
areas (101.3 per 1,000 individuals in MSAs and 128.8 per 1,000 individuals in
non-MSAs).13 Ischemic heart disease, which contributed to over 60
percent of heart disease mortalities in 1998,40 is nationally higher
in rural counties among men 20 years of age and older.9
True prevalence data
for heart disease and stroke in rural versus urban areas are not readily
available. However, differences in mortality data often reflect disparities
between rural and urban areas. From 1985-1995, declines in mortality rates for
premature coronary heart disease in African Americans and whites were found to
be slower in the rural South than their counterparts in other geographic areas.
For African-American women and men, the slowest rates of annual decline were in
the rural South, with rates of 1.6 percent and 0.7 percent, respectively. The
fastest areas for decline of coronary heart disease mortality among African
Americans were in less metropolitan areas (counties with fewer than one million
people) outside the South, which had declines measuring 3.3 percent for
African-American women and 3.9 percent for African-American men.12
IMPACT
OF THE CONDITION ON MORTALITY
Cardiovascular disease remains the leading
cause of death in the
In recent years
there have been numerous medical advances both in therapy and in technology of
CVD. Improvements in medicine and Medicare coverage of
expensive procedures have contributed to decreased mortality overall. From 1986
to 1998, mortality following an AMI admission declined by one-third—from 24
percent to 16 percent.41 Nonetheless, disparities of benefits in
medical advances in rural areas when compared to urban areas sometimes result
in increased mortality.
Heart disease and
stroke are leading causes of disability, annually costing the United States an
estimated $19 billion and $5.6 billion, respectively.15 Compared to
population norms, quality of life domains represented by physical function,
role physical, role emotional, vitality, social functioning, bodily pain,
mental health, and general health are lower for people living with coronary
heart disease and stroke as compared to population norms.42, 43
In 1999, the most
common diagnosis for individuals 65
years of age and older was heart disease¾comprising 23
percent (4.5 million) of total inpatient discharges, with an average stay of
4.7 days.26 In recent years, more people have received cardiac
procedures. From 1986 to 1998, angioplasty increased from 1.3 to 8.4
individuals per 1,000, and CABGs increased from 2.7 to 4.8 individuals per
1,000.41
CONTRIBUTOR
TO MANY OTHER HEALTH PROBLEMS
With heart disease
and stroke, there is increased likelihood of recurrence and other macrovascular
complications.16 There are a significant number (1 in 40) of AMI
patients who suffer from an ischemic stroke within six months of discharge.16
Individuals over 65,
females, blacks, those with frailties, and those with prior medical history of
stroke are at increased risk of stroke occurrence after an AMI.16
Depression is
significantly associated with both heart disease17 and stroke.18,
19 Some studies suggest a causal relationship between depression and AMI
and stroke,19 while others report the evidence of depression after
other debilitating events44 and intensive medical treatments, such
as CABG surgery.45 Morris18 reported in a 10-year
follow-up study that individuals diagnosed with depression after suffering a
stroke had a mortality rate three times higher than those not diagnosed with
depression. In an analysis of several studies, Glassman17 found a
strong association between depression and heightened occurrence of and
mortality from cardiovascular disease.
Rural populations
have certain behaviors and attitudes that contribute to their heightened risks
of coronary heart disease and stroke. Rate of lifestyle change, individuals’
perception of heart disease risk, and attitudes of health care providers may
heighten the disparity in heart disease and stroke incidence in rural versus
urban areas.
Pearson5 proposes that rural areas do not adopt changes in behaviors
as rapidly as do urban areas. Historically, rural areas have not adopted
behaviors such as smoking, high-fat diets, and sedentary lifestyles as readily
as urban areas. Similarly, once these coronary heart disease and stroke risk
factors are adopted in the rural areas, they are reversed at a slower rate than
urban areas. In one study of ischemic heart
disease patients in rural West Virginia, 27 percent continued smoking after
diagnosis.46 This delay in lifestyle changes
partially explains the initial lower rate of coronary heart disease in rural
areas compared to urban areas, and the gradual evolution to higher rates of
coronary heart disease in rural areas.5
Another possible
contributor to the higher rates of coronary heart disease in rural areas is
that of socioeconomic status. Lower standards of living and social and economic
restrictions, rampant in some rural areas, lead to higher prevalence of
coronary heart disease risk factors, such as cigarette smoking, poor dietary
habits, and sedentary lifestyles.47
Perception of risk
may also play a role in the rural/urban disparity for heart disease. Some rural
inhabitants do not perceive themselves at risk for heart disease and stroke,
and their behaviors are modeled by these misperceptions. Older rural women
reportedly have a decreased perception of heart disease and are less likely to
participate in primary prevention efforts, such as screening procedures. This
lower perceived risk is exacerbated by the decreased availability of screenings
in rural areas.20
Attitudes of health
care providers toward patients in rural settings can determine the quality of
medical care. In a scenario-survey sent to a random selection of family
physicians, heart patients with reduced access to services were not as likely
to be referred to a cardiologist or to receive a left ventricular function test¾two heart failure guidelines. Physicians’ treatment
methods were affected by the patient’s environment.48
Beyond social and
behavioral barriers, rural residents are faced with access challenges and
service gaps in seeking treatment and prevention services. The unique
challenges faced by rural residents include the prolonged distance to provision
of comprehensive post-discharge care of heart failure21 and limited
access to personnel, screening services (e.g., cholesterol checks), and
treatment services for heart disease and stroke. When screening does occur,
dietary assessments and other needed follow-up measures are often unavailable.49
Furthermore, organizations disseminating heart disease and stroke prevention
strategies may have only limited activities in rural areas.5
Procedures in the
treatment of heart disease and stroke are also more limited in rural areas than
in urban areas. Availability of technology is a main factor for geographic
differences in testing patients for stroke diagnosis.50 Some
physicians in rural areas are averse to treating stroke patients with
anticoagulant therapy because of limited experience in administration and
monitoring of the drug and fear of drug complications, such as excessive
bleeding and/or fatal bleeding.38 A study of Medicare patients in
one state yielded an antithrombolytic therapy utilization rate 1.7 times
greater in urban hospitals than in rural hospitals and demonstrated that
patients who were prescribed antithrombolytic therapy were less likely to
suffer adverse outcomes.22
The relationship between volume and outcome has been the subject of numerous studies. According to a meta-analysis study, the relationship between AMI outcome/stroke outcome and volume is somewhat controversial.51 Thiemann52 reported that high mortality rates of elde