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CDC Telebriefing Transcript
Dr. George Mensah Discusses Sudden Cardiac Deaths
February 14, 2002
CDC MODERATOR: Hello. This is Kathy Harben with CDC's National Center for
Chronic Disease Prevention and Health Promotion. Happy Valentine's Day.
Today's topic is State-Specific Mortality from Sudden Cardiac Death in the
United States for the year 1999. Joining us is Dr. George Mensah, and that's
spelled M-e-n-s-a-h. Dr. Mensah is chief of CDC's Cardiovascular Health
Program. Also with us is Dr. Z.J. Zheng, and that is spelled--his first name
is Z-h-i-J-i-e, last name Zheng, Z-h-e-n-g. He's the lead author and a CDC
cardiac epidemiologist. Dr. Mensah will have a few comments and then we'll
turn to questions.
DR. MENSAH: Thank you very much, Kathy. Good afternoon. As Kathy said, I am
George Mensah. I am a medical doctor and a heart disease specialist, and
chief of CDC's cardiovascular health program. I am joined by Dr. Zheng, who
is also a medical doctor and a heart disease epidemiologist. He took the
lead on this research work.
We want to thank you first for the opportunity to share with you some of the
new information about the burden of heart disease and especially about the
proportion of heart disease deaths that occur outside of hospitals or in
emergency rooms in this country, and for the rest of this conference we are
defining these deaths as deaths outside of hospitals or death in emergency
rooms after sudden cardiac death.
Now just for a little background, as most of you know, cardiovascular
diseases, including heart attack, stroke, and high blood pressure, kill
nearly a million Americans every year, making it the leading cause of death
among men and women in all racial and ethnic groups.
About 62 million Americans live with some form of cardiovascular disease. In
fact, this year alone heart disease is expected to cost our nation about
$329 billion in health care expenditures and lost productivity.
This week's morbidity and mortality weekly report includes findings from our
latest study on sudden cardiac death or sudden heart disease death, as I
defined. About 63.4 percent of heart disease deaths in 1999, that's more
than 460,000 (inaudible), and nearly half of all heart disease deaths
occurred outside of the hospital, according to the latest death certificate
data from CDC's Center for National Health Statistics.
Leading the states with a high percentage of sudden cardiac deaths were
Wisconsin. 72.9 percent of all heart disease deaths in that state were
sudden, followed by Idaho, at 72.2 percent, Utah at 72.1 percent, Colorado
at 71.3 percent, and Oregon at 71 percent.
Just for comparison, the states with the lowest percentages of sudden
cardiac death still had percentages close to 60 percent. For example, Hawaii
had 57.2 percent, Arkansas had 57.5 percent, New Jersey was 57.6 percent,
Kentucky was 58.4 percent, and Oklahoma was 58.5 percent.
It's important to mention that women were more likely than men to die
outside of the hospital. About 52 percent of women died before reaching the
hospital, compared to 42 percent of men.
CDC and its partners are concerned about these sudden cardiac deaths and are
working with partners of the American Heart Association and the American
(inaudible) of Cardiology to raise awareness about the symptoms of heart
disease, particularly heart attack, and to encourage people to seek
Uncommon symptoms that the public and health care providers should watch for
include breaking out in a cold sweat; having nausea and lightheadedness; but
more common symptoms are chest discomfort or pain, a pain or discomfort in
one or both arms or in the back, in the neck, the jaw, or stomach and, of
course, shortness of breath.
Treatment of heart disease, including heart attack and cardiac arrest, is
time-dependent. The earlier a patient is treated, the better the outcome.
When an emergency occurs, the public should immediately initiate the chain
of survival, call 911, attempt cardiopulmonary resuscitation or CPR, and use
other (inaudible) external defibrillators when they're available until
emergency personnel arrive.
People can reduce their chances of developing heart disease in the first
place by being physically active, eating a diet low in fat and high in
fruits and vegetables, and stopping or never starting smoking.
Currently CDC funds about 28 states to assess the burden of heart disease
and stroke in (inaudible) and to develop partnerships to reduce that burden
mainly through heart-healthy policies that encourage physical activity and
Thank you for listening, and we will be very happy to answer any questions
that you have about these findings.
