Disparate US Trends in Early CVD Deaths Speak to Need for Targeted Prevention

By and large, the rate of early death due to cardiovascular disease has been on the decline in the United States, but new data from 2000 to 2015 show that the improvements haven’t been equal. American Indians/Alaska Natives younger than age 50 have seen a rise in CVD mortality, while white women in this demographic have seen their progress stall.

Overall, there has been an upswing in deaths due to hypertensive heart disease among individuals ages 25 to 64.

“Part of what was striking,” said study co-author Tiffany M. Powell-Wiley, MD, MPH (National Heart, Lung, and Blood Institute, Bethesda, MD), is how widespread the impact of hypertension has been. “Pretty much all racial and ethnic groups were seeing increases in the incidence of mortality from hypertensive heart disease, particularly when you think of the age of the populations we were looking at,” she noted.

To TCTMD, Powell-Wiley said that for her “as a physician, it really hits home how much more work we need to do addressing hypertension in the US.”

Sadiya Khan, MD (Northwestern University Feinberg School of Medicine, Chicago, IL), whose own research has found that prior gains in CVD survival began leveling off in recent years, with persistent racial disparities, told TCTMD that what’s unique about the current study is its focus on younger adults.

Beyond capturing the disease burden in the US population, this look at the loss of years early on in people’s life spans draws attention to the personal costs for individuals and their families as well as to financial concerns like loss of income when death comes at a young age, she pointed out.

These numbers, Khan said, may be the “tip of the iceberg, in that there are a lot of data now showing that nonfatal events are increasing in these younger adults under the age of 65. I think this is just an early signal of what is potentially going to be the burden of premature mortality from cardiovascular disease to come.”

What the new data highlight is “how much more we need to do in terms of primordial and primary prevention earlier in the life span,” Khan advised, “because if we have deaths occurring before the age of 65—before what the mean life expectancy is for most groups in this country—that’s a very important high-risk population to target.”

To better prevent CVD and effectively use healthcare resources, Powell-Wiley said, it’s necessary to understand how early such prevention should start. “This really suggests it’s not something you can think about once that patient is referred to a cardiologist. It takes all clinicians: from the primary care physician [to] the ob-gyn . . . it really takes all of us” to address risk factors, she stressed.

Powell-Wiley along with lead author Yingxi Chen, MD, PhD (National Cancer Institute, Bethesda, MD), and colleagues detail their findings in a paper published online recently in JAMA Cardiology.

More Than 2 Million Premature Deaths

Using the Surveillance, Epidemiology, and End Results data set, the researchers identified 2.3 million CVD-related deaths that occurred between 2000 and 2015 among adults ages 25 to 64.

CVD death rates declined for black, Latino, and Asian/Pacific Islander individuals; still, black people had the highest age-standardized rate per 100,000 individuals: 101 among women and 190 among men.

Meanwhile, the CVD mortality rate rose for American Indian/Alaska Native individuals ages 25 to 49 years, by 2.1% for women and 1.3% for men. White men in this age group saw their CVD deaths decrease by 1.1% annually, whereas the rate did not change among women.

The biggest contributors to CVD premature deaths between 2000 and 2015 were ischemic heart disease (54%), cerebrovascular disease (13%), and hypertensive heart disease (10%). Most of the declines in death related to decreases in ischemic heart disease, though there also were reductions related to cerebrovascular disease, PAD, and rheumatic heart disease.

Yet the rate of deaths attributed to ischemic heart disease actually increased among American Indian/Alaska Native women ages 25 to 49 years (1.7% annually) and held steady for white women in that age group. Notably, hypertensive heart disease increased for most groups, with the largest rise seen in white women ages 25 to 49. Endocarditis-related deaths in that younger group increased annually by 3.9% and 3.7% for white men and women, respectively, and by 5.6% in American Indian/Alaska Native men.

County-level analysis showed that areas with the highest prevalence of diabetes had the greatest risk of CVD mortality. Age-standardized mortality rates “were consistently higher in counties with lower socioeconomic factors (ie, lower education levels and rural areas)” and “were also generally higher in counties with a high prevalence of diabetes, obesity, and smoking,” the researchers note.

This study “highlights the importance of understanding the diversity and disparities in CVD mortality by risk factors among different groups,” they observe. Additionally, Chen et al say, it shows the potential for “states to target public health resources for primary and secondary CVD prevention toward counties based on socioeconomic status and rurality.”

Hypertension Called Out

As for drivers of the differences, Khan said the “larger socioeconomic disparities in the United States contribute to some of these risk factors that are on that causal pathway. So I think highlighting hypertensive disease as a big problem is really important, because of how prevalent hypertension is in the general population [while being] extremely disproportionately higher in certain racial/ethnic groups and low socioeconomic groups. Not only is the prevalence significantly higher, the level of control is significantly lower.”

There are signs, Khan noted, that hypertension is developing at younger ages and thus resulting in a larger cumulative burden over the life span. This could be due to the growing obesity epidemic, she suggested, also pointing to research showing that not only obesity per se but also weight gain in young-to-middle adulthood seem to impart higher mortality.

For Khan, the Million Hearts Initiative stands out as a public health effort that’s working well to increase awareness about both prevention and control of hypertension. Moreover, she added, the 2017 US hypertension guidelines, “which helped to intensify blood pressure-lowering in higher-risk groups, is a great example of steps that are needed to help reduce the burden of cardiovascular disease related to hypertension.”

Individual clinicians can employ the concept of lifetime risk when treating and counseling younger patients, Khan said. “We know that about 50% of Americans may be at low 10-year or short-term risk of cardiovascular disease but continue to be at high lifetime risk of cardiovascular disease.”

Powell-Wiley emphasized that the study is a “wake-up call” to be aware of cardiovascular disease no matter how young a patient might be.

“For instance, as a primary care physician you may see a young woman who is thinking about starting a family or may not have any inkling of what her blood pressure is or what her blood glucose or diabetes risk is,” she said. “Even in that context there needs to be some discussion about cardiovascular risk, because if we’re seeing increasing mortality from, in particular, hypertensive heart disease, we’re clearly not reaching people as soon as we need to.”

Mobile health technology may help reach these individuals by tracking things cardiovascular risk factors while also providing education about risk reduction, Powell-Wiley suggested. “That’s a whole space [where] there’s a lot of interest.”