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Cardiovascular disease (CVD; ICD 'Diseases of the circulatory system') includes all diseases and conditions that affect the heart and blood vessels . CVD presents a significant burden for Aboriginal and Torres Strait Islander people in terms of prevalence, hospitalisation, and mortality . Coronary heart disease (or ischaemic heart disease), cerebrovascular disease (including stroke), hypertension (high blood pressure), and rheumatic heart disease (RHD) are of particular importance to Indigenous people.
Most types of CVD (excluding RHD) are subject to the same set of modifiable or non-modifiable risk factors . Modifiable behavioural factors for CVD include tobacco use, physical inactivity, dietary behaviour, and excessive alcohol consumption . Modifiable biomedical factors include hypertension, high blood cholesterol, overweight and obesity, and depression. Certain related health conditions, particularly diabetes and chronic kidney disease, can also increase the risk of developing CVD. Non-modifiable risk factors that can influence the risk of CVD include, age, sex, family history, and ethnicity.
Unlike other types of CVD, RHD occurs when acute rheumatic fever (ARF)—an illness that affects the heart, joints, brain and skin—leads to permanent damage to the heart valves . ARF, which is rare among non-Indigenous Australians, is caused by an untreated bacterial (group A streptococci or GAS) throat infection.1 Reducing ARF and RHD in Indigenous communities will require initiatives that address poverty, overcrowded housing and poor sanitation, all of which contribute to the spread of GAS infection.
The persistence of ARF in Indigenous communities highlights the impact of social determinants of health that underpin RHD  and CVD more broadly.2 As with other areas of Indigenous health, reducing the burden of CVD will require efforts to address the social, economic and environmental inequities that Indigenous people experience.
Around 13% of Indigenous people aged 2 years and over reported in the 2012-2013 Australian Aboriginal and Torres Strait Islander health survey (AATSIHS) that they had some form of CVD . When the data for Torres Strait Islander people3 and Aboriginal people4 were analysed separately, the levels of CVD were similar (12% and 13% respectively) .
CVD was reported more frequently by Indigenous females (14%) than by Indigenous males (11%) . After age-adjustment, CVD was reported 1.2 times more frequently by Indigenous people than by non-Indigenous people. CVD increased with age for both Indigenous and non-Indigenous people; the prevalence was higher for Indigenous people than for non-Indigenous people in all age-groups except those aged 55 years or older (Figure 2) . Indigenous people living in remote areas (18%) were more likely to report having heart disease than those living in non-remote areas (11%) .
Figure 2. Prevalence (%) of people reporting cardiovascular disease as a long-term health condition, by Indigenous status and age-group, Australia, 2012-2013
Hypertensive heart disease was the form of CVD most commonly reported by Indigenous people (5.8%) in 2012-2013 . After age-adjustment, the level of hypertensive heart disease among Indigenous people was similar to that among non-Indigenous people (Table 18). The greatest disparities between Indigenous and non-Indigenous males and females for age-adjusted rate ratios (1.5 and 1.7 respectively) were for ‘Heart, stroke and vascular diseases’, which include ischaemic and cerebrovascular diseases and heart failure.
|Cardiovascular disease type||Males||Females|
|Source: ABS 2014 |
|Hypertensive heart disease||5.6||1.0||6.0||1.1|
|Heart, stroke and vascular diseases||4.0||1.5||3.8||1.7|
|All cardiovascular disease||11.1||1.2||14.2||1.3|
Around 4% of Indigenous people (2.8%5 of Torres Strait Islander people and 4.0% of Aboriginal people ) reported that they had ‘heart, stroke and/or vascular diseases’ in 2012-2013 . Heart disease, stroke and/or vascular diseases were reported in almost the same proportions by Indigenous males and females (4.0% and 3.8% respectively) . These diseases were prevalent from about 35 years of age onwards; 4% of Indigenous people aged 35-44 years reported heart, stroke and/or vascular disease, compared with 10% of those aged 45-54 years and 20% of those aged 55 years and over .
