二. 美国流行病学对心血管疾病预防和治疗的帮助（相对有效治疗疾病范例）

　　美国从1950年代开始宣传教育控制高血压和改变饮食和生活习惯。同一个时
期，中国忙着搞革命，到了1990年代中国才开始这方面工作。比美国晚了40年。
下面这个列表总结了60年代到90年代的这30年间对于美国心血管和脑血管疾病的
明确致病因素（也叫危险因素risk factors）的控制和治疗的结果。这个结果导
致了美国心血管和脑血管疾病发病率的减少。

　　TABLE 1. Estimated change in risk factors and correlates for heart
disease and stroke, by selected characteristics

　　1．20 岁到74岁诊断有高血压的人：1960-1962年是37%，而1988-1994年是
23%。
　　Adults aged 20-74 years with hypertension*+
　　2．高血压病人中接受治疗和改变生活习惯的：1985年是79%，而1990年是
90%。
　　Persons with hypertension who are taking action to control their
blood pressure (e.g., medication, diet, reducing salt intake, and
exercise)
　　3．高血压被有效控制的人：1976-1980年是11%，而1988-1991年是29%。
　　Persons with hypertension whose blood pressure is controlled
　　4．20 岁到74岁胆固醇升高的人：1960-1962年是32%，而1988-1994年是19%。
　　Adults aged 20-74 years with high blood cholesterol+&
　　5．成人平均胆固醇水平：1960-1962年是220 mg/dL，而1988-1994年是
203mg/dL。
　　Mean serum cholesterol levels mg/dL of adults aged >=18 years+

　　6．18岁以上抽烟的人：1965年是42%，而1995年是25%。
　　Adults aged >=18 years who are current smokers+
　　7．肥胖：1960-1962年是24%，而1988-1994年是35%。
　　Persons who are overweight+@
　　8．从脂肪慑入的卡路里比例：1976-1980年是36%，而1988-1994年是34%。
　　Percentage of calories in the diet from fat**
　　9．从饱和脂肪慑入的卡路里比例：1976-1980年是13%，而1988-1994年是
12%。
　　Percentage of calories in the diet from saturated fat**
　　10．对全民的心血管病的宣传教育，指导，治疗作为主业的医生人数：1975
年是5046人，而1996年是14304人。
　　Number of physicians indicating cardiovascular diseases as their
primary area of practice
　　
----------------------------------------------------------------------
--------------------------------------
　　* Systolic pressure >=140 mm Hg, diastolic pressure >=90 mm Hg, or
taking antihypertensive medication.
　　+ Estimate is age-adjusted to the 1940 U.S. population.
　　& Serum cholesterol level >=240 mg/dL (6.2 mmol/L).
　　@ Defined as a body mass index >=27.8 kg/m2 among men and 27.2
kg/m2 among women.
　　** Based on 1-day dietary recall.
　　Source: References 11-14.

　　（王澄注：这篇美国的文章引用的最新文献是1998年的。对于医生来说，这
篇文章有些旧了。我看好的是这篇文章中对流行病学的简要和准确地阐述，与中
医的治未病形成鲜明的对照。另一方面，有心的人可以从最新的2007年报告中比
较这个6-7年以前的文章中的计划和今天的实施有哪些出入。可以看出科学是怎
样实事求是地，一步一步走过来的。下面有很多英文原文，不读英文的读者可以
跳过英文部分。）

　　自从1921年，心脏病成为美国人死亡的第一大原因。自从1938年，脑血管疾
病成为美国人死亡的第三大原因。两个病死的人数占总死亡人数的40%。 从1950
年代到20世纪末的40 多年里，美国人死于心血管病的减少了60%。它代表了20世
纪美国公共健康最重要的成就之一，这是因为对致病因素采取了积极干预的结果。
相反，中国从来不把注意力放在医疗正事上，政府整天跟着中医瞎吆喝。到了美
国心血管病明显减少的时代，中国迎来了心脑血管病对公共卫生的重大冲击。

　　Achievements in Public Health, 1900-1999: Decline in Deaths from
Heart Disease and Stroke -- United States, 1900-1999
　　Heart disease has been the leading cause of death in the United
States since 1921, and stroke has been the third leading cause since
1938 (1); together they account for approximately 40% of all deaths.
Since 1950, age-adjusted death rates from cardiovascular disease (CVD)
have declined 60%, representing one of the most important public
health achievements of the 20th century. This report summarizes the
temporal trends in CVD, advances in the understanding of risk factors
for CVD, development of prevention interventions to reduce these risks,
and improvements in therapy for persons who develop CVD.

　　心血管疾病死亡率从1950年的每10万人有307.4人下降到1996年的每10万人
有134.6人。降幅56%。各种心血管病中，冠心病是主要死因，直到1960年以后才
开始下降。和1963年比，直到1996年冠心病比预估值总共少死了621,000人。

　　Decline in CVD Death Rates
　　Age-adjusted death rates per 100,000 persons (standardized to the
1940 U.S. population) for diseases of the heart (i.e., coronary heart
disease, hypertensive heart disease, and rheumatic heart disease) have
decreased from a peak of 307.4 in 1950 to 134.6 in 1996, an overall
decline of 56% (1) (Figure 1). Age-adjusted death rates for coronary
heart disease (the major xxxx of CVD contributing to mortality)
continued to increase into the 1960s, then declined. In 1996, 621,000
fewer deaths occurred from coronary heart disease than would have been
expected had the rate remained at its 1963 peak (1).

