Cardiovascular Disease Prevention in the 21st Century Heart disease and stroke have been the first and third leading causes of death in the United States since 1921 and 1938, respectively. Preliminary data from 2009 indicate that stroke is now the fourth leading cause of death in the United States. During the past decade, the age-adjusted coronary heart disease and stroke death rates declined from 195 to 126 per 100,000 population and from 61.6 to 42.2 per 100,000 population, respectively, continuing a trend that started in the 19003 for stroke and in the 19605 for coronary heart disease. Factors contributing to these reductions include declines in the prevalence of cardiovascular risk factors such as uncontrolled hypertension, elevated cholesterol, and smoking, and improvements in treatments, medications, and quality of care