Cardiovascular health in the United States: Exploring the good, the bad and the ugly

 

 WOW! Even the American College of Cardiology (ACC) doesn't know that stroke has been called neurological disease by the WHO since 2006 not cardiovascular, once again proving our medical 'professionals' don't keep up to date in their field!

Cardiovascular health in the United States: Exploring the good, the bad and the ugly

In many ways, cardiovascular health throughout the United States has improved significantly over the years. However, thanks in part to an aging population and the impact of the COVID-19 pandemic, there are certain areas where patient outcomes are trending in the wrong direction.

To learn more about this topic, researchers performed the first comprehensive report of its kind, tracking the latest data on a variety of risk factors and cardiovascular conditions. They published their findings in JACC, the flagship publication of the American College of Cardiology (ACC).[1] 

“Progress in cardiovascular health depends on knowing where we stand,” wrote first author Rishi K. Wadhera, MD, MPP, MPhil, associate director and section head of health policy at Richard A. and Susan F. Smith Center for Outcomes Research at Beth Israel Deaconess Medical Center, and colleagues. “To improve, we must measure—not occasionally, but consistently, transparently and with purpose.”

One key takeaway from the report is that there is still plenty of room for improvement in terms of patient outcomes.

“Across all risk factors and conditions, persistent disparities by race, geography, and socioeconomic status emerge as a central finding—one that demands focused attention and action,” the authors wrote. “The report also reveals other critical gaps: places where information is incomplete, where our collective understanding falls short, and where new data are urgently needed.”

In their analysis, Wadhera et al. examined several key areas of cardiovascular health:

Hypertension

Hypertension rates have stayed the same for many years, possibly due to a lack of progress in the field in terms of new therapies. One-third of U.S. adults with hypertension miss out altogether on medical treatment, the authors noted, and that statistic has showed “no evidence of improvement” over the last 15 years. 

“Even among those receiving treatment, blood pressure control rates remain suboptimal,” the authors wrote. “As of 2021-2023, only 66.6% of adults with hypertension achieved blood pressure control on medical therapy, with little evidence of improvement over the past 15 years. These patterns in hypertension treatment and control vary by age, sex, and income levels.”

One concerning trend—again, due in part to an aging U.S. population—is the fact that hypertension-related deaths have increased significantly. In fact, they nearly doubled from 23 per 100,000 adults in 2000, to 43 per 100,000 adults in 2019. 

Diabetes

Even with more and more diabetes drugs hitting the market—and many of them crossing over to a more general population—this is one area that has seen little positive progress in recent years. Diabetes rates are on the rise, especially among younger adults, low-income adults and non-Hispanic Black adults. Glycemic control rates remain low, the authors added, and mortality has increased.

“Treatment of diabetes is critical to prevent the onset of serious complications, including heart disease, stroke, and kidney disease,” the authors wrote. “Beyond established therapies such as insulin and oral antihyperglycemic medications, novel classes of antihyperglycemic agents—sodium-glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists—have emerged in recent years and transformed diabetes management. Beyond lowering glucose, these medications reduce major cardiovascular events, heart failure (HF) hospitalizations, and kidney disease progression. Although use of these therapies is increasing, uptake remains uneven across health systems and insurance types.”

Obesity

The management of overweight/obese patients is another area where there is still plenty of room for improvement. The mean BMI for U.S. adults increased from 28.6 kg/m² in 2011-2012 to 29.6 kg/m² in 2021-2023, for example, and the percentage of adults who can be categorized as obese has also climbed. Obesity-related mortality is on the rise as well, jumping from 1.8 per 100,000 adults in 2010 to 3.1 per 100,000 adults in 2020.

“Despite transformative pharmacologic advances like GLP-1 therapies and effective behavioral and surgical treatments, obesity care remains profoundly underutilized,” the authors wrote. 

The authors did share some positive news in this area: The percentage of U.S. adults who are overweight has decreased in the last decade or so.