CDC OPERATOR: And, ladies and gentlemen, once again, if you do have a
question, at this time please press the one. And we do have a question from
the line of Ira Dreyfuss with AP Radio. Please go ahead.
QUESTION: This is a question relating to exercise. Being physically active
can reduce the risk of all causes of mortality and coronary artery problems,
but does CDC have a specific recommendation on physical activity for sudden
DR. MENSAH: This is Dr. Mensah. It's a very good question. You know, the
Surgeon General's recommendation really is moderate levels of physical
activity most of the days of the week, and frankly, that we can assume is
what CDC supports, and we encourage, when we do educational activities, we
encourage moderate levels of physical activity on most days of the week.
QUESTION: But does that mean specifically for cardiac, to reduce the risk of
DR. MENSAH: That's really difficult to say without having a specific study
that looks at what parameters you give a patient and then assess the
outcome. We do have some evidence in the literature, though, that in
individuals who are above the 80th percentile of say physical activity in
their population, their risk for sudden cardiac death is cut by more than
half, and that's data from Seattle, Washington. But, again, we don't have at
CDC any specific study that looks at exercise recommendations and the impact
on sudden cardiac death.
CDC OPERATOR: Our next question is from the line of Kim Dixon with Bloomberg
News. Please go ahead.
QUESTION: Hi. Thanks. I'm trying to find out or figure out some sort of
comparison to this number, this number that 63 percent of all cardiac
disease deaths are heart attacks, basically. Is this number increasing from
previous years? And, if so, can you give me some sort of, you know, percent
or some sort of basis to judge how things are changing?
DR. MENSAH: I think the first part that you mentioned is that these are not
really all heart attacks. They are sudden deaths from--related to heart
disease. It could be from heart muscle disease, it could be from arrythmia,
so they are not all heart attacks.
DR. MENSAH: And the second part of your question was?
QUESTION: Was what is the comparison number? Are sudden cardiac deaths of
the percentage of cardiac disease deaths, are they going up? I mean
what's--the 63 percent, what was that five years ago?
DR. MENSAH: It's a very important question. One thing we say is there really
isn't a very consistent pattern, although we know that if you look at the
data for out-of-hospital deaths, and I think here what we have to be very
clear, if you look at out-of-hospital deaths in 1989 and look at the trend
through 1998, there has been an increase. We're talking by about 36 percent
in 1989, about 41 percent around 1993, and 46 percent in 1998.
I should mention that this report was not a study that was specifically
designed to look at this, so we cannot tell you whether this is a
significant change or what are the determinants of that, but just looking at
the proportion of out-of-hospital deaths alone, it looks like there has been
QUESTION: Is the proportion of out-of-hospital deaths due to sudden cardiac
DR. MENSAH: From this definition, yes. And, again, what we're calling the
out-of-hospital sudden deaths are all the deaths that an be
related to the heart, meaning being certified on the death certificate as
caused from the heart, and those deaths that were not in the hospital or, in
this case, were not also in the emergency room.
The proportion in the emergency room has sort of gone down a little bit. We
can't say that that's a significant change. If you look for comparison, in
1989, it was about 18 percent. It was still 18 percent or 18.7 percent in
1993, and about 16 percent in 1998.
So there there is less confidence in saying that there has been a
significant change, but if you restrict it to only the out-of-hospital
deaths, then that has increased.
QUESTION: Could you repeat the out-of-hospital numbers?
DR. MENSAH: The out-of-hospital numbers--
QUESTION: '89, '93, and '98?
DR. MENSAH: 1989 was about 37.8 percent, and 1991 was 38.6 percent. 1993 was
about 39.2 percent, and actually this, I believe the full report in the
morbidity and mortality publication would have the exact percentages also.
The--in the previous publication that looked at sudden cardiac deaths from
1989 to '98, the trend is charted, and you would have those exact
DR. MENSAH: The most recent was 1998, and that was 46.7 percent for the
QUESTION: Okay. Okay. All right. And do you have a hypothesis as to why that
might be happening? Those are my last questions.
