Cardiologists confront rise in preventable CV events

In September, the CDC released a Vital Signs report on premature CVD in U.S. adults that prompted concern. The report detailed that in 2016, among Americans aged 35 to 64 years, approximately 775,000 hospitalizations and 75,000 deaths occurred from MIs, strokes and other related conditions that are largely preventable.

“We are battling a fearsome foe, and indications are strong that we’re losing ground,” Janet S. Wright, MD, FACC, executive director of the CDC’s Million Hearts initiative, told Cardiology Today. “This report shows the magnitude of the problem, including that these preventable events are now occurring in younger people and that in others, progress is slow or stalling.”

Million Hearts is an initiative focused on preventing 1 million MIs, strokes and other CV events by 2022 through the help of health care and public health professionals, health care systems and communities.

The new CDC report underscores that many people are not taking recommended medications or making recommended lifestyle choices that would reduce risk for a CVD-related event. According to the report, approximately 9 million U.S. adults are not taking aspirin despite a strong recommendation, 40 million have uncontrolled high BP and 39 million are not using statins when indicated. In addition, approximately 54 million U.S. adults still smoke and 71 million are physically inactive (see graphic).

“The good news is that it’s not too late to make small changes that matter to heart health,” Anne Schuchat, MD, principal deputy director for the CDC, said during a press conference held by the agency when the report was released in September. “At any age, as adults, we all need to find out if you need ... to control high blood pressure and cholesterol with changes in diet or by taking medicine, to stop smoking and to be more physically active.”

“We know that getting to 80% performance of the ABCS — aspirin use, particularly in secondary prevention, blood pressure control, cholesterol management (statin as indicated) and smoking cessation and improvements made in sodium consumption and cardiac rehab participation, if all of those targets were hit, at least 1 million fewer CV events would be prevented over the 5-year period,” Wright said.

The Vital Signs report also addressed racial and geographical trends related to premature CVD. Black patients are more likely to develop high BP and less likely to have it under control compared with white patients. People who live in the Southeast and Midwest areas of the United States had higher rates of CV events compared with the rest of the country.

’Storm clouds on the horizon’

The rising rates of CHD and CV-related events in patients aged 35 to 64 years may be related to decades of increases in diabetes, obesity and physical inactivity. People are not eating as healthfully and are consuming more foods that are less heart healthy. As caloric intake increases and activity levels decrease, body weight and diabetes incidence increase as well, experts told Cardiology Today. Smoking plays a critical role, with an estimated 37.8 million U.S. adults who report smoking cigarettes, according to the CDC.

“It is as though we have seen the storm clouds on the horizon,” Wright told Cardiology Today. “We knew that these trends in diabetes, obesity and inactivity were operating in the background and at some point would have an impact on heart attacks, strokes and even deaths, and now we’re seeing that happen.”

Another factor is that many middle-aged adults may not be aware of or concerned about their increased risk for CHD and CV events based on their age alone. Clinicians may be overlooking these risks or hesitant to start medications that could be prescribed for a lifetime.

“It’s not just about age because we know that things like cigarette smoking could cause heart attacks earlier when you’re younger, that the rise in obesity is also shown in the rise in type 2 diabetes — a very strong risk factor for heart disease — and that many young people are developing type 2 diabetes a lot earlier than in the past,” Nieca Goldberg, MD, medical director of the Joan H. Tisch Center for Women’s Health at NYU Langone Health, said in an interview.

Even with these worsening risk factors, it is difficult to pinpoint the extent to which they may be the major cause of premature heart disease, experts said.

“Hypertension rates are going down, smoking is way down and high cholesterol rates are flat, but what’s changing is an almost doubling of diabetes rates in the last 20 years and an explosion of overweight and obesity,” Cardiology Today Editorial Board Member Karol Watson, MD, PhD, professor of medicine/cardiology, co-director of the program in preventive cardiology and director of the Barbra Streisand Women’s Heart Health Program at UCLA David Geffen School of Medicine, said in an interview.

As shown in the recent report, patients with indications for medical therapy are often not taking recommended therapies such as aspirin, statins and BP-lowering drugs. Although statins have been shown to reduce cholesterol, some patients are often hesitant to take them due to risk for potential side effects. Cardiac rehabilitation is another underutilized tactic shown to reap benefit in patients after ACS, especially among women, people of color, those with socioeconomic challenges and people living in certain parts of the country.

Increasing public awareness of premature heart disease is a critical step in trying to reduce the number of events in this population.

“There is the need to have the CDC, [American Heart Association] and other organizations continue their public educational efforts to counter come of the misleading information that’s on the internet that causes fear in our patients and often gets them to stop the lifesaving therapy, because they’re afraid of a side effect, a relative who had a side effect or they read something on the internet,” Robert Rosenson, MD, FACC, FACP, FAHA, FESC, professor of medicine (cardiology) at Icahn School of Medicine at Mount Sinai and director of cardiometabolic disorders at Mount Sinai Medical Center, told Cardiology Today.

“Part of the reason is that patients are not symptomatic, so they’re not experiencing any symptoms associated with high blood pressure or elevated cholesterol,” Eugene Yang, MD, associate professor of medicine at University of Washington in Seattle, member of the cardiovascular disease prevention council for the American College of Cardiology and chair of the hypertension group for the ACC, said in an interview. “Unless somehow we raise awareness of the importance of having these screened at the population level, then we’re potentially missing many people who have high blood pressure and high cholesterol who need to be either treated with medication or recommended for significant lifestyle interventions in order to try to optimize these risk factors.”

