Focus On...Cardiovascular Diseases

The Wisconsin Cardiovascular Health Program: A Partnership Effort to Improve the Health of Wisconsin Residents

Mary Jo Brink, RN, BSN, MS; Wendy L. Schell, MS; Peter D. Rumm, MD, MPH

In October 2000, the Centers for Disease Control and Prevention (CDC) awarded the Wisconsin Department of Health and Family Services a three-year cooperative agreement to establish the Wisconsin Car-diovascular Health Program (CHP). The CHP is located in the Bureau of Chronic Disease Prevention and Health Promo-tion in the Division of Public Health (DPH).



Author Affiliations: Authors are from the Bureau of Chronic Disease Prevention and Health Promo-tion, Division of Public Health, Depart-ment of Health and Family Services. Ms. Brink (Program Supervisor) and Ms. Schell (Epidemiologist) are in the Wisconsin Cardiovascular Healt

Corresponding Author: Please address correspondence to the Wisconsin Medical Society at 608.442.3800

Editorials

Look for the cardiovascular data in your county

Thomas C. Meyer, MD, WMJ Medical Editor

This is the first of two issues this year devoted to cardiovascular diseases. Appropriately so, since they remain the principal hazard facing our population and are a major contributor to the slowing of Wisconsin’s economy. This issue explores the public health data.


Author Affiliations: WMJ Medical Editor

Corresponding Author: Please address correspondence to the Wisconsin Medical Society at 608.442.3800

Original Research

Regional Variations in Coronary Heart Disease Mortality in Wisconsin, 1979-1998

LeAnn D. Andersen, MS; Jennifer L. Commons, MS

Background: Although coronary heart disease mortality has declined in Wisconsin during recent decades, progress in reducing mortality was not equal in all counties.

Methods: Expected and observed numbers of coronary heart disease deaths from 1994 to 1998 were calculated for all 72 Wisconsin counties using data from the Centers for Disease Control and Prevention. The estimated percent decline in coronary heart disease mortality from 1979 to 1998 was also calculated for each county.

Results: Significant regional disparities are apparent in both recent coronary heart disease morality rates and declines in coronary heart disease mortality during the past two decades in Wisconsin. Counties that experienced the smallest declines in reducing coronary heart disease mortality during 1979-1998 tended to have the highest rates at the end of the period. Counties with lower income, lower education levels, less population density, and more blacks had higher rates of coronary heart disease.

Conclusions: These results may be useful in targeting resources to reduce regional disparities in coronary heart disease mortality in Wisconsin.



Author Affiliations: Ms. Andersen and Ms. Commons are graduates of the Population Health Program, University of Wisconsin-Madison.

Corresponding Author: Address correspondence to: LeAnn Andersen c/o Dr. Patrick Remington, Department of Population Health Sciences, 610 N Walnut St, Room 760, Madison, WI 53705.

Decline in Mortality of Coronary Heart Disease Among Whites and Blacks in Wisconsin 1979-1998

Hyunjoon Park, MA; Nasia Safdar, MD; Hugh Schmidt, MS

Objectives: 1) To examine overall trends in Coronary Heart Disease (CHD) mortality in Wisconsin from 1979 to 1998 to assess progress toward Wisconsin’s “Public Health Agenda for the Year 2000” goal; and 2) to compare the trends in mortality rates due to CHD by race, gender, and age groups between the periods of 1979-1983 and 1994-1998.

Methods: Mortality data for CHD (ICD codes 410- 414, 429.2) were retrieved from the Center for Disease Control and Prevention’s WONDER database. Age-specific CHD mortality rates were calculated as averages over the 5-year periods, 1979-1983 and 1994-1998. Both the percentage change in mortality rates between the two periods and the number of lives saved during the 1994-1998 period as a result of change were obtained. To look at racial disparities in mortality, relative rates, that is, ratios between mortality rates of blacks and whites in the 1994-1998 period, were calculated.

Results: Between the two time periods (1979-1983 and 1994-1998) there was a 40% reduction of CHD mortality in most age groups for white men and women. The slowest decline in mortality occurred among black men: 11% in the 35-44 age group and less than 30% among those 55 years and older. Although the mortality rate declines for black women over the study period were similar to those for whites overall, in the 1994-1998 period mortality rates among younger black women aged 35 to 54 were 2 to 4 times higher than those for white women in the corresponding age groups.

Conclusion: Wisconsin achieved its year 2000 objective for CHD mortality reductions in 1998, experiencing a 49% decline in CHD mortality from 1979 to 1998. Despite this overall decline, however, there was a noticeable difference in the trends among demographic groups, suggesting a further focus on racial disparities in CHD mortality.