Around 6% of Indigenous people (5.3% of Torres Strait Islander people and 5.8% of Aboriginal people ) reported that they had hypertensive heart disease . Hypertensive heart disease was reported in almost the same proportions by Indigenous males and females (5.6% and 6.0% respectively) . Hypertensive disease increased in prevalence from about 25 years of age onwards; 12% of Indigenous people aged 25 years and over reported hypertensive heart disease  with rates ranging from 4% of those aged 25-34 years to 25% of those aged 55 years and over .
The 2012-13 AATSIHS also provides data for selected risk factors for CVD . These self-reported results are supplemented—for the first time—by biomedical results obtained from a subset of Indigenous adults (18 years and over) who provided blood and urine samples . The self-reported  and biomedical results  show that various CVD risk factors are more prevalent among Indigenous people than among their non-Indigenous counterparts, including: daily smoking (rate ratio 2.66); obesity (rate ratio 1.66); inadequate daily fruit and vegetable intake (rate ratios 0.9 and 0.8 respectively for meeting the guidelines6); high blood pressure (rate ratio 1.2); abnormal high density lipoprotein (HDL) cholesterol (rate ratio 1.87); high triglycerides (rate ratio 1.97); and dyslipidaemia (rate ratio 1.17).
Jurisdictional data for the prevalence of RHD and the incidence of ARF are currently only available from the NT, Qld and WA Rheumatic Heart Disease Registers . It is not possible to directly compare data from these registers8 but, despite low rates of RHD and ARF in Australia, it is clear that these diseases are disproportionately represented in the Indigenous population.
Of the recorded cases of RHD in the NT (1,479 at 31 December 2010), Qld (939 at 27 August 2012) and WA (158 at 30 June 2011), 93%, 90% and 100% respectively were Indigenous people . More details are available for the NT where, after age-adjustment, the prevalence of RHD among Indigenous Australians was 26 times that among other Australians. Two-thirds (66%) of the people with RHD were females and around one-third (34%) were males . After age-adjustment, the prevalence of RHD was 36 times higher among Indigenous males living in the Top End, and 13 times higher among those living in the Central Australia part of the NT, than the prevalence among non-Indigenous males. The age-adjusted prevalence of RHD was 28 times higher among Indigenous females living in the NT Top End, and 17 times higher among those living in the Central Australia part of the NT, than the prevalence among non-Indigenous females. The prevalence of RHD in Indigenous people was highest in the 45-54 years age-group (3.6%). The greatest disparities in Indigenous:non-Indigenous RHD prevalence ratios were in the 15-24 years and 25-34 years age-groups (120 and 131 respectively).
Of the recorded cases of ARF in the NT (317 from 2005-2010), Qld (178 from 2009-2011) and WA (21 from 2010-11), 98%, 90% and 100% respectively were of Indigenous people . More details are available for the NT in the period 2007-2010 when 221 of 226 new and recurrent cases of ARF were identified as Indigenous people . As is the case for RHD, the majority of cases among Indigenous people were for females (63% female compared with 37% male). After age-adjustment, the rate of 0.8 cases per 1,000 population for Indigenous females was 75 times higher than for non-Indigenous females. The rate of 0.4 per 1,000 for Indigenous males was 70 times higher than for non-Indigenous males. The numbers and rates of new and recurrent cases of ARF were highest in the 5-14 years age-group for both Indigenous females (81 cases; 2.8 per 1,000) and Indigenous males (54 cases; 1.8 per 1,000). The incidence of ARF was the same for Indigenous people living in the Central Australia part of the NT and the NT Top End (0.6 per 1,000). The incidence rate for Indigenous females living in the Central Australia part of the NT (0.9 per 1,000) was slightly higher than for their NT Top End counterparts (0.7 per 1,000).