Impact with Million Hearts

The Million Hearts initiative was launched by HHS to focus on CVD prevention on national and local levels in an effort to improve CV health and care. Million Hearts began its first 5-year phase in 2012, with a goal to prevent 1 million MIs, strokes and other CV events by 2017.

Million Hearts 2022 is the second 5-year phase, informed by a refreshed review of the evidence and powered by new and expanded partnerships.

Members of the initiative are informed on what it will take to improve outcomes and achieve its goal. Some changes in lifestyle and medical therapy will be more difficult to achieve than others, experts said. When assessing the number of events that can be prevented, the two most powerful factors from a population-level perspective are hypertension control and statin use to reduce cholesterol, Wright said, noting that increasing patient participation in cardiac rehab can also have a great impact.

In a study published in the Journal of the American Heart Association in 2017, researchers found that 115,210 events were prevented in the first 2 years of the Million Hearts initiative with stable baseline strategies, and there was an excess of 43,934 events when baselines were based on trends. Authors called for an intensification of national action to address the recent plateaus or reversals in some event rates in order to further prevent CV events.

“I don’t feel that the effort was a failure,” Wright told Cardiology Today. “Instead, the foundation is now set for the really tough work of implementation. The job now is to try to accelerate progress in doing what works everywhere for everyone. The key is to keep sharply focused on a small set of evidence-based actions with the greatest impact.”

Adherence to aspirin may face a new challenge now that new evidence has emerged casting doubt on its role in primary prevention. In the ARRIVE trial, presented at the European Society of Cardiology Congress in August, aspirin did not reduce initial vascular events in a moderate-risk population with low event rates. In the ASCEND trial of patients with diabetes but no prior CVD, also presented at ESC Congress, aspirin prevented vascular events but caused major bleeding events. Then, in the ASPREE trial of older adults without CVD, aspirin did not reduce CVD risk and increased risk for major hemorrhage (see page 34).

Some say that the Million Hearts initiative is a success in progress but has been thrown off by dietary recommendations from the past.

“Most primary prevention strategies are working, but we probably inadvertently worsened the diabetes and obesity epidemics with our primary prevention dietary recommendations of decades past,” Watson said in an interview. “Carbohydrates were recommended in hopes of increasing fruits [and] vegetables and limiting fats. Unfortunately, many people chose simple carbohydrates [such as] cookies, candies and starches instead.”

Prevention is key

Although efforts to reduce the risk for CV-related events and CHD have been well-established, one of the main issues is the number of available health care providers for prevention, experts said.

“There are too many people seeing too few health care providers who can implement effective prevention,” Robert H. Eckel, MD, professor of medicine in the division of endocrinology, metabolism, diabetes and cardiology; professor of physiology and biophysics; Charles A. Boettcher II Chair in Atherosclerosis at the University of Colorado Denver Anschutz Medical Center; director of the lipid clinic at University of Colorado Hospital in Aurora; and past president of the AHA, told Cardiology Today.

Time is another issue, with CVD prevention discussions with patients often limited to a 15- or 20-minute interactions.

“Someone [may live] in a community where it’s not safe to exercise or be physically active, or they don’t have access to healthy food or don’t know how to prepare healthy food, or they are in a work setting that doesn’t promote healthy habits like nonsmoking and physical activity during the workday,” Wright told Cardiology Today. “It would be very hard for that clinician to have the kind of impact that he or she might want to have, which is why it is critical to couple clinical efforts with those of communities and public health professionals.”

Physicians can show patients how their lifestyle is contributing to higher risk for heart disease, which can help them take their CV health more seriously, experts said. This can carry over to the workplace, for example, as employers can provide areas where employees can be physically active, have their BP checked and learn how to monitor BP at home, in addition to having heart-healthy food options available at cafeterias and vending machines.

“The [Million Hearts] initiative alone can’t succeed without interventions from actual employers to take an active role in trying to help because the population we’re talking about are generally people who are employed working in different companies, etc,” Yang said in an interview. “They need to share a greater responsibility to try to ensure the health of their employees. They clearly have a vested interest because the loss of time from their own employees going out because of developing these complications is significant.”

Cardiologists’ role

The role of cardiologists and other health care professionals is critical to reduce the number of CV-related events in patients aged 35 to 64 years, especially in implementing the ABCS of CV health, according to the Vital Signs report.

“Cardiologists can serve as a resource to try and provide important guidance to the family,” Rosenson told Cardiology Today. “Then hopefully they’ll go to the family members, the primary care physician and other medical subspecialists regarding risk factor modification. The cardiologist should know the data and make recommendations that are consistent with our national guidelines and national consensus documents. Cardiologists play a very important role as professionals in this system.”

Cardiac rehab is another area where cardiologists can weigh in so that patients who have an indication for it not only get referred, but also have the value of it emphasized to them, experts said. Cardiologists can be advocates for cardiac rehab to their patients through their leadership roles within their institution and within their health system, experts said.

Above anything else, a cardiologist’s focus on prevention can make a major impact on reducing the risk for CV events in this patient population, especially in those with multiple risk factors, a strong family history of premature heart disease or one severe risk factor like high cholesterol, experts said.

Cardiologists who have access to a rehabilitation clinic have the potential to reduce the risk for CV events by making sