OBJECTIVE:This study aimed to examine the correspondence between seven established risk factors for coronary heart disease (CHD) and CHD mortality among the states in the United States. An ecologic analysis relating CHD risk factor prevalences to CHD mortality rates among 49 states was undertaken in 1991-1992.METHODS:Approximately 68,000 men and women ages 45-74 were randomly sampled and interviewed by telephone in surveys conducted in 49 states in 1991 and 1992. From these interviews, we estimated state-specific prevalences of smoking, overweight, physical inactivity, hypertension, elevated cholesterol, diabetes, and alcohol abstinence. These seven CHD risk factors were also combined to create a CHD risk index for each state. The main outcome measures were mortality rates from CHD (ICD9 codes 410.0-414.9) in each of 49 states in 1991-1992 for men and women ages 45-74. The analysis was based on multiple linear regression and Spearman's rank-order correlations between the CHD risk factor prevalences, the combined CHD risk index, and the CHD mortality rates among the 49 states.RESULTS:The prevalences of most of the CHD risk factors correlated with CHD mortality rates in the expected directions, and correlations were similar for men and women. The CHD risk index correlated strongly with CHD mortality for both men (r = 0.75) and women (r = 0.80).CONCLUSION:About 60% of the variance in CHD mortality between the states in the United States (56% for men and 64% for women) is attributable to differences between the states in the prevalences of seven established risk factors for CHD. As state health agencies prioritize resources for chronic disease prevention programs, they should consider the potential benefits of increased efforts to reduce the prevalences of modifiable CHD risk factors in their populations to reduce CHD mortality.

Major depression has been associated with mortality from ischemic heart disease (IHD). In addition, a symptom of depression--hopelessness--has been suggested as a determinant of health status. We studied the relation of both depressed affect and hopelessness to IHD incidence using data from a cohort of 2,832 U.S. adults age 45-77 years who participated in the National Health Examination Follow-up Study (mean follow-up = 12.4 years) and had no history of IHD or serious illness at baseline. We used the depression subscale of the General Well-Being Schedule to define depressed affect and a single item from the scale to define hopelessness. At baseline, 11.1% of the cohort had depressed affect; 10.8% reported moderate hopelessness, and 2.9% reported severe hopelessness. Depressed affect and hopelessness were more common among women, blacks, and persons who were less educated, unmarried, smokers, or physically inactive. There were 189 cases of fatal IHD during the follow-up period. After we adjusted for demographic and risk factors, depressed affect was related to fatal IHD [relative risk = 1.5; 95% confidence interval (CI) = 1.0-2.3]; the relative risks of fatal IHD for moderate and severe levels of hopelessness were 1.6 (95% CI = 1.0-2.5) and 2.1 (95% CI = 1.1-3.9), respectively. Depressed affect and hopelessness were also associated with an increased risk of nonfatal IHD. These data indicate that depressed affect and hopelessness may play a causal role in the occurrence of both fatal and nonfatal IHD.