US Mortality Rates for CVD Have Stalled as Racial Disparities Widen

Gains made in decreasing mortality for ischemic heart disease in the United States over the past two decades have been offset by stagnant or increasing death rates for most other forms of heart disease, including heart failure and hypertension, according to a new analysis. Moreover, stark racial disparities continue to exist within all subsets of heart disease.

“While some of the trends and patterns are things we may have expected based on our prior work, . . . the fact that we wiped out the progress that we've made with the increases was quite alarming,” senior author Sadiya Khan, MD (Northwestern University Feinberg School of Medicine, Chicago, IL), told TCTMD.

The reasons for this are likely multifactorial, she said. “From a heart disease prevention standpoint, we've done a great job in public policies and treatment for cholesterol and statin treatment and aspirin, and so these things have been transformational for coronary heart disease or preventing heart attack deaths. Where we've seen less progress has been heart failure and high blood pressure, and I think there's a lot of different reasons for that, but one of them is the growing obesity epidemic.”

Namely, Khan added, “there's a growing burden related to how many people are overweight and now how long they've been overweight and obese. We see so many more children and young adults who are living with obesity for much, much longer that's leading to some of this for sure.” Healthcare gaps related to unemployment, as were seen during the 2007-2009 recession, may also play a role, she said. “We need to act quickly to ensure that these trends are not amplified in the current pandemic.”

Given the millions of COVID-19 survivors, Khan said it will be important to further study “how the virus can directly infiltrate the heart as well as cause heart failure. We have to be very vigilant about prevention in those individuals who have recovered from COVID-19. And I think the other bigger national policy issue is how do we ensure preventive care so that we are proactive about this rather than waiting for things to get worse and have to be reactive.”

‘Heed the Wake-up Call’

For the study, published online last week in the BMJ, Nilay Shah, MD (Northwestern University Feinberg School of Medicine, Chicago, IL), Khan, and colleagues reviewed national registry data and death certificate information from the Centers for Disease Control and Prevention on the 12.9 million people who died from heart disease in the United States between 1999 and 2018.

We need to act quickly to ensure that these trends are not amplified in the current pandemic. Sadiya Khan

Overall heart disease deaths fell between 1999 and 2011—from 752,192 to 596,577—but increased to 655,381 in 2018. The proportion of deaths attributable to ischemic heart disease decreased over the study period from 73.0% to 55.8%, but there were increases in those linked with both heart failure (7.6% to 12.8%) and hypertensive heart disease (3.6% to 9.2%). Among middle-aged individuals, the proportion of deaths increased over the study period (13.7% to 17.3%).

In subgroup analyses broken down by race, sex, age, and region, the researchers consistently found the highest age-adjusted mortality rates for ischemic heart disease. Mortality rates for both total and all heart disease subtypes were highest in the South compared with other regions, as well as in rural compared with urban counties. Following 2011, mortality rates due to both heart failure and hypertension grew faster than all other subcategories. Specifically, Black men reported the fastest surges in heart failure mortality (mean annual percentage change 4.9%), whereas white men had the quickest increases in hypertensive heart disease (6.3%).

Heart disease accounted for about 3.8 million years of life lost in 2018 alone, with ischemic heart disease leading to the greatest potential loss of life-years overall. But the biggest disparities observed between Black and white individuals were driven by heart failure and hypertension.

The racial disparities observed in this study are no different from what has been seen in COVID-19 and other chronic diseases, but they should encourage the medical community to “continue to heed the wake-up call that's been coming for many, many years and say that we can no longer continue to observe these disparities and have to act upon them,” Khan said. “The new aspect of this study in terms of the disparities was being able to observe the differences in each type of heart disease and seeing that there really was a much greater disparity among heart failure and high blood pressure deaths in Black versus white men and women. And so that gives us some insight into what the key targets for prevention need to be as well.”

Increasing Health Equity

Commenting on the study for TCTMD, Dipti Itchhaporia, MD (Hoag Hospital, Newport Beach, CA), who serves as the chair of the American College of Cardiology’s newly created Health Equity Task Force, said the findings have “some serious public health implications.”

While most in the cardiology community are aware that improvements in total heart disease mortality have slowed, “this sort of goes beyond it and says: okay, are there other things we can learn? Why did it slow down and why did it plateau in 2011?” she said. “I can see that we bent the curve a little bit on the ischemic heart disease portion, but ultimately I think this study highlights what we've sort of known, which is that we haven't done as good a job in certain risk factors.”

Between growing rates of obesity, diabetes, and hypertension, it’s no surprise to Itchhaporia that heart failure rates have increased. Heart failure specifically may deserve to be studied as its own endpoint and not a subtype of heart disease, she added, given that it can be caused by ischemic heart disease, hypertension, and other risk factors. “We really need to target the at-risk population,” she said, by focusing heart failure prevention on populations at the highest-risk patients, while simultaneously promoting equality, to “really look at clinical quality improvement to optimize primary and secondary prevention.”

While she supports policies that improve diet quality and facilitate physical activity, Itchhaporia said future gains in this space will mostly be attained by employing novel approaches to prevention. “We need more dissemination and implementation of some of the interventions we know that have worked,” she argued, citing the success of both the barbershop hypertension study from 2018 and an initiative, in which she took part, teaching children how to check their parents’ blood pressure.

And with the recent growing focus on telehealth, Itchhaporia said reaching patients in their homes “will be one of the things that we can do” to achieve greater health equity.