Here’s the good news: Deaths due to ischemic heart disease — when coronary arteries are blocked — fell by more than half from 1990 to 2023 in the United States, thanks to better control of up to a dozen risk factors. What’s still on the table: Almost 9 out of 10 of the most recent deaths could have been prevented by better managing those risk factors.
Much of the progress recorded since the start of the Global Burden of Disease study, published Wednesday in JAMA Cardiology, stemmed from drops in deaths from smoking (down 33.3%) and particulate air pollution (down 74.9%). But in the last year of the study, 419,000 of the estimated 473,000 coronary artery disease deaths — or 88.8% — were still linked to modifiable risk factors.
The warning signs for coronary artery disease in 2023 are familiar ones. Higher body mass index (up 12.5%) and higher blood glucose levels (10.5%) since 1990 are singled out as growing problems that align with greater prevalence of diabetes as well as development of the newly recognized cardiovascular-kidney-metabolic syndrome, an umbrella term that includes heart disease, kidney disease, diabetes, and obesity.
“I think it bears repeating that coronary artery disease is preventable,” study co-author Gregory Roth, professor of cardiology at the University of Washington, told STAT. “For those of us who are in the health space, that sounds maybe obvious, but I see patients every week who are not aware that for the leading cause of death in the United States, we know how to modify risk factors so that we could potentially remove 80% or 90% of it.”
High blood pressure, high “bad” cholesterol, and kidney dysfunction also lead to fatal heart disease. Behavioral risk factors include poor diet, low physical activity, smoking, and alcohol use. The environmental risks arise from pollution, heat, and lead exposure.
“We’re definitely seeing that ischemic heart disease mortality rates have gone down. We have made progress, but it seems we’re losing ground in areas like BMI and diabetes specifically,” Sadiya Khan, professor of cardiovascular epidemiology at Northwestern Medicine, told STAT. She was not involved in the study. “We can celebrate the success we’ve had without saying the job is done. These data are critical to help drive where we prioritize our attention.”
Where people lived made a difference, the systematic analysis of data drawn from the U.S. National Vital Statistics System revealed.
The highest coronary artery disease death rates were recorded in Kentucky, Tennessee, West Virginia, Mississippi, and Arkansas, while Massachusetts, Oregon, Hawaii, Colorado, and Minnesota saw the lowest.
Looking back to 1990, Massachusetts, New Jersey, and Minnesota had the biggest drops, when adjusting for the age of their populations, averaging more than 63% fewer coronary artery disease deaths than in 1990.
States that adopted policies addressing tobacco smoking saw more improvement in heart disease, for example. “We want to communicate with individuals about choices they can make, but we really want to communicate this information to people who are in a position to guide health policy,” Roth said.
Almost half of the heart disease deaths in 2023 were attributed to metabolic and behavioral risks, led by high blood pressure (47.2%), diet (38.6%), and LDL cholesterol (28.5%). As the U.S. population increased and grew older, there were additional deaths, against a backdrop of slower progress since 2010, when improvements in risk factors stalled.
Robert Califf, a cardiologist, former commissioner of the Food and Drug Administration, and a member of the Duke Clinical Research Institute, identified cardiovascular-kidney-metabolic syndrome, social media, and conflicting public policies as targets.
“It is ironic that a society with such a surplus of resources is not aggressively addressing this issue when it is overwhelmingly likely that a combination of policy interventions, attention to reliable communication about health in our information ecosystem, and wider use of generic medicines would dramatically reduce the scourge of CKM syndrome,” he wrote in an editorial appearing with the study in JAMA Cardiology.
“The recent swing in policy to emphasize individual choice over public health is concerning, because there is evidence that policies that promote and subsidize an unhealthy environment for food, exercise, and air can reverse progress and cause further harm,” Califf continued.
Califf cited a shortage of primary care physicians and CKM specialists to address greater demand for care. He also flagged as problematic the divergence between federal recommendations in the new Dietary Guidelines for Americans and the American Heart Association’s Dietary Guidance to Improve Cardiovascular Health, which hews more closely to scientific consensus by advising people to eat more plant-based foods and less fats.
Such conflicting advice comes amid a confusing social media environment short on data, he said.
“We must join the battle on social media, using modern methods for effectively communicating reliable and useful information to counter the overwhelming volume of misinformation used to sell ineffective, unproven wellness interventions and unhealthy food choices,” Califf wrote.
At an individual level, prevention is the best tool, study co-author Roth said. That means detecting coronary artery disease before it causes a heart attack or sudden death from a blocked artery. The challenge is finding a disease that can be slow and hidden for most of people’s lives. It takes years to develop, without symptoms to spark concern or prompt a visit to a doctor.
High blood pressure, high cholesterol, and kidney dysfunction may be invisible, but screening at an annual checkup can sound the alarm. Blood tests can be the first signal, followed by CT scans if warranted to decide on treatment. Medical societies recommend screening at earlier ages than in the past, which could mean taking statins to lower cholesterol at 30, knowing that heart diseases develop over many decades.
“The main message is not that people need medicines,” Roth said. “The main message is that these risk factors are modifiable. I see this all the time where people don’t understand the impact that they can have on their health over the long term.”
Northwestern’s Khan invoked a comprehensive approach.
“Weight loss drugs right now are very, very effective and helpful at reducing cardiovascular risk in the right patient,” she said. “But let’s talk about the food environment and let’s talk about our green spaces, making sure that there are safe spaces and places for a healthy lifestyle, opportunities for structured exercise. Then let’s talk about what are the appropriate medications and what are appropriate steps to ensure affordability and access to the right medications.”
Newer, more costly obesity drugs may be prominent in the next analysis of heart disease mortality, Roth said, which will be extended from 2023 to 2025.
“We see very large changes in the way the federal government is deciding on investing in the health of its population by making changes in Medicare and Medicaid,” he said. “These new medications that we hear about all the time are not reaching most patients, and we need to look holistically across all of the risk factors.”
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.