It was a dramatic call to action by the American Heart Association: The organization declared its decade-long goal culminating in 2020 was to slash deaths from cardiovascular disease and stroke by 20%. It also promised in its scientific journal to move all Americans toward “ideal cardiovascular health.”
That never happened. Deaths did decrease by 15% from 2010, but it was a “disappointment” that fatalities linked to conditions like high blood pressure, heart failure, and atrial fibrillation were not falling more. As for ideal cardiovascular health? Fewer than 1 in 10 Americans qualify, other research reported.
Today, the AHA’s forecast for the next three decades is more chilling: Cardiovascular disease and the risk factors predicting them will mostly increase by 2050, worsened by deep racial and ethnic disparities and complicated by an aging population. Mortality will follow suit, keeping these diseases atop the leading causes of death.
How did we get here?
In a series of interviews with STAT, 11 cardiologists and other clinicians, including the FDA commissioner, said a crisis in primary care is dragging back progress in the nation’s cardiovascular health.
They noted that almost half of Americans have some type of cardiovascular disease. They are seeing conditions associated with older adults show up in younger patients, even adolescents — a trend shown to be accelerating in recent studies of heart failure, stroke, and hypertension.
“We’re going in the wrong direction for heart disease,” said Eric Topol, cardiologist and geneticist and director of the Scripps Research Translational Institute.
Similarly, “We’re losing ground,” said Food and Drug Administration Commissioner and cardiologist Robert Califf. Why? “I think the biggest single remediable issue for us is that we don’t have a primary care system in the U.S. that’s functional,” he said.
Health care providers are struggling to guide patients through multiple challenges. “If we are moving the obesity crisis, the liver crisis, and the diabetes crisis in the United States to younger ages, what we are observing right now is shifting the heart failure incidence curve to [a] younger age group,” said Marat Fudim, medical director for the Heart Failure Research Unit and Heart Failure Remote Monitoring at Duke University Medical Center.
On top of that, Covid-19 put the system and patients through a sort of stress test, highlighting racial, economic, and rural disadvantages. In the pandemic’s first year, more people died of cardiovascular-related causes than in any year since 2003. Deaths increased the most among Asian, Black, and Hispanic Americans, underscoring the uneven toll diseases take and identifying a clue to falling lifespans.
“Covid unmasked the underlying structural disease, accelerated underlying inflammation which leads to heart failure, and underlined and worsened socioeconomic things that might prevent you from seeking appropriate care, from losing weight or treating diabetes,” Fudim said.
The experts find the stumbles particularly galling because we know so much and have so many tools to prevent and treat heart disease, including underused hypertension medications and the buzzy new GLP-1 drugs.
“We have never before had such access to incredible treatments. At the same time, our life expectancy is falling,” Asaf Bitton, executive director of Ariadne Labs at Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health. “It’s a tragedy because we have the tools, the investments to extend life expectancy to improve people’s lives. We don’t have a health system that’s invested or constructed to do that.”
Nevertheless, the experts offered ideas for setting cardiovascular health back on an upward path. Some even expressed optimism, given previous progress.
Great strides, for a while
Back in 1924, a diagnosis of heart disease was as good as a death sentence. Research findings we may now take for granted — high blood pressure is a silent killer, for one — and the treatments built on them have lengthened lives that once would have been cut short by heart attack or stroke. Death rates have been cut in half for heart disease in the last 100 years and by one-third for stroke in the last 25 years.
We can thank medications to calm hypertension and cut artery-clogging cholesterol, now both cheap and widely available. Obesity is now recognized as a cardiovascular risk factor, one that new drugs can counter with once unfathomable power, albeit at a high price. Just one change in behavior — quitting smoking — shines as a public health success story after the surgeon general’s thunderclap report in 1964. Smoking rates have plunged since then by 40%, driving down lung cancer as well as cardiovascular illnesses.
The drop in cardiovascular illness started to slow over the last decade and then began trending upward over the last five years, in step with the rising prevalence of risk factors like high blood pressure and obesity linked to heart disease and stroke.
Sean Pinney, chief of cardiology at Mount Sinai Morningside in New York City, points out that the rising rates of heart failure, in which hearts can no longer pump well, mask a degree of progress.
“Heart failure is more prevalent now than it was in the past, and it’s more prevalent because of the successes of cardiovascular care, particularly around myocardial infarction and hypertension,” he said. “There are more baby boomers alive, and therefore there are more baby boomers who also have heart failure with preserved ejection fraction.”
But the consensus of the experts interviewed — including Pinney — is that heart disease is far higher than it should be given the tools we have. This is compounded by a disconnect that has formed in the public’s mind between threat and perception. This year, an American Heart Association survey revealed that just over half of Americans are unaware that heart disease remains the leading cause of death, outstripping cancer.
Nor are most people aware of the vulnerability of particular groups. “People don’t know that cardiovascular disease is actually the leading cause of mortality in pregnant or postpartum women,” said Janet Wei, assistant medical director of the Biomedical Imaging Research Institute at Cedars-Sinai Medical Center in Los Angeles.
If current trends continue, the heart association estimates, by 2050 at least 6 in 10 U.S. adults will live and die with cardiovascular disease of some type, reflecting an older population burdened by high blood pressure and obesity, despite what we know about those conditions predicting disease.
Pushing all the levers
The consensus of the experts interviewed by STAT: There’s no magic bullet to reverse the trend lines.
“People want to prolong aging, like David Sinclair and all these guys want to come up with miracle drugs for living. But if you stop and think about it, it’s very simple,” said Joseph Wu, past president of the American Heart Association and director of the Stanford Cardiovascular Institute.