DR. MENSAH: Well, the--the one that we're most concerned about is access to
care and also people acting in time when they have symptoms of heart
disease. Again, this study was not designed to look at it, so it is not the
best source for identifying the determinants of that change. But definitely
if more people were to take very seriously what constituted the signs and
symptoms or the early-warning signs of heart disease and heart attack,
definitely the number of people dying outside of hospitals could go down,
and you would see an increase in more people reaching the emergency room
(inaudible) and people getting to care facilities much, much earlier.
QUESTION: Okay. Thank you.
DR. MENSAH: Thank you very much.
CDC OPERATOR: And we have a question from the line of Richard Donex with the
National Public Radio. Please go ahead.
QUESTION: Okay. First, just to clarify something you mentioned a minute ago
in response to the Bloomberg reporter's question. I missed something. When
you talked about 18 percent in '89 and so, what were those referring to?
DR. MENSAH: Okay. Again, remember that sudden cardiac death has been defined
very differently in the literature, and so we want to make sure that for
this conference while we are talking about these numbers that we are talking
about the same thing.
For the out-of-hospital deaths, they can be deaths in the emergency room or
they can be people who get to the emergency room and are pronounced dead, or
people who are found dead at room. And so the first percentages that I gave
were the proportion of people who are either dead on arrival in emergency
room or those who died in the emergency room, not in hospital. That--those
were the 18.5 percent in 1989 and 16.7 percent in 1998. And there, there
really isn't confidence in any trend, but the higher percentage is the
proportion of deaths that are out of the hospital. So not in the emergency
room and not dead on arrival, but in the--found dead at home or dying before
they reach the hospital, and those were a much higher proportion with about
37.8 percent in 1989, and that's where there is a trend of an increase with
46.7 percent in 1998.
QUESTION: And that is significant (inaudible)?
DR. MENSAH: We have to say yes because usually on these data, since we are
dealing with populations, we very often don't talk of statistical, they're
sort of the real numbers, and so the 46.7 percent is different from the
QUESTION: Okay. Now if I--thanks for clarifying it. If I can get to my
question. Is one of the issues underlying here that--I seem to recall that
women who have heart attacks may have atypical symptoms that may not be
identified or recognized as cardiac symptoms. Is that one of the issues that
you think is behind the fact that there are a high proportion of women with
DR. MENSAH: You're absolutely right. We believe that that's one of the
factors. And, again, you recognize that it's definitely a complex issue.
It's not just the lack of recognition of the signs and symptoms. That's an
important part, but also having access to medical care would be an important
The--one of the major reasons we are very interested in this is we think if
we can do some education, not just patients and families, but also health
care providers or professionals, we can make a big difference and reduce the
disparity between what we see in women and what we see in men.
QUESTION: Is there something we should mention, though, in talking about
these data with respect to women about how the symptoms may be different in
women rather than men? So what--you know, what should women be alert to
other than the classic chest pain and so on?
DR. MENSAH: Probably a two-part message. I think the most important thing to
emphasize is that the symptoms for heart attack in the majority of cases are
similar between men and women, and so chest discomfort, tightness or
squeezing in the chest, these are very important. And there are more
similarities than there are differences, but women are more likely to have
the atypical type of symptoms and, in fact, that's the reason why we may
miss more women, and those tend to be the nausea or pain in the neck and
pain in the back, jaw pain.
But, again, I think it's important to emphasize that in the majority of
cases, we need to pay attention to the common symptoms and treat both men
and women in the same fashion, with the same level of urgency and immediacy.
QUESTION: May I just have one more? Are there other people waiting here?
I know that there's been overall for a couple of decades, at least, probably
more, a decline in the cardiac--or cardiovascular mortality and
heart-specific mortality. I haven't heard anything in very--about very
recent years. Does that continue, and does it continue at the same rate?
DR. MENSAH: It has continued, and I think that's one of the successes of the
health care system, the National Heart, Lung and Blood Institutes campaigns
to increase awareness for blood pressure education, all of these have
helped. The death rate, not the number of people dying, but the death rate
for heart disease has continued to go down. The death rates for stroke have
also continued to go down.
