US heart disease death rates declining, but more slowly in South

Herman A. Taylor, MD, MPH, FACC, FAHA

This is a very important study. I think it is a red flag waving for anyone concerned about the health, happiness and longevity of people who live in the South. It fairly dramatically points out that the South, particularly the Southeast, has emerged as the epicenter of the ongoing CV epidemic. I eagerly anticipate more in-depth research by this group and others who are focused on geographic disparities.

We have to put that into context of the generally good news of the decline of heart disease as a cause of death among Americans. Not every part of the country has experienced the decline as dramatically as others. Some parts are truly benefiting from advances in modern research and therapeutics, while the South lags significantly behind. This is the region where the poorest Americans live as well, and the two facts are probably related. Additionally, around half of all African Americans call the South home; the fact that significant disparities along ethnic lines persist in our country are at least partly responsible for the patterns observed.

Societally, we have further to go in the South in terms of ensuring adequate access to care for all our citizens of every economic and ethnic group. While these data likely don’t reflect the impact of the Affordable Care Act, the reluctance to embrace the current version of universal access to health insurance is counterproductive, even if you disagree with some specifics of current law. Being last to expand Medicaid will not help these statistics. Other policy initiatives could be embraced: Smoking bans in public places have been proven to reduce MI admissions to EDs in municipalities across the U.S. and internationally, but many Southern communities have been slow to adopt these life-saving measures. Similarly, policy decisions about green spaces, walking spaces, school exercise and school lunches can play a role; people with power in those realms should pay close attention to these data. Advancing obesity, diabetes and hypertension levels in our region are clearly contributory; we lead the country in all those categories of risk factors. With such high levels of CV risk factors, as well as social impediments to resources that support health care and healthful living, it stands to reason that you would see this manifest in excess deaths from heart disease.

We need to use all available means to catch up with the rest of the country in terms of enjoying all the advances in research, advances in medical care and improved access to care. More research to increase the precision of our understanding of the micro-level details of these macro-trends that the maps reflect must continue. Precision medicine must be accompanied by an appreciation of the concept of “precision public health” — the study by Casper and colleagues is a good example of an important step in this direction — so we understand better what’s going on, so our solutions have maximal impact. Also, while we attack the known culprits, we also need to understand better how some people and places avoid disease. What is the source of the resilience of some people and communities despite the risks that social, personal and environmental factors might pose to individuals and the population? Indeed, there are Southerners who live long healthy lives, sometimes despite high-risk environments. Closer investigation of these hardy individuals and communities may reveal some surprises that might point to new ways to intervene and reduce disparities.

When people have the latest options available to manage their health, and they can get to those options and lack of insurance is not an issue, that’s an important component of good overall outcomes. Making good, nutritious diets universally available, as well as doing all we can to improve healthy food selection options and the quality of the food supply are also very important. The “Southern diet” needs to be looked at carefully, and we need to inform the populace about the challenges posed to heart health by a diet with such a high calorie intake and high fat intake, and about healthy alternatives. We must offer opportunities for exercise, even in hot summer in the deep South. In some communities, the local schools offer the opportunity for people to use their facilities for exercise in relative comfort, and the population benefits. We should also emphasize systems of care, such as the ones developed by Kaiser Permanente and the Veterans Administration, to help reduce hypertension, which has such a dramatic impact on CHD and HF in the South. This is an important concept in the modern practice of cardiology.

Cardiologists need to heed these data. First, the distribution of manpower should be impacted. Young cardiologists, especially, can seize the opportunity to locate where they can be a part of the solution to the heart disease epidemic where it is most profoundly impacting American life and productivity — in the Southern U.S., often away from the biggest population centers. The emphasis on hospital-based care and risk-factor intervention by cardiologists needs to be evidence-based, consistent and aggressive, and it absolutely must involve non-physician partners who are effective in counseling on diet, exercise and other health behaviors. We must stay attuned to developments in patient-centered, decentralized services, including of practices that help individuals improve self-care, such as home BP monitoring, telehealth links with remote areas, and the evolving mobile health solutions as they mature and become increasingly important. Finally, cardiologists must use their expert status to advocate for policies at the local, state and higher levels to make their communities as heart-friendly as possible. All Americans should have an equal shot at lives free of disability and early death tied to heart disease.