Author Affiliations: Authors are with the University of Wisconsin-Madison. Hyunjoon Park is a graduate student in Department of Sociology; Dr. Safdar is a fellow in Infectious Diseases at the UW Medical School; Mr. Schmidt is on the staff of the Population Health Science depa

Corresponding Author: Address correspondence to Hyunjoon Park, Department of Sociology, 1180 Observatory Drive, Madison, WI 53706.

Regional Variation in Stroke Mortality in Wisconsin, 1989-1998

Steven A. Haas, MS; Lisette R. Jehn, BS; Patrick D. Meek, PharmD

Objective: To evaluate the regional variation in stroke mortality and determine the level of excess stroke mortality in Wisconsin over the period 1989-1998.

Methods: Wisconsin stroke mortality (ICD-9 430-438) data from the Center for Disease Control and Preven-tion (CDC Wonder) were analyzed by county for the period 1989-1998 using indirect age standardization.

Results: Estimates of observed and excess number of deaths associated with cerebrovascular disease in Wisconsin varied considerably by county during the 10-year time frame studied. Twenty-five counties had an observed number of stroke deaths that were statistically significantly different from what was expected given the age structure of their population. Of these, 14 had significantly more deaths than expected while 11 had significantly fewer.

Discussion: There is substantial variation in stroke mortality between Wisconsin counties. Potential reasons for regional variation are unknown and warrant further research. This paper may give Wisconsin counties a benchmark of their progress in preventing stroke mortality to date and give direction for future public health efforts.



Author Affiliations: Haas is a PhD student at the University of Wisconsin-Madison Department of Sociology and a NIA Predoctoral Trainee at the Center For Demography of Health and Aging. Jehn is a Program Coordinator at the Wisconsin Women’s Health Foundation, Madison, W

Corresponding Author: Address correspondence to Steven A. Haas, Center for Demography of Health and Aging, University of Wisconsin-Madison, 1180 Observatory Dr, Madison, WI 53706, 608.263.3853, e-mail shaas@ssc.wisc.edu.

Progress in Reducing Stroke Mortality in Wisconsin, 1984-1998

Kristine Dawson, MS; Barbara J.Gordon, MS; Abdelhani Guend, MS

Background: Despite recent advances in the prevention and treatment of stroke, it remains one of the leading causes of death in Wisconsin and the nation. This report examines trends in stroke mortality in Wisconsin over the past two decades and assesses progress toward reaching the Healthier People in Wisconsin 2000 objective of a 33% reduction in stroke mortality. Methods: Trends in stroke mortality for Wisconsin were examined across gender, age, and racial subgroups. Stroke mortality rates (ICD-9 430-438) were extracted from the Centers for Disease Control and Prevention’s database via WONDER, for the period 1979-1998. Results: Overall stroke mortality rates in Wisconsin decreased 11% from 1984-1986 to 1996-1998. Blacks had higher stroke mortality rates than whites, and males had higher rates than females. From 1984 to 1998, stroke mortality decreased more in men than in women for both races. In blacks under 65, both males and females experienced an increase in stroke mortality from 1984 to 1998. Conclusion: This analysis indicates mixed progress in the reduction of stroke mortality in Wisconsin. As of 1998, Wisconsin had not made enough progress to enable it to meet the public health agenda goal for the year 2000.



Author Affiliations: Authors are graduates of the MS program in Population Health Sciences at the University of Wisconsin – Madison. Additionally, Dawson is a Project Assistant with the Wisconsin Public Health and Health Policy Institute; Gordon is a Research Specialist

Corresponding Author: Reprint requests to Patrick Remington, MD, MPH, University of Wisconsin-Madison, Department of Population Health Sciences, 610 N Walnut St, Madison, WI, 53705-2397

Second Case of Infective Endocarditis Caused by Gemella sanguinis

Sanjay K. Shukla, PhD; Tahir Tak, MD, PhD; Ray C. Haselby, DO; Charles S. McCauley, Jr., MD; Kurt D. Reed, MD

Background: A 69-year-old man presented with a history of spiking fevers and symptoms of transient expressive aphasia and a left hemispheric cerebrovascular accident. A transthoracic echocardiogram revealed thickened mitral leaflets. A subsequent transesophageal echocardiogram demonstrated vegetations on both mitral leaflets and severe mitral regurgitation by color flow imaging. A gram-positive coccus was isolated from the blood culture of this patient.

Methods: The bacterium was identified by polymerase chain reaction (PCR) amplification of its 16S rRNA gene with the broad range eubacterial primers, FD1 and RD1, followed by sequencing of the PCR product. The obtained sequence was compared to all sequences deposited in GenBank and the ribosomal database project II. A phylogenetic tree was created to determine the relatedness of this bacterium to other bacterial species.

Results: The phylogenetic tree created from the 1389 bp 16S rDNA sequence indicated that the endocarditis was due to Gemella sanguinis, a member of the normal oral flora and a rare cause of bacteremia.

Conclusion: This report describes the second case of endocarditis caused by G. sanguinis. A history of periodontal disease and tooth abscess in this patient suggests that the oropharynx was the probable origin of the Gemella bacteremia. We propose that G. sanguinis should be added to the list of Gemella species that can cause endocarditis.



Author Affiliations: Dr. Shukla and Dr. Reed are with the Clinical Research Center, Marshfield Medical Research and Education Foundation, Marshfield, WI. Doctors Tak and McCauley are with the Department of Cardiology and Dr. Haselby is with the Department of Infectious Diseas

Corresponding Author: Send correspondence to Sanjay K. Shukla, PhD, Clinical Research Center, Marshfield Medical Research and Education Foundation, 1000 N Oak Ave, Marshfield, WI 54449; 715.389.5363; e-mail shuklas@.mmrf.mfldclin.edu

Evolving Clinical Applications of Cardiac Markers: A Review of the Literature

William W. Chu, MD, PhD; Robert S. Dieter, MD; Charles K. Stone, MD

Ischemic coronary syndrome is still the most frequent cause of mortality in the United States. Despite extensive investigation into the diagnosis of acute myocardial infarction (MI), this process remains quite complex because the majority of patients with chest pain have atypical symptoms and nonspecific electrocardiogram (ECG) changes and fall in the low or medium risk category. The biochemical cardiac markers play an important role in helping physicians make the diagnosis of acute MI and stratify patients for risk modifications. The use of cardiac markers in the diagnosis of acute MI is discussed extensively on pages 36-44 of this issue.1 This article focuses on reviewing other clinical applications. This field is large and rapidly expanding, making it impossible to cover every single clinical application of cardiac markers. Several research efforts are underway to find better cardiac markers and develop new applications for them. We review the literature on the use of cardiac markers, particularly troponin, with the risk stratification of acute coronary syndromes, the detection of reperfusion, perioperative MI, periprocedural MI, myocarditis, cardiac contusion, and MI associated with sepsis.



Author Affiliations: Doctors Chu and Dieter are Fellows, Section of Cardiovascular Medicine, Department of Medicine, University of Wisconsin Hospital and Clinics. Doctor Stone is Associate Professor of Medicine and Radiology, Section of Cardiovascular Medicine, Department of

Corresponding Author: Please address correspondence to the Wisconsin Medical Society at 608.442.3800

Review Articles

A Review of Clinically Relevant Cardiac Biochemical Markers

William W. Chu, MD, PhD; Robert S. Dieter, MD; Charles K. Stone, MD

Acute coronary syndromes remain the leading cause of mortality in the United States and represent an enormous cost to the health care system. Despite decades of investigation into the diagnosis of acute myocardial infarction (MI), the diagnostic process is still quite complex because the majority of patients with chest pain fall in the low or medium risk category with atypical symptoms and nonspecific electrocardiogram (ECG) changes. Cardiac biochemical markers play an important role in helping physicians make the diagnosis and stratify the risk to patients. However, the ideal cardiac marker and the best diagnostic approach to patients with chest pain in the Emergency Department (ED) remain elusive. Currently, among many cardiac markers, cardiac troponin I seems the most cardiac-specific in the diagnosis of acute MI. This article is focused on reviewing the characteristics of different cardiac markers and comparison of their usages in the diagnosis of acute MI. However, since this field is large and rapidly expanding, it is impossible to cover every aspect of cardiac markers. As the search for the most efficacious, specific and cost-effective means to approach patients with chest pain continues, further prospective, randomized, multicenter trials are needed to confirm the value of troponins and other diagnostic strategies in the early diagnosis of acute MI.



Author Affiliations: Doctors Chu and Dieter are Fellows, Section of Cardiovascular Medicine, Department of Medicine, University of Wisconsin Hospital and Clinics. Doctor Stone is Associate Professor of Medicine and Radiology, Section of Cardiovascular Medicine, Department of

Corresponding Author: Please address correspondence to the Wisconsin Medical Society at 608.442.3800

Your Practice

Cardiovascular research probes genetics, reaches out to community

Michael J. Dunn, MD, Dean, Medical College of Wisconsin

The Medical College of Wisconsin is committed to cardiovascular research. Physicians and scientists at the Cardiovascular Center are in the forefront of identifying chemical factors responsible for vasodilation and vascular disease. We have made great strides toward identifying the genes that interact to cause hypertension and diabetes. And we are testing methods for improving survival rates for out-of-hospital cardiac arrests.


Author Affiliations: Dean, Medical College of Wisconsin


Corresponding Author: Please address correspondence to the Wisconsin Medical Society at 608.442.3800