In the case of stroke, the rate at which it's been decreasing has been a bit
slower in the past decade than the previous two, three decades. But so the
trend for the nation is downward.
QUESTION: So for heart, it continues to decline at the same rates as it had
been in the '70s and '80s, or is it also declining slower?
DR. MENSAH: In general, the rate of decline has continued, and even the most
recent data have continued. The--for stroke, it's much clearer to
demonstrate that the rate has slowed down, that it's still declining. So
there is more of a change in the stroke mortality rate decline than there is
in the coronary mortality decline.
It's really important to emphasize, though, that because the death rate is
decreasing, that means more people are living with heart disease, and
especially as we do a better job in preventing people from dying from a
first heart attack, it means more and more people are living with damaged
hearts, and so they are at increased risk for having heart failure, at
increased risk of dying prematurely and dying suddenly.
So death is important, but it's only half the story, and there are far more
people living, 62 million, as we mentioned, who are living with some form of
QUESTION: Thank you.
DR. MENSAH: Thank you very much.
CDC OPERATOR: Our next questions are from the line of Ted Verdunsky with
WABE, Atlanta. Please go ahead.
QUESTION: Dr. Mensah, I hope you can hear me on this phone. I'm recording on
it. I'll ask my question and then click off.
This is to me, having to tell the story briefly, a story about minutes,
where minutes count, and I'm wondering as part of the education message
you're trying to get across, you said this can be used in an educational
context, what is in there about the person making sure they leave a list of
their medications around, like if they're on Coumadin or something like
that, or their power of attorney, or cell phone numbers? I wonder how many
more lives would be saved if these things were handy when the EMTs arrived?
DR. MENSAH: You're absolutely right. I think the more information the
emergency personnel have about the patient, the more likely they are able to
help them. So, in general, I think physicians and nurses and other health
care providers try to do a good job in helping patients recognize the
importance of that.
For the purposes of sudden cardiac death, though, the time issue is so
important because every minute makes a huge difference. We're talking about
a 10 percent decrease in the likelihood that you would survive after a
cardiac arrest. And so even though knowing about the medications, knowing
about previous medical conditions and surgeries are important, when someone
is down and they don't have a pulse, and you can't arouse them from shaking
and it's cardiac arrest, 911 is the best, and looking at their medications
and their other history certainly would help, but that should come later.
So the message we're trying to get out is it's important to know the signs
and symptoms, both for the patient themselves, but also for neighbors and
families to recognize what are the signs of the cardiac arrest, and to dial
911 and to get help immediately.
CDC OPERATOR: And once again, ladies and gentlemen, if you do have a
question, please press the one at this time.
We do have a follow-up from Richard Donex. Please go ahead.
QUESTION: Yes, just to follow up on what you said. Every minute that passes,
there's a 10 percent decrease in survivability, is that what you said?
DR. MENSAH: That's correct. It's really--it's really pretty serious.
QUESTION: I think--don't we normally think that after three or four minutes
without a pulse, that somebody is a goner?
DR. MENSAH: We would say that. I think if we know, as you recognize,
sometimes the difficulty is knowing when the event really happened. If you
find someone whose pulse (inaudible), it's never clear when it happened. So
we always assume that it might have been sooner than we think, so we should
still go ahead and call 911. But in general, the more time you waste, if you
waste five minutes, that person's likelihood of surviving that cardiac
arrest is already decreased by 50 percent. But I think what we do not want
to say is for someone to make the assumption that perhaps the person has
been pulseless or has been down for an hour or two so it's a lost cause. I
think that may not be appropriate. Unless we know for a fact that this
is--we're talking hours and hours and days, I think every time we see an
opportunity for instituting either CPR or calling 911 and getting help
immediately, I think we should do that.
QUESTION: And to Ms. Harvin, no further questions in queue.
CDC MODERATOR: Okay. It looks like we're getting close to the end of the
half hour, then. If there are no more questions, we'll sign off.
CDC OPERATOR: And, ladies and gentlemen, that does conclude your conference
for today. Thank you for your participation, and you may now disconnect.