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Issue: June 2021
Source: Virani SS, et al. Circulation. 2021;doi:10.1161/CIR.0000000000000950.
Disclosures: Breathett reports she received support from the NHLBI and Women as One. Poppas reports she is a guest editor-in-chief for JACC. Ferdinand, Itchhaporia and Virani report no relevant financial disclosures.
June 17, 2021
11 min read

Discouraging CVD trends highlight need to ‘stem the tide,’ focus on reducing disparities

Issue: June 2021
Source: Virani SS, et al. Circulation. 2021;doi:10.1161/CIR.0000000000000950.
Disclosures: Breathett reports she received support from the NHLBI and Women as One. Poppas reports she is a guest editor-in-chief for JACC. Ferdinand, Itchhaporia and Virani report no relevant financial disclosures.
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Heart disease remains the leading cause of death globally, according to recent statistics, putting the spotlight on prevention and eliminating race and sex disparities.

According to the American Heart Association Heart Disease and Stroke Statistics 2021 Update, nearly 18.6 million people worldwide died from CVD in 2019, an increase of 17.1% in the past decade. Moreover, 523.2 million people had CVD in 2019, up 26.6% from 2010.

Although the AHA’s 2021 Update compiled statistics from before the COVID-19 pandemic, the authors said they believe the pandemic will make the CVD numbers worse in the coming years.

In 2020, COVID-19 was the third leading cause of death in the United States, after CVD and cancer, with heart disease again in the No. 1 spot, according to provisional data released by the CDC in late March.

According the CDC, there were 370,000 deaths from COVID-19 in 2020, “but we have other data showing that, throughout 2020, CVD-related deaths and deaths related to diabetes have all gone up during the pandemic year,” Salim S. Virani, MD, MPH, FAHA, professor of medicine and cardiology at Baylor College of Medicine, staff cardiologist at the Michael E. DeBakey VA Medical Center and chair of the AHA 2021 Update writing committee, told Cardiology Today.

The discouraging trends highlight the need for a focus on primordial prevention, closing the disparity gap for historically underrepresented individuals, and reinforcing patient education using new tools and innovations brought about from necessity during the COVID-19 pandemic, experts told Cardiology Today.

“We need to start looking at primordial prevention, rather than primary and secondary prevention. We need to take our initiatives to kids early on in their lives. That is the No. 1 priority,” Virani said. “Second is looking at our investment in not just in CVD, but as a country, in health care and understanding what is our return on investment. Where are the inefficiencies? Third is looking at how care is delivered in our country. We need to go where our patients are, which is in the community. There are few initiatives in our country that do wellness-related activities for the community, as part of our regular health care spending. We do not have a robust strategy for community engagement as part of our regular health care spending.”

Up-to-date statistics on heart disease

Published in Circulation, the AHA’s 2021 Update overviews decades of population research in CV events and mortality, and includes information on prevalence of specific CVDs, risk factors and identifies at-risk subgroups.

As in previous years, the authors report high rates of obesity and diabetes and a lack of physical activity in the United States.

Among U.S. adults aged at least 20 years, the adjusted prevalence of obesity was 40% among men and 41% among women. An estimated 26 million U.S. adults have a diagnosis of diabetes, and nearly 92 million have prediabetes. Only 24% of U.S. adults report meeting the U.S. recommendations for physical activity each day.

The European Society of Cardiology: Cardiovascular Disease Statistics 2019 report, published in January in European Heart Journal, paints a similar picture and describes a threefold increase in the prevalence of obesity and diabetes across 56 European countries over a 30-year period.

Although the prevalence of smoking has consistently declined in the past 3 decades, the ESC report projects that the WHO 2025 targets for hypertension, alcohol consumption, obesity and diabetes will be missed.

Keith C. Ferdinand

“We would hope that we not accept the rise in obesity and diabetes, persistent levels of hypertension and poor BP control, especially across racial and ethnic minorities as inexorable,” Cardiology Today Editorial Board Member Keith C. Ferdinand, MD, FACC, FAHA, FASPC, Gerald S. Berenson Chair in Preventive Cardiology and professor of medicine at Tulane University School of Medicine, said in an interview. “These findings of increasing heart disease burden should energize the CV community to work together to stem the tide of the increase in burden of CV mortality, which has been reported on both sides of the Atlantic.”

Promoting childhood CV health

Approximately 20.6% of children aged 12 to 16 years have obesity; one-quarter have a chronic condition; and approximately 31.2% of high school students use a tobacco product, according to CDC statistics.

As reported in the AHA statistical update, the overall prevalence of obesity among youth aged 2 to 19 years was 19% based on data from the National Health and Nutrition Examination Survey 2015-2018. E-cigarette use among adolescents increased from 1.5% in 2011 to 27.4% in 2019, with e-cigarettes now the most-used tobacco product by adolescents.