He cited the AHA’s eight essential rules: Exercise, eat a healthy diet. Don’t smoke. Get plenty of sleep, get your weight under better control. Control your cholesterol, control your blood pressure so that you don’t get a heart attack or a stroke or kidney failure. And control your glucose. “That’s the best anti-aging lifestyle,” he said.
In other words, the best medicine is prevention, a path paved by better access to health care and starting with primary care providers.
“All of this is still a downstream consequence of the fundamental issue: how do we prevent heart disease?” Clyde Yancy, chief of cardiology at Northwestern University Feinberg School of Medicine, said about deaths from heart disease, which total about 1,905 deaths each day in the U.S. “We’re talking now about moving upstream and really addressing how we can change lifestyles at an earlier age.”
Wu noted that instilling healthy habits is hard for both doctors and patients.
“You could do all the basic research you want, but if you can’t implement it, it doesn’t translate to improved outcomes,” he said. “Patients themselves know that obesity is bad. Patients themselves know that high blood pressure, high cholesterol is bad, but they just don’t take on active participation until they’re sick.”
The experts differed in their enthusiasm for the new GLP-1 drugs like Wegovy and Zepbound, whose benefits are being shown to go beyond diabetes and weight loss.
“New therapies, particularly those ostensibly developed to effectuate blood sugar lowering, have a remarkable cardiac protective and cardiac therapeutic effect,” Yancy said of the GLP-1s.
U.S. biotech companies are pursuing more advanced solutions. Verve Therapeutics, for example, is working on gene therapies to edit out heart attacks for millions of people at risk from high cholesterol.
But other experts, citing the high cost and unequal access of the GLP-1s, pointed to older and cheaper medications. Renu Garg, a physician who is senior vice president for cardiovascular at the global public initiative Resolve to Save Lives, notes that hypertension is going untreated in 1.3 billion people globally and causes 10.7 million deaths per year. There are many inexpensive solutions, such as eliminating trans fats and introducing low-sodium salt.
“It’s a high burden and it’s amenable, so the impact is high. You don’t need a cardiologist to treat hypertension,” she said. “This has to be done close to communities by health workers who don’t have to be doctors who treat hypertension. And we’ve shown that that is possible.”
Another low-cost treatment would be a daily “polypill” that combines generic, low-dose medications for high blood pressure and cholesterol and possibly aspirin. The approach has been approved in other countries.
Califf, for one, thinks the polypill is worth consideration though he concedes there are hurdles. “It’s a logical thing that for the average person who doesn’t want to have to remember four pills, what if you just had one and they’re good clinical trials? I think it’s a viable clinical approach. It’s a complicated regulatory pathway in the U.S. to get there,” he said.
The patient component, of course, is crucial. Doctors have frustrations: Why is prevention a harder sell than a pill? Why do half the patients who start cholesterol-lowering drugs stop within a year? After a heart attack, why do people skip rehab intended to help them avoid another one?
As founding director of the Cardiovascular Disease Research Institute at Morehouse College and founding director of the Jackson Heart Study, Herman Taylor is deeply aware of how structural barriers have damaged the health of African Americans in particular. “You can get pretty discouraged when you begin to list data, like 1.6 million excess deaths among African Americans in the last 20 years, 35% of them to do with cardiovascular disease,” he said.
Yet Taylor is optimistic that great strides can be made to move Black and other patients to be healthier. “Some of our early work suggests that neighborhoods characterized by social cohesion and mutual activity among the neighbors are neighborhoods that showed a significantly higher rate of people having ideal cardiovascular health,” he said. He added: “I don’t think the remedy ultimately hinges on brand new discoveries. I think if we found a way to equitably distribute the fruits of American research to date, I think we can make an incredible change in our health outcomes and what people experience.”
Ann Marie Navar, a preventive cardiologist at UT Southwestern, emphasized that the conversation has to be bigger than the doctor’s office, encompassing the environment, the food industry, and more. “A lot of my patients don’t live in neighborhoods that have sidewalks, or they don’t live in neighborhoods where there is a park or a recreation center for people to be out at safely,” she said. “If we don’t give people access to the kind of spaces that they need to do the physical activity that we recommend, then I think we can’t be surprised when we don’t get those types of results.”
Fixing the system by tuning the incentives
Where does that leave us? Primary prevention through primary care may be the key, but making that work is far from simple.
Califf spoke wistfully of primary care models elsewhere where patients would have more support. “What differentiates other countries is that they have primary care clinics in neighborhoods so people can easily see their primary care clinician,” he said. “And often that’s a team that would include, let’s say, a doctor or a nurse and someone who’s sort of like a social worker who can actually visit people in their homes.”
Bitton, at Ariadne Labs, blames a systematic lack of investment in preventive systems that form the foundation of primary care. Paying more for acute care is “not a smart move,” he said.
Navar pointed to the sheer lack of primary care doctors. “We don’t have enough primary care doctors to see everybody, and that goes to reimbursement,” she said. “You can make a lot more money doing an MRI or a surgical procedure on a patient than you can doing a preventive wellness check. And so we shouldn’t be surprised that the results we get are not good in prevention.”
Wu now looks to the AHA’s efforts to reach a new set of goals by 2030, led by a broad imperative to help people live longer lives, in the U.S. and around the world. At home, he said it comes down to incentives. “There’s no magic bullet. All the interested parties need to work together: the doctors, the patients, the family members, the insurance companies, the hospitals. Everybody needs to come together, and there has to be some type of incentive program system so that everybody has some skin in the game.”
Moving the needle toward ideal heart health starts there.
STAT’s coverage of chronic health issues is supported by a grant from Bloomberg Philanthropies. Our financial supporters are not involved in any decisions about our journalism.