　　和1950年代比，中风（脑血管病）死亡已经下降了70%。从1950年的每10万
人有88.8人降到1996年的每10万人有26.5人。

　　Age-adjusted death rates for stroke have declined steadily since
the beginning of the century. Since 1950, stroke rates have declined
70%, from 88.8 in 1950 to 26.5 in 1996. Total age-adjusted CVD death
rates have declined 60% since 1950 and accounted for approximately 73%
of the decline in all causes of deaths during the same period (1).

　　美国流行病学的历程（也就是中医说的治未病）
　　Disease Epidemiology

　　二战后，美国在1940年代大大加强了心血管病的流行病学研究。最著名的有
两个研究，Ancel Keys 和Frammingham Heart Study。通过这些研究，发现了心
血管病的主要致病因素 the major risk factors：1。高胆固醇，2。高血压，3。
抽烟，4。饮食中胆固醇，脂肪，和钠盐含量高。也发现了其它重要致病因素
other important factors：1。贫富，2。肥胖，3。少运动。这些因素涉及到生
物生态，生活方式，文化，社会状况（条件），环境等等多方面内容。

　　Intensive investigation into the CVD epidemic largely began in the
1940s following World War II, although causal hypotheses about CVD and
recognition of geographic differences in disease rates occurred
earlier (2-4). Landmark epidemiologic investigations, including the
cross-country comparisons of Ancel Keys (5) (see box) and the
Framingham Heart Study (6), established the major risk factors of high
blood cholesterol, high blood pressure, and smoking and dietary
factors (particularly dietary cholesterol, fat, and sodium). The risk
factor concept--that particular biologic, lifestyle, and social
conditions were associated with increased risk for disease--developed
out of CVD epidemiology (3,4). In addition to the major risk factors
(i.e., high blood pressure, high blood cholesterol, and smoking),
other important factors include socioeconomic status, obesity, and
physical inactivity (7). Striking regional differences were noted
particularly for stroke mortality, with the highest rates observed in
the southeastern United States (1). Cross-national and cross-cultural
studies highlighted the importance of social, cultural, and
environmental factors in the development of CVD.

　　预防
　　Advances in Prevention

　　40年代调查，50年代确认，（大众教育已经开始了），60年代开始实验性干
扰心血管病的各种致病因素，看看能不能把心血管病的发病率和死亡率减低下来。
70年代和80年代，无数临床实验确定了抗高血压药和降血脂药的预防心血管疾病
的作用。其它公共健康事业的努力不仅减少了个人患心血管疾病的危险，同时也
减少了群体患心血管疾病的危险，比如禁止抽烟，大幅度提高烟税和烟价，减少
抽烟人数。减少精神压力。国家加强对医务人员，病人和普通民众的教育。

　　Early intervention studies in the 1960s sought to establish
whether lowering risk factor levels would reduce risk for CVD (2-4).
During the 1970s and 1980s, along with numerous clinical trials
demonstrating the efficacy of antihypertensive and lipid-lowering drugs,
community trials sought to reduce risk at the community level (9).
Public health interventions to reduce CVD have benefited from a
combination of the "high risk" approach--aimed at persons with
increased risk for CVD--and the population-wide approach--aimed at
lowering risk for the entire community (10). National programs that
combine these complementary approaches and that are aimed at
health-care providers, patients, and the general public include the
National High Blood Pressure
　　Education Program (11), initiated in 1972, and the National
Cholesterol Education Program, initiated in 1985 (12).

　　以前国家的目标集中在心血管脑血管疾病，1989年开始展开慢性疾病的预防
和教育。
　　Although earlier CDC community demonstration projects focused on
cardiovascular health (9), CDC established its National Center for
Chronic Disease Prevention and Health Promotion in 1989, with a high
priority of promoting cardiovascular health.

　　哪些工作对心血管病死亡率下降起到作用？
　　Factors Contributing to the Decline in CVD Deaths

　　（见前表）减少抽烟人数。减少抽烟也同时减少癌症的发生率。降低血压。
更多的高血压得到控制。降低血中胆固醇。改变饮食成分。
　　Reasons for the declines in heart disease and stroke may vary by
period and across region or socioeconomic groups (e.g., age, sex, and
racial/ethnic groups). Prevention efforts and improvements in early
detection, treatment, and care have resulted in a number of beneficial
trends (Table 1), which may have contributed to declines in heart
disease and stroke. These trends include

　　a decline in cigarette smoking among adults aged greater than or
equal to 18 years from approximately 42% in 1965 to 25% in 1995 (13).
Substantial public health efforts to reduce tobacco use began soon
after recognition of the association between smoking and CVD and
between smoking and cancer and the first Surgeon General's report on
smoking and health published in 1964.
　　a decrease in mean blood pressure levels in the U.S. population
(11,13,14).
　　an increase in the percentage of persons with hypertension who
have the condition treated and controlled (11,13,14).
　　a decrease in mean blood cholesterol levels (12-14).
　　changes in the U.S. diet. Data based on surveys of food supply
suggest that consumption of saturated fat and cholesterol has
decreased since 1909 (15). Data from the National Health and Nutrition
Examination surveys suggest that decreases in the percentage of
calories from dietary fat and the levels of dietary cholesterol
coincide with decreases in blood cholesterol levels (16).