The prevalence of elevated BP and hypertension decreased from 16.2% in 2003-2004 to 13.3% in 2015-2016 among children and adolescents aged 8 to 17 years.

“We need to move from cardiovascular disease to cardiovascular health,” Virani said. “We know that CVD starts at an early phase in one’s life, even in kids. What we need to do is take these interventions that we currently have to our children. We need to take them to schools, and we need to change our mindset whereby we’re not treating CVD-related risk factors when they appear, [but we] move toward primordial prevention early on in life.”

In a study published in JAMA in 2020, The Healthy, Hunger-Free Kids Act of 2010 improved dietary quality of school lunches among presumed low-income, low-middle-income and middle-high-income students in kindergarten through grade 12.

“There was an effort by a previous presidential administration to modify the amount of saturated fats and sodium in school lunches,” Ferdinand told Cardiology Today. “These efforts need to be refigured later since Gerald S. Berenson, MD, with the Bogalusa Heart Study, identified decades ago that cardiometabolic risk, including diabetes, high cholesterol and elevated BP, are not manifestations of adulthood, but actually start in preteen and adolescent periods, with higher risk seen, especially related to BP in self-identified Black youth, even prior to adulthood.”

In a study published in Circulation, individuals who met at least five of the AHA’s Life’s Simple 7 metrics of CV health (smoking cessation, healthier diet, more physical activity, weight loss, controlled BP, controlled cholesterol and low blood sugar) had greatly reduced risk for all-cause mortality (adjusted HR = 0.22; 95% CI, 0.1-0.5) and CV mortality (aHR = 0.12; 95% CI, 0.03-0.57) compared with those who met none of the metrics.

“Major priorities in the battle against CVD include prevention and control of risk factors. Among U.S. adults, trends reveal improvement in tobacco cessation, where 80% of the population does not use tobacco compared to approximately 75% in the past decade,”

Khadijah Breathett

Khadijah Breathett, MD, MS, FACC, FAHA, FHFSA, assistant professor of medicine in the division of cardiology at the University of Arizona in Tucson, advanced heart failure and transplant cardiologist at Banner – University Medical Center in Tucson, told Cardiology Today. “No racial or ethnic population has more than 60% of their population achieve ideal control of the other six risk factors. The least controlled risk factor is nutrition, of which no more than 5% of any racial or ethnic group have ideal control.

“Fortunately, ideal CVD health among U.S. youth is better than among adults for most risk factors, but nutrition is also poor,” Breathett said. “Almost no U.S. racial or ethnic group achieves ideal nutrition in youth. Additional interventions are needed to change the trajectory for both adult and youth populations.”

Eliminating sex, race disparities

The recent statistics spotlight age-, sex- and race-specific variation in the prevalence of CVD and risk factors, particularly HF in Black adults and chronic hypertension in Black women.

Disparities highlighted in the most recent AHA report include a higher prevalence of extreme obesity in women (10.5% vs. 6.2%) and a higher prevalence of HF among women compared with men aged at least 80 years.

There are also gaps in hypertension, with large increases in hypertension awareness, treatment and control within each race/ethnicity and sex subgroup except for Black women in the NHANES 1999-2002, 2007-2010 and 2015-2018 surveys. Levels of hypertension awareness, treatment and control among Black women increased from 1999-2002 and 2007-2010, but decreased from 2007-2010 and 2015-2018, according to the AHA update.

“The Southern diet — traditionally high-in-sodium fried foods, high-fat dairy products and sugar-sweetened beverages — may be one of the links with the increase in hypertension, morbidity and mortality and overall CVD, especially in Black individuals,” Ferdinand told Cardiology Today. “Therefore, although devices and other interventions remain lifesaving for specific patients, population burden of disease will never be optimally controlled without addressing the environmental factors related to fluid intake, physical activity and access to appropriate prevention.”

Efforts to address some racial disparities in hypertension at a community level are underway, including pharmacist-led interventions in barbershops to reach Black men and initiatives in churches.

“The data that there are continued health disparities is concerning,”

Athena Poppas

Athena Poppas, MD, FACC, director of the Lifespan Cardiovascular Institute in Providence, Rhode Island; chief of cardiology and professor of medicine at the Warren Alpert School of Medicine at Brown University; and immediate past president of the ACC, told Cardiology Today. “We saw that people from historically underrepresented groups and people with lower socioeconomic status had worse health outcomes amid the COVID-19 pandemic and that is a harbinger of the CV risk factors and the mortality there. What is equally alarming is that the 30-day, 1-year and 5-year mortality for women is higher compared with men; it’s higher for Black men compared with white men; and it is higher for Black women compared with Black men, a dramatic difference.”

