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AHA: Prevalence of HF projected to rise dramatically; CVD still No. 1 killer in US, world
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The number of U.S. adults living with HF rose by approximately 800,000 between 2009 and 2014, and is projected to rise 46% by 2030, according to the American Heart Association’s 2017 Heart Disease and Stroke Statistics Update.
According to the report, the latest data indicate that CVD is still the most common cause of death in the United States and the world.
“We know that advances in [CV] health are not distributed evenly across the population,” Emilia J. Benjamin, MD, SCM, FAHA, professor of medicine in the section of cardiovascular medicine at Boston University School of Medicine and chair of the update’s writing group, said in a press release. “In particular, individuals who live in rural communities, have less education, have lower incomes, and are ethnic or racial minorities have an undue burden of [CVD] and its risk factors.”
American adults living with HF rose from approximately 5.7 million in 2009-2012 to approximately 6.5 million in 2011-2014, and the figure is projected to reach 8 million by 2030, the researchers wrote.
Paul Muntner, PhD, MHSc, professor and vice chair in the department of epidemiology at the University of Alabama at Birmingham and a member of the writing panel, said in the release that the rise in HF incidents could be tied to more people surviving MI, as prior MI increases risk for HF, but aging of the population and increase in other comorbidities could also be factors.
Leading cause of death
According to the researchers, the latest data indicate that CVD killed 17.3 million lives worldwide in 2013, making it the leading cause of death; 92.1 million U.S. adults, more than one-third, have some form of CVD, attributable to 807,775 deaths in 2014; MI occurs in approximately 790,000 Americans each year, killing approximately 114,000; stroke occurred in approximately 795,000 Americans in 2014, killing approximately 133,000; and out-of-hospital cardiac arrest affected approximately 350,000 Americans in 2014, killing nearly 90% of them.
Some form of CVD is present in nearly half of non-Hispanic black U.S. adults (women, 47.7%; men, 46%), the researchers wrote.
Among U.S. deaths attributable to CVD, CHD (45.1%) is the leading cause, followed by stroke (16.5%), hypertension (9.1%), HF (8.5%) and diseases of the arteries (3.2%), according to the researchers.
However, the annual death rate attributable to CHD declined 35.5% from 2004 to 2014, and the death rate from stroke dropped 28.7% from 2004 to 2014, whereas the absolute number of stroke deaths declined 11.3% during that time, they wrote.
‘Life’s Simple 7’
The researchers also compiled statistics related to the AHA’s “Life’s Simple 7” measures — not smoking, engaging in physical activity, healthy diet, appropriate body weight, control of cholesterol, control of BP and control of blood glucose.
They found that tobacco use is declining in the United States but increasing worldwide; that 30.4% of U.S. adults do not engage in leisure-time physical activity; that U.S. consumption of whole grains has increased and consumption of sugar-sweetened beverages has decreased; that U.S. obesity prevalence rose from 30.5% in 1999-2000 to 37.7% in 2013-2014; that nearly 1 in 3 U.S. adults have elevated LDL; that 34% of U.S. adults have hypertension, a figure projected to increase to 41.4% by 2030; and that 9.1% of U.S. adults are known to have diabetes. – by Erik Swain
Disclosure: Benjamin reports no relevant financial disclosures. Muntner reports receiving a research grant from Amgen. Please see the full report for a list of the relevant financial disclosures of the other researchers and reviewers.
Perspective
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Keith C. Ferdinand, MD, FACC, FAHA, FNLA, FASH
Each year, practitioners, providers, researchers and public health officials eagerly await the AHA’s Heart Disease and Stroke Statistics Update. The 2017 report brings together in one single document the most up-to-date data related to heart disease, stroke and risk factors.
As a hypertension specialist and a clinical cardiologist, I was especially interested in some of the comments related to hypertension, a major risk factor for CVD and stroke. It was noted in the report that the elimination of hypertension could reduce CVD mortality by 30.4% among men and 38% among women. The disparities in hypertension prevalence, morbidity and mortality are well-known, and the AHA update again highlights that the prevalence of hypertension in black individuals in the United States is among the highest in the world. The authors further note that curtailing to a large degree the impact on CVD mortality can be directly addressed by the elimination of risk factors, especially hypertension among women and all factors except smoking in men. Hypertension percentage among non-Hispanic black men was 45%, and 46.3% among non-Hispanic black women. This is significantly higher than that seen in non-Hispanic white, non-Hispanic Asian and Hispanic men and women.
Unfortunately, the prevalence of hypertension did not decrease among non-Hispanic black men (38.8% in 1999-2000 vs. 39.6% in 2009-2010) or among non-Hispanic black women (40.8% in 1999-2000 vs. 43.1% in 2009-2010).
Interestingly, the new AHA report brings attention the fact that African-American individuals are more likely than white individuals to have non-dipping hypertension, ie, BP that declines > 10% from daytime to nighttime, and to have greater percentages of nighttime hypertension on ambulatory BP monitoring. In the United Kingdom, ambulatory BP monitoring has been suggested as a diagnostic tool for all new hypertensives. Perhaps in the future, ambulatory BP monitoring will be more widely used in the U.S. to address the levels of BP, the adequacy of hypertension control and the presence of nocturnal hypertension, which is linked to an increased risk for CVD.
Chapter 9 of the report brings to the forefront the SPRINT trial, which demonstrated lower CVD and mortality risk with a systolic BP goal of 120 mm Hg vs. 140 mm Hg. The authors further estimate that 16.8 million U.S. adults meet SPRINT eligibility criteria. This affects the practicing providers, including primary care providers and specialists such as HF specialists, hypertension specialists and general cardiologists. In view of a new guideline released by the American College of Physicians and American Academy of Family Physicians that calls into question the benefit of tight BP control, providers are eagerly awaiting another updated guideline from the American College of Cardiology, AHA and multiple other societies, which may address the benefits and risks of more intensive BP control.
One of the other areas of concern noted throughout the report was the increased rates of HF as the population ages, from 5.7 million in 2009-2012 to 6.5 million in 2011-2014 in Americans 20 years of age and older. Black men had the highest proportion of hospitalized HF with reduced ejection fraction, and below the age of 75 years, HF incidence is higher in black individuals than in white individuals. Associated with this increase in HF morbidity and mortality is an economic cost. Efforts to curtail the increased costs associated with HF must include better prevention, including control of risk factors, specifically hypertension.
New areas noted in the report included an interesting discussion on chronic venous insufficiency, including varicose veins; post-thrombotic syndrome; and a recognition of the importance of early recognition of pulmonary hypertension.
Overall, this report stimulates interest in CVD and the need to do more to achieve the AHA 2020 Impact Goals of reducing death attributable to CVD and stroke by 20%. Because of the somewhat slowing in the decline in CV mortality, achievement of these goals by 2020 will be difficult. It has been estimated that CV health has improved only by 6% between 2010 and 2020, well short of the AHA goal of a 20% improvement.
Continued interest in decreasing the prevalence of smoking, high cholesterol and high BP, and perhaps paying more attention to the increasing prevalence of obesity and diabetes in the U.S. are equally as important as the treatment of acute CVD events and secondary pharmacologic intervention in reducing the high burden of CVD in our society.
Providers, researchers and public health officials should pay strict attention to the common thread throughout the report on disparities related to race, ethnicity and socioeconomic status. The AHA report includes important charts demonstrating the higher death rates from CVD and stroke in African-American individuals, and it is unacceptable that CV health and the burden of heart disease and stroke are distributed in a nonequitable manner in the U.S. Indeed, clinicians and public health officials should be aware that if we don’t address these disparities, achieving overall health for the general population will be impossible.
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