　　改进诊断和治疗心血管病和脑血管病的技术。开发更好的更有效的药物。培
养更多这方面的医务人员。加强心肌梗死和中风的急症治疗。增加急症治疗（医
院）单位。
　　improvements in medical care, including advances in diagnosing and
treating heart disease and stroke, development of effective
medications for treatment of hypertension and hypercholesterolemia,
greater numbers of specialists and health-care providers focusing on
CVD, an increase in emergency medical services for heart attack and
stroke, and an increase in coronary-care units (13,17). These
developments have contributed to lower case-fatality rates, lengthened
survival times, and shorter hospital stays for persons with CVD (1,17).

　　21世纪美国面临的心血管疾病问题
　　Challenges for the 21st Century

　　发现了心血管和脑血管病有种族，性别，贫富，地区之间的差异。（后略）
　　70%的高血压病人的血压没有降到标准值，140/90。中风病人的死亡率不再
下降了（1998年报告）。老人多了，心肌梗死后人死的少了，造成心衰病人多了。
美国肥胖的人数在增加。

　　Although many trends have been positive, trends for some important
indicators have not improved substantially, have leveled off, or are
reversing. For example, approximately 70% of persons with hypertension
do not have the condition controlled at levels below 140/90 mm Hg, and
death rates for stroke have not declined in recent years (1,11,13).
Heart failure has emerged as a health concern for older adults (20),
and adults who survive a myocardial infarction or other
hypertension-related diseases remain at increased risk for heart
failure. In addition, the pr????ence of obesity has increased among
both children and adults in the United States (13).

　　面向21世纪
　　Major public health challenges for the 21st century include

　　美国需要：继续减少和预防致病因素。进一步研究和发现心血管病的社会，
精神病学，环境，生理学，和遗传学因素。（王澄注：这就是中医说的天人合
一。）重视发病率高的种族群体。减少中风死亡率。对相对缺医少药的地区和人
群要加强指导和教育。促进对人民健康（行为）有利的政策和环境法规出台。确
定遗传和心血管疾病的关系，特别是遗传和环境之间的相互作用。今后遗传（和
环境）的因素的研究会越来越重要。因为癌症和心血管疾病都有两大原因，环境
和遗传。当一个有钱且负责的政府尽力把环境因素减到最小的时候，比如饮食饮
水卫生，饮食结构合理，减少环境污染等等，人类的遗传因素就越来越凸现了。

　　发现和确定新的因素，比如homocyst(e)ine, fibrinogen, and C-reactive
protein, and infectious agents such as Helicobacter pylori and
Chlamydia pneumoniae. 面对人口老化和心血管病存活的人增加，功能障碍和生
活品质问题越来越突出。防止已有心血管病的病人病情恶化。国际合作，心血管
病在发达国家人口中比例高，但是在发展中国家病人人数多。和发达国家比，发
展中国家还多了一个困难，就是感染性疾病。比如，中国2006年报告了174506例
梅毒病例。

　　reducing risk factor levels and preventing the development of
adverse risk factors. Continued research is needed to understand the
determinants (social, psychological, environmental, physiologic, and
genetic) of CVD risk factors.
　　reducing the racial/ethnic disparities in heart disease and stroke
mortality.
　　increasing the ability to reach underserved groups with
appropriate and effective public health messages.
　　promoting policy and environmental strategies that enhance healthy
behavior.
　　determining the relation between genetics and disease. The
associations of genetic variants with CVD, and especially the
interplay between genetic and environmental factors, may play
increasingly important roles in the nation's efforts to prevent CVD.
　　identifying new or emerging risk factors and determining their
potential for public health intervention. New or emerging risk factors
that have been associated with CVD include elevated levels of total
homocyst(e)ine, fibrinogen, and C-reactive protein, and infectious
agents such as Helicobacter pylori and Chlamydia pneumoniae.
　　focusing on secondary prevention and disability. An aging U.S.
population and an increasing number of persons surviving
life-threatening cardiovascular conditions requires public health
programs to focus on issues such as disability and quality of life.
Persons with existing cardiovascular conditions are at increased risk
for future life-threatening events related to those conditions.
　　addressing the needs of the global community. Although CVD death
rates are higher in developed nations, most cases occur in developing
nations (8). Developing countries may face a double burden of
infectious and chronic diseases. International collaboration to
improve cardiovascular health (9) will need to continue to reduce the
burden of CVD worldwide.
　　Reported by: Cardiovascular Health Br, Div of Adult and Community
Health, National Center for Chronic Disease Prevention and Health
Promotion, CDC.

　　参考文献（略）