Adverse pregnancy outcomes

New in the AHA 2021 Update is statistics on adverse pregnancy outcomes, which are known to increase the risk for CVD in mothers and their babies. Pregnancy complications including hypertensive disorders, gestational diabetes, preterm births and small for gestational age at birth deliveries occur in 10% to 20% of all pregnancies in the U.S. CV deaths are the most common cause (26.5%) of maternal death in the U.S.

Risk for adverse pregnancy outcomes is greater among those with higher prepregnancy BMI levels and greater degrees of gestational weight gain.

“An interesting part of the AHA 2021 statistical update was the fact that they included the adverse pregnancy outcomes, which occur in 10% to 20% of pregnancies,” Cardiology Today Editorial Board Member Dipti Itchhaporia, MD, FACC, FESC, president of the ACC; the Eric & Sheila Samson Endowed Chair in Cardiovascular Health and director of disease management for Jeffrey M. Carlton Heart and Vascular Institute at Hoag Memorial Hospital, Newport Beach, California; and assistant clinical professor of medicine at University of California, Irvine, said in an interview. “We need to routinely evaluate their history of pregnancy outcomes because that can potentially tell us about future cardiac events. We know that gestational hypertension is associated with a 67% higher risk of subsequent CVD. If they had preeclampsia, there was a 75% higher risk of subsequent CV-related mortality, and that’s significant.”

Dipti Itchhaporia

COVID-19 and CV health

Experts predict the global burden of CVD will grow exponentially over the next few years as the long-term effects of the current COVID-19 pandemic evolve.

“Research is showing that the unique coronavirus can cause damage to the heart. Importantly, we also know people have delayed getting care for heart attacks and strokes, which can result in poorer outcomes,” Virani said in a press release.

An even more critical issue, he said, will be the CV health risks that are exacerbated by poor lifestyle behaviors that were prevalent throughout the pandemic, including unhealthy eating habits, increased consumption of alcohol, lack of physical activity, and the mental toll of isolation and fear, which can all adversely impact risk for CV health.

“We’ll need to watch and address these trends as the full ramifications will likely be felt for many years to come,” he said.

In a commentary published in April in Circulation, Robert M. Califf, MD, MACC, former FDA commissioner and head of strategy and policy for Verily Life Sciences and Google Health, wrote that there is an oncoming “wave of death and disability due to common chronic diseases, with cardiometabolic diseases at the crest” following the acute phase of the pandemic.

“It is imperative now that we take noncommunicable diseases like CVD very seriously, because there is this big concern that when we’re done with the pandemic, the gains that we had made in the last decade may be lost and deaths from CVD may go up because of what this pandemic has done to our diet; to our physical activity levels; to our mental health; and to our increasing substance abuse.”

Robert M. Califf

Identifying those at risk for CV events during the pandemic remained a barrier to care; however, widespread advances in telehealth during the pandemic meant clinicians could safely reach patients to monitor and manage their treatments and care.

“During the pandemic, one thing that was surprising was the effectiveness of telehealth — something that we were optimistically cautious about, previously,” Itchhaporia told Cardiology Today. “We found that we were able to provide care at home and we recognize that this may be a good way to improve access to care. For people with transportation issues or people who physically cannot come into a clinic setting to be seen, it has pushed us forward toward that digital transformation that we needed to have. We recognize that maybe innovation is how we’re going to overcome issues in health equity.”

Future directions

Awareness, education and spreading the message of importance of prevention of CVD is of paramount importance, experts told Cardiology Today.

“We need to be able to focus on reducing noncommunicable diseases, not only in the U.S., but globally,” Poppas said in an interview. “Health policy that expands access to care is crucial.”

In addition to illuminating the inequities faced by historically underrepresented populations, the AHA update provided a roadmap to the areas and people where future research efforts and clinical trials are most needed.

“We know which interventions work. The problem is implementing the evidence-based interventions in real-life society,” Breathett told Cardiology Today. “I believe that systematically tackling these issues through health policies, institutional commitment, reallocation of resources, diversification of the workforce and promotion of anti-racist changes will move our country closer to CV health equity.”

Managing CV risk factors where they begin with targeted primordial prevention, community-based interventions and patient education may be the cumulative key reversing the discouraging trends in CVD morbidity and mortality reported in the AHA and ESC updates and other research.

“As part of the community, we as cardiologists can be the spokespersons toward primordial prevention,” Virani said in an interview. “We can all be active players in our communities. We need to expand our horizon to reach out to our primary care and family practice colleagues and the communities where we live to be a part of those wellness initiatives.

“Of course, there is a need for us as a nation to invest more in community-

based research. Areas where people do not have to come to the clinic or the hospital to be part of a study,” Virani told Cardiology Today. “What can we do in terms of behavioral interventions? What are good practices that we can learn and then take to the communities at large and make an impact. Those are things that as a cardiology community we could do better.”