LDL cholesterol

There has been some definite improvement in the LDL cholesterol (LDL-C) levels of U.S. adults. Even with that progress, however, the levels remain “suboptimal.” The report’s authors emphasized that far too many U.S. adults with a history of atherosclerotic cardiovascular disease (ASCVD) are still not hitting their guideline-recommended LDL-C targets.

“Statins and other lipid-lowering therapies remain underused, underscoring persistent gaps in implementation,” they added.

Cigarette smoking

One major victory in the fight against cardiovascular disease is the significant decline in cigarette smoking rates. In fact, smoking is down among men, women an all racial/ethnic groups. 

“Tobacco use is a well-established and modifiable risk factor for cardiovascular disease,” the authors wrote. “Smoking drives excess rates of coronary heart disease, acute myocardial infarction, stroke, heart failure, and peripheral artery disease. Understanding patterns and trends in cigarette use remains critical for ongoing efforts to reduce the burden of cardiovascular morbidity and mortality.”

Coronary heart disease

Coronary heart disease, which includes coronary artery disease (CAD) and any patient with a history of myocardial infarction, is a mix of positive and concerning trends. Ischemic heart disease decreased substantially from 1990 to 2019, for instance, but then CAD rates have increased across the board from 2019 to today. CAD-related mortality has also increased slightly since 2019—however, prior to that uptick, it was down dramatically from 2000 to 2020. The authors said those gains were likely due to progress in risk factor management and treatment. 

Acute myocardial infarctions

Another positive takeaway from this new report is the fact that acute myocardial infarction (AMI) deaths and hospitalizations are both decreasing as time goes on. However, some of these gains have not been universal. 

“Decreases in AMI hospitalizations have not been realized equally among different patient groups,” the authors wrote. “Women, Black adults, individuals dually enrolled in Medicare and Medicaid, and those living in rural communities experience a disproportionate burden of AMI. Moreover, emerging data suggest a reversal of progress among younger adults aged 25 to 64 years, for whom age-standardized AMI hospitalization rates increased from 155 to 161 per 100,000 person-years between 2008 and 2019.”

Heart failure

Heart failure-related mortality was on the decline from 1999 to 2011, but then that trend stopped in its tracks. COVID-19 made the statistics much worse, but this is a trend that was apparent well before the pandemic.

While the use of various heart failure medications is rising, their adoption has still been much slower than one may hope.  

“Beyond the use of guideline-directed medical therapy, multiple national programs and policies have aimed to improve transitions of care, discharge planning, and postdischarge care for older adults hospitalized with heart failure, with mixed evidence on how they have impacted quality and outcomes,” the group wrote.

Peripheral artery disease

Lower extremity peripheral artery disease (PAD) remains underdiagnosed in the United States, and nearly one-half of PAD patients who undergo treatment are not being discharged on the proper medications. In addition, major amputations remain common for these patients, suggesting there is still a lot of work to be done in terms of both diagnosis and management.

“Outcomes of amputation, whether above or below the ankle, are poor,” the authors noted.

Stroke(This is ugly, not knowing it is not a cardiovascular disease)

Stroke-related mortality has decreased substantially over the last several decades, representing a major accomplishment for the U.S. healthcare system. Among Black and middle-aged adults, however, there have been “concerning increases” that cardiologists should keep an eye on going forward. 

The quality of care(NOT RECOVERY!) for stroke patients, meanwhile, “has improved markedly,” though there is still room for improvement.

Survivors want recovery; when will that get through your thick heads?

‘A more effective path forward’

“If we want a healthier future, we must understand how far we have come, how far we have yet to go and what stands in our way,” Harlan M. Krumholz, MD, editor-in-chief of JACC, said in a statement about the importance of this report. “By putting data at the center of JACC’s collective awareness, we aim to help the cardiovascular community, including clinicians, researchers, policymakers and the public, see the landscape clearly and chart a more effective path forward.”

Click here to read the report in full.