Why aren’t we doing better in the battle against cardiovascular disease?
Over the last few months, STAT put that question to nearly a dozen experts in cardiology, primary care, endocrinology, and vascular disease. Nearly all of them, as a related article details, pointed to a crisis in primary care.
“We’ve lost our traction on mitigating the risk for cardiovascular disease in general, but particularly for heart failure, the trio of hypertension, obesity, and diabetes, all accelerated by age,” said Clyde Yancy, a former president of the American Heart Association.
But weakness in the primary care system isn’t the only factor degrading cardiovascular health. These experts also had a lot to say about the corrosive effects of racial and sex disparities, the urban-rural divide, unhealthy environments, inadequate education, and research gaps — and also how to tackle those factors.
Here is a selection of their responses:
Care that ‘works for that individual person’
Joseph Wu, past president of the American Heart Association, director of the Stanford Cardiovascular Institute, and professor of medicine and radiology at Stanford School of Medicine
Wu offers a history lesson. If you go back to 1950, death rates from cardiovascular disease were about 1 in 2, compared to 1 in 8 now. More than 40% of Americans smoked back then, compared to 11% now. Now we have better therapies to dissolve blood clots and lower blood pressure, successfully staving off cardiovascular disease. Still, more than 40% of Americans now live with obesity or overweight. Meanwhile, diseases of older age such as heart failure are striking at younger ages.
Looking back: “In 1950, if you go to the hospital with a heart attack, there’s nothing we can do. You just lie there. And if you die, you die. If you go home, you get a pat on the back. Now we have stents, we have pacemakers, surgeons can do bypass, they can put a new valve in — a whole bunch of new technology innovations that have been developed over the past 70 years. That’s why the death rates from cardiovascular disease have declined by about 60%.”
Looking forward to the need for more precise medicine: “How do we improve this whole process so that we know the medication that we pick really works for that individual person? Because right now we just give it based on a guideline.”
‘Backlash is significant’
Herman Taylor, professor and director of the Cardiovascular Research Institute at Morehouse College and founding director of the Jackson Heart Study, a prospective population study modeled on the Framingham Heart Study but focused on African Americans in Mississippi not captured in Massachusetts’ largely white population
Like Wu, Taylor also looks to history, but further back to the experiences of African Americans over a dozen generations. He cites Frederick Hoffman, a statistician highly regarded in the 1890s but notorious now, who foresaw the association between tobacco and lung cancer 70 years before the Surgeon General’s ground-breaking report. After noting lynchings and other violence during Reconstruction and taking into account tuberculosis rates that were 50% higher for African Americans than for whites, Hoffman peered through a white supremacist lens to blame people experiencing poverty for their ills — and to predict African Americans would be extinct over the next century.
Now, that legacy takes the form of diminished life expectancy, Taylor said.
And yet: “The dominant narrative for me of the African American experience over the last 400 years is one of survival and resilience,” Taylor said. “Of course, we have disparities. Those challenges have been relentless. But African Americans, I think, can also look to the fact that, there is hope in the fact that one, you have survived, two, that there are legitimate questions for me as a researcher, legitimate scientific questions about how that was possible.”
After George Floyd’s murder in 2020, progress is fragile: Today, “it’s almost anathema to bring up certain aspects of the race problem for some funding agencies. So to me, that backlash is significant,” Taylor said. “It’s so important for us to continue to tell the story of disparities and inequities and call upon America’s better angels to do everything we can, whether it’s medical or societal, to begin to correct some of these inequities.”
‘Start in kindergarten’
Ann Marie Navar, preventive cardiologist, UT Southwestern
As her specialty signals, prevention is the foundation on which Navar’s philosophy and practice are built. If people don’t need to see a doctor for a problem, they miss opportunities to avoid or forestall future disease. One example: Many Americans have no idea what their LDL, or “bad,” cholesterol is, so those who have high cholesterol might miss potential benefits from treatments known to defeat heart disease.
Outside the time-strapped primary care doctor’s office: “The challenge again comes back to payment, right? I know that pharmacists can do a really great job at lipid management, but how do we set up a health care system that can afford to hire these folks and create these programs and pay for them?”
Outside the health care system: “If you start in kindergarten, if we could at least ensure healthy eating and access to healthy food for everybody there, it would be wonderful. We can also ensure there’s enough physical activity in school.”
‘We’re still using fairly crude measures’
Clyde Yancy, chief of cardiology at Northwestern Feinberg School of Medicine
Yancy believes in intervening early to avoid cardiovascular disease. That means changing lifestyles at an earlier age, before they can lead to high blood pressure, high glucose levels, obesity, and the damage they do.
There are some levers to pull:
Policy. “We need to do more in our communities to enable heart-healthy living.”
Science. “We really do need to discover more about preventing disease earlier on. We’re still using fairly crude measures, targeting high blood pressure, targeting diabetes. It’s got to be something even more central.”
Access to care, which remains challenging. “It’s attributable to the persistence of health inequities largely driven by the social construct.”
Lowering the preponderance of risk factors, especially among the poor, those in rural environments, those who are self-described under-represented minorities.
‘Treatment of hypertension is not rocket science’
Renu Garg, senior vice president for cardiovascular, Resolve to Save Lives
Garg is a physician and public health specialist who brings experience at the World Health Organization and the U.S. Centers for Disease Control and Prevention to the global public health initiative called Resolve to Save Lives, founded in 2017. Her focus is hypertension, a condition afflicting 1.3 billion people who need treatment and responsible for 10.7 million deaths per year.
