Deadly Deceleration? Annual Declines in US Cardiovascular Death Rate Start to Slow

Much headway was made in reducing the death rates associated with cardiovascular disease as a whole, heart disease, and stroke up until the first decade of the 21st century. But between 2011 and 2014, the declines started to decelerate “substantially” across the United States, according to a new study.

The gains that were made over a four-decade timespan are now slowing down, lead author Stephen Sidney, MD (Kaiser Permanente Northern California, Oakland, CA), told TCTMD. “The big question is, why is this happening?”

More primary prevention in terms of less smoking and better cholesterol control, better treatment of cardiovascular disease and events when they happen, and improved secondary prevention all went into reducing mortality, Sidney said. The problem is that, at the same time, both obesity and diabetes were on the upswing. Now, there are delayed consequences. “These things after 25 years or so are finally kicking in and stopping the declines,” he explained.

To TCTMD, senior author Jamal S. Rana, MD, PhD (Kaiser Permanente Northern California and University of California, San Francisco), said the study “has taken a lot of people by surprise. It’s a wake-up call for the cardiovascular community and society as a whole to take these things seriously.”

Their findings were published this week in JAMA Cardiology.

Trends Consistent Across Subgroups

Sidney et al used data from the US Centers for Disease Control and Prevention to assess national trends in age-adjusted mortality rates from 2000 to 2014.

Mortality rates continued to decline over the entire study period, but declines were sharper in 2000-2011 than they were in 2011-2014. Cardiovascular disease mortality decreased by 3.79% each year between 2000 and 2011 but only by 0.65% each year between 2011 and 2014.The declines also shrunk for heart disease (from 3.69% to 0.76%) and stroke (from 4.53% to 0.37%; P < 0.001 for all).

An important take-home message, Rana and Sidney emphasized, is that the patterns were consistent between men and women and across race/ethnicity groups.

In contrast, the annual decreases in rates of death from cancer held steady at 1.49% in 2000-2011 and 1.55% in 2011-2014 (P = 0.82).

Still Number One

“Heart disease has been the leading cause of death for a century,” and unfortunately that continues to be the case, Rana said. While cardiologists have made much progress in terms of patient care, he added, “it’s time to rethink and stay innovative and stay vigilant, and try to come up with new ideas to make sure this doesn’t continue.”

Donald M. Lloyd-Jones, MD (Northwestern University, Chicago, IL), points out in an editorial that it was once anticipated that, by approximately 2013, heart disease would no longer be the number-one killer in the United States.

“Many in the cardiovascular community were poised to celebrate the ‘We’re number two’ moment,” by virtue of being surpassed by cancer deaths,” he says.

Asked whether cardiovascular disease mortality could simply be hitting a plateau—given that the rate is unlikely to ever reach zero—Sidney explained why the researchers credit diabetes and obesity with the negative trends.

“Diabetes is a major risk factor for cardiovascular disease and is on the increase, largely because of the increasing rates of obesity,” he said. “We think that through . . . better diet and a better lifestyle with more physical activity, we can prevent obesity [and in turn] can prevent diabetes. We ought to be able to get the rates going down again, but it could take a while. Right now we can’t predict from year to year, but it’s not promising based on these data.”

In fact, the situation could be worsening. There are no final mortality data yet available for 2015, but provisional numbers from the first three-quarters of the year suggest that death rates might even rise, Sidney reported.

This would make it difficult for the American Heart Association to meet its strategic goal of reducing deaths from cardiovascular disease and stroke by 20% from 2010 to 2020, he pointed out. “If this keeps up, it’s not going to happen.”

Prevention should be the focus, Sidney emphasized. “We have to get ahead of the obesity epidemic. That is, I think, the biggest single thing we can do.”

Lloyd-Jones agrees that the 20% target might “elude us. As a societal imperative we must redouble our prevention efforts on all fronts.

“Until we are serious about primordial prevention, beginning in utero and lasting through early childhood well into middle age, we will continue to require more medical interventions, and incur more costs, to curb [cardiovascular disease],” he writes.

“For now,” Lloyd-Jones adds, “it appears we will be reaping what we have sown in the obesity epidemic over the last several decades. This bitter harvest can still be largely avoided if patients, physicians, public health officials, and politicians can finally create meaningful policies and pathways to enable a culture that prioritizes health and promotes prevention. The time is now, if not already past for some.”

 

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