There were 11,588 hospital separations for diseases of the circulatory system among Indigenous people in 2012-13, accounting for 3.0% of separations identified as Indigenous . After age-adjustment, hospitalisation rates for circulatory disease were 1.6 times higher for Indigenous people than for non-Indigenous people . The hospitalisation rates for various types of circulatory disease were also consistently higher among Indigenous people than among their non-Indigenous counterparts with the following rate ratios: 2.2 for ischaemic heart disease, 1.7 for stroke, 2.5 for hypertension and 3.7 for RHD. Both Indigenous males and females had consistently higher rates for ischaemic heart disease, stroke, hypertension and RHD than their non-Indigenous counterparts, but the rate ratios were greater for females (with 1.8, 1.5, 2.3 and 2.4 for males compared with 3.0, 1.8, 2.6 and 4.7 for females).
Between 2007-08 and 2009-2010 in NSW, Vic, Qld, WA, SA and the NT9 there were 1,065 hospitalisations of Indigenous people with RHD/ARF10 . After age-adjustment, the hospitalisation rate for Indigenous people was 67 per 100,000, 6.7 times the rate for non-Indigenous people.
CVD was the leading cause of death of Indigenous people in 2012, being responsible for 25% (621) of the deaths of people identified as Indigenous living in NSW, Qld, WA, SA and the NT . After age-adjustment, deaths from diseases of the circulatory system were 1.6 times more common for Indigenous people than for non-Indigenous people .
Of the various types of circulatory diseases, ischaemic heart diseases11 were the leading cause of death for Indigenous people (338 deaths) in 2012, followed by cerebrovascular diseases12 (108 deaths) . Ischaemic heart diseases were also the overall leading cause of death for Indigenous people, accounting for almost 14% of all deaths. After age-adjustment, deaths from ischaemic heart diseases and cerebrovascular diseases were about twice as high for Indigenous people than for non-Indigenous people (2.1 and 1.5 times respectively). There were more deaths from ischaemic heart diseases among Indigenous males (217) than among Indigenous females (121), but more Indigenous females died from cerebrovascular diseases than Indigenous males (65 compared with 43). Indigenous males were more likely to die from ischaemic heart diseases and cerebrovascular diseases than non-Indigenous males (2.3 and 1.6 times respectively) and Indigenous females were more likely to die from these diseases than non-Indigenous females (1.9 and 1.5 times respectively).
Despite disproportionately high death rates for ischaemic heart diseases (also known as coronary heart disease—CHD) among Indigenous people, recent analysis reveals an improvement in the overall CHD mortality gap between 2001-2002 and 2009-2010 . This is due in large part to greater declines in CHD mortality among Indigenous women, particularly those in the age groups 40-54 years and 70 years and over.
Avoidable mortality data (mortality data associated with potentially preventable and treatable conditions for people aged less than 75 years) is available for the period 2008-2012 for Indigenous people in NSW, Qld, WA, SA and the NT . There were 92 potentially avoidable deaths from rheumatic and other valvular heart disease among Indigenous people in this period. After age-adjustment, potentially avoidable deaths from rheumatic and other valvular heart disease were 12.4 times more common for Indigenous people than for non-Indigenous people.
For the period 2006-2010, RHD alone was responsible for the deaths of 90 Indigenous people in NSW, Qld, WA, SA and the NT . The age-adjusted death rate for Indigenous people was 4.7 times that of non-Indigenous people. Both Indigenous males and females were more likely to die from RHD than their non-Indigenous counterparts (3.5 and 5.3 times respectively).
The striking difference between Indigenous people and non-Indigenous people in CVD mortality is the much greater impact among young and middle-aged Indigenous adults. In 2009-2010 in NSW, Qld, WA, SA and the NT, the death rates for CHD (the leading cause of CVD-related deaths) were 7 to 13 times higher for Indigenous men and women in the 25-39 years and 40-54 years age-groups than the rates for their non-Indigenous counterparts .