What that means: “Treatment of hypertension is not rocket science. It is simple. And that’s what Resolve has done. We’ve demystified treatment of hypertension from something that only cardiologists will be treating.”
In practice: “We have to create an environment that is a healthier environment and people make healthier choices by default,” she said. Three examples are eliminating trans fat from the global food supply chain (where it still exists, unlike in the U.S.), reducing salt in the packaged foods, and promoting low sodium salt, especially and in countries like China and India where most of the salt is discretionary, added during cooking. “That’s a very important intervention and it’s a very cost-effective intervention.”
Then there’s detection: “Four out of five people with high blood pressure don’t have their blood pressure under control, putting them at risk of heart attacks and strokes. And this is solvable and this is preventable.”
The common thread: “You don’t blame the patient, but you make provisions within the health care system or health care intervention to provide high quality care to the patient.”
‘There’s still hope’
Eric Topol, a cardiologist and geneticist who is also founder and director of the Scripps Research Translational Institute
“We can do so much more there,” Topol said, looking at a recent report listing heart disease and stroke among the leading causes of death among Americans, he said.
It’s not too late. “These are diseases that take more than two decades to get rooted so we have lots of time to get on them.”
Facing those diseases now, he looks to the new class of obesity drugs that target GLP-1 receptors. “Obesity and diabetes can be better treated with GLP drugs, but people can’t get the drugs and they’re not covered by insurance.”
Next: “There’s still hope that between the things that we know are preventable and better treatments, we’re going to start putting a dent in it. But we haven’t really done that yet.”
‘We see sex disparities’
Janet Wei, co-director of the Stress Echocardiography Lab and assistant medical director of the Biomedical Imaging Research Institute at Cedars-Sinai Medical Center
Like her colleagues, Wei is alarmed by mortality rates that have been rising for cardiovascular disease both in women and men since 2015. She notes that more women under age 55 are dying of heart disease, a curve that has been increasing.
A challenge: Her research has a particular focus on why mostly women have microvascular dysfunction, leading to chest pain and heart attacks, even when there are no big blockages of their coronary arteries. “Those women end up getting dismissed by their clinicians when they go to the emergency room or when they go to their primary doctor,” she said. “We’ve made a lot of strides over the last decade, but there’s still a lot more work to be done.”
For example: “We see sex disparities related to the treatment of high blood pressure as well as high cholesterol,” potentially including sex-specific thresholds, she said. “We need to be able to develop ways to improve that detection, improve the education of primary care physicians, OB-GYNs, and all of our clinicians to address that.”
In research: “Women still represent less than 30% of all our clinical trials,” she said, acknowledging the challenge but also the need to study pregnancy. “Can we reduce adverse cardiovascular outcomes in pregnant or postpartum women?”
‘This is as much of a tsunami as you can imagine’
Marat Fudim, transplant cardiologist at Duke University Medical Center
It’s a disturbing metaphor: “If you marinate your body in bad disease — comorbidities, diabetes, liver disease, the metabolic syndrome, or kidney disease — let’s see you in 10 years.” That’s when the long-term progressive conditions like heart failure can take hold, with that time frame moving to younger ages.
Heart failure follows only childbirth as the leading cause of hospital admissions among Americans. “If you would have talked to me five to 10 years ago, we would have made that statement only for Medicare patients,” he said about hospitalizations. “But now it’s true for all patients in the United States.”
Rural vs. urban inequity: “I am highly concerned that we are doing too little to provide health care to the rural community. As a matter of fact, we are shutting down clinics,” he said. As for the federal agency for health coverage, “We need CMS to actually step it up and not cut funding for remote care and hypertension and heart failure.”
Fudim pushed for better remote care before Congress at a hearing of the Ways and Means Committee earlier this year. “We need to dive into subgroups to paint a picture that the entire country is having a problem rolling its way. This is as much of a tsunami as you can imagine.”
‘You can cut mortality in half’
Sean Pinney, chief of cardiology at Mount Sinai Morningside
Pinney shares his colleagues’ concerns around cardiometabolic syndrome, meaning high cholesterol and diabetes in patients in their 30s and 40s. That premature coronary disease was unheard of 20 years ago.
Prevention is the remedy: “We need to do a better job focusing on our systems of care delivery, to get the medications into the patient,” he said. “We know that if you can get all four classes of heart failure medications into patients with heart failure, with a reduced ejection fraction [a measure of pumping function], you can cut mortality in half.”
What gives him hope: “I do remain optimistic that advances in science and advances in therapeutics and advances in care delivery and also a focused effort to eliminate the racial disparities that exist in terms of access to care. And also in the environment of care, urban versus rural.”
‘It requires investment, focus, and discipline’
Asaf Bitton, executive director of Ariadne Labs at Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health
Bitton, who said, “Everyone knows it’s the primary care crisis,” believes healthier behavior can be instilled if health systems make it a priority.
Why life expectancy is falling: “We have not been managing our chronic conditions very well over the last five years, including, but not limited to, Covid.”
What can be done? “We know how to deliver better cardiology, outpatient, and primary care. And we know how to integrate behavioral health into patient care. It requires investment, focus, and discipline on the part of a health system to deliver what it ostensibly promises.”
If we don’t? “We’re going to see the rebound of these nasty chronic conditions, taking their horrible toll in an inequitable way. We’re going to basically leave a lot of preventable mortality on the table. And that’s just really sad.”
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.