As Trends Reverse in CVD, AHA Warns of Soaring Costs and Illness

The US healthcare system is on a collision course with CVD and its risk factors, a situation that, if left unchecked over the next few decades, could result in an estimated one in six adults having CVD and hypertension and a doubling of those with diabetes. What’s more, the American Heart Association (AHA) estimates, the costs of CVD-related on track will become astronomical—as much as 4.6% of the gross domestic product (GDP) by 2050.

Those projections come from two presidential advisories commissioned by the AHA and published this week in Circulation.

Dhruv Kazi, MD (Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA), vice chair of the writing committee for both papers, told TCTMD he thinks they demonstrate that the United States is at an inflection point.

“For five decades, we've had a consistent year-on-year decline in cardiovascular mortality rates and we've had much to celebrate. Yet, over the past decade this progress has stalled, and in some subpopulations reversed,” he said. “It should force public health officials, the medical profession, and the patient community to sit back and say: what are we doing wrong, what has changed, and what do we need to do better to get back to that prior trajectory?”

Similarly, Elizabeth A. Magnuson, ScD (Saint Luke’s Mid America Heart Institute, Kansas City, MO), who wrote a commentary accompanying the reports, says they are “a call to arms” to tackle these challenges now before the impact on society and the healthcare system becomes profound.

“A strategic and comprehensive approach involving expertise across a wide range of fields should be taken to understand factors underlying inequities with respect to CV care and outcomes in minority populations, and to develop innovative programs that counteract the fragmented nature of US healthcare delivery, with a focus on the needs of the elderly,” she writes.

Prevalence Rate Projections

Kazi and colleagues led by chair Karen E. Joynt Maddox, MD, MPH (Washington University School of Medicine, St. Louis, MO), used the National Health and Nutrition Examination Survey (NHANES) and the Medical Expenditure Panel Survey (MEPS) to estimate trends from 2020 through 2050 in CV risk factors based on adverse levels of Life’s Essential 8 and the presence of clinical CVD and stroke. The projections were by age, race, and ethnicity, and accounted for changes in disease prevalence and demographics.

When considering the clinical manifestations of the four health factors included in Life’s Essential 8—blood pressure, blood lipids, healthy weight, and blood sugar—the estimates show the population prevalence of hypertension increasing from 51.2% to 61%, diabetes increasing from 16.3% to 26.8%, obesity increasing from 43.1% to 60.6%, and hypercholesterolemia decreasing from 45.8% to 24.0%.

Among the four health behaviors that round out Life’s Essential 8, only inadequate sleep is projected to worsen, with poor diet, inadequate physical activity, and smoking all projected to improve over time.

In terms of disease prevalence, CHD is projected to increase from 7.8% to 9.2%, heart failure (HF) from 2.7% to 3.8%, stroke from 3.9% to 6.4%, atrial fibrillation (AF) from 1.7% to 2.4%, and total CVD from 11.3% to 15.0%.

According to Joynt Maddox and colleagues, 45 million adults in the US will have clinical CVD by 2050, and those with CVD and hypertension could number more than 184 million, or about 60% of the population.

While obesity will likely affect more than 50% of the adult population overall, the toll is projected to be worse among Black individuals and older adults, in whom the obesity prevalence may be more than 80%.

“Among the most striking findings were the projected inequities in risk factors and outcomes, disparities that will be magnified as the population becomes more diverse,” the authors write, given the disproportionate burden of specific risk factors borne by certain groups. “For instance, a doubling in the number of Hispanic American individuals and Asian American individuals by 2060 will translate to large increases in the number of CVD and stroke events occurring in these populations, even if the rate of CVD were to remain unchanged.”

The Economic Toll

The other presidential advisory, with Kazi as first author, addresses the economic burden of CVD and related risk factors using nationally representative health, economic, and demographic data to estimate healthcare costs.

In addition to a tripling of the annual inflation-adjusted costs of managing CV risk factors from 2020 to 2050 (from $400 billion to $1,344 billion), annual healthcare expenditures related to coronary heart disease, stroke, HF, and AF could nearly quadruple (from $393 billion to $1,490 billion). Productivity losses could be increased by more than 50% (from $234 billion to $361 billion).

The condition projected to account for the largest absolute increase in healthcare expenses is stroke, with a whopping 535% increase, driven largely by an aging population and projected rise in hypertension.

We are not committing ourselves to these numbers unless, of course, we choose not to act on them. Dhruv Kazi

Although the largest absolute increase in CVD and stroke expenditures will be among white Americans, large relative increases are projected for Asian Americans and Hispanic Americans as well.

“Asian American people are among the fastest growing racial or ethnic group in the United States, and many Asian American subpopulations such as Filipinos and individuals of South Asian ancestry have a higher-than-average risk of cardiometabolic conditions such as diabetes and premature coronary disease,” Kazi and colleagues write. ”Similarly, in the Hispanic ethnic group, there are subpopulations with higher and lower risk of cardiometabolic disease; disaggregating these subpopulations could be crucial for identifying opportunities to reduce the burden of disease and associated spending.”

Given the aging population—with all baby boomers reaching age 65 by 2030—Medicare will bear the greatest burden of the projected healthcare costs, shouldering about two-thirds of the estimated increases.

What Can Be Done?

To TCTMD, Kazi said he was surprised by some of the data.

“It's not just the fact that our population is getting older. We're seeing these risk factors go up across the lifespan, including in children and adolescents,” he noted. “Although the prevalence of obesity and type II diabetes is much lower in adolescents than in adults, it is rapidly rising, and it's higher than it's ever been. I think that is real cause for alarm.”

But Kazi said an important takeaway from these reports is that projections are not destiny.

“We are not committing ourselves to these numbers unless, of course, we choose not to act on them,” he added. “It’s easy to say let the policymakers take care of this, but change will have to begin with ourselves first.”

With indications that younger individuals and Hispanic and Asian populations are at particularly increased risk, Magnuson says intensified efforts are warranted “so that optimal preventive healthcare and evidence-based therapies are accessible and utilized.”

Doing so, will “require recognizing and addressing areas in which institutional racism contributing to worse outcomes as well public policy directed towards the upstream social determinants of health such as income, housing, education and food security that predispose minority populations to increased CVD risk,” she adds.

Another important piece of this challenging puzzle is the likely outpacing of demand in relation to healthcare workers. Magnuson says innovative solutions such as “safe and effective roles for nonphysician health professionals in team-based care for chronic conditions, including medication management, could free up physicians to focus in areas that require their expertise, while potentially decreasing costs.”

She also notes that the projected absolute increase in stroke prevalence suggests the need to consider a shift toward technology-forward solutions like self-measured BP-guided therapy led by pharmacists or nurse practitioners in telehealth settings.

For Kazi, some of the changes also will need to come in the form of better relationships with patients to understand their individual challenges and barriers to improving their health.

“When I sat back and looked at the data both on prevalence and costs, one of the things that jumped out at me is that there is no way to address the epidemic of cardiovascular disease in this country without thinking about how we tackle obesity and diabetes,” he said. “One step up from that is essentially how do we tackle food.”

Last year, the AHA issued a presidential advisory on food as medicine, which among other things suggests medically tailored meals, medically tailored groceries, and produce prescriptions.

“We're talking about [having] 180 million people with obesity by 2050. That’s just obesity; we’re not talking about overweight,” Kazi said. “We're going to have to fundamentally rethink the economics of food, access to food across the income spectrum, across the geographic spectrum, and how we tax or incentivize healthy foods versus unhealthy foods. All solutions should be on the table if we agree that this is a primary focus of ensuring that Americans have access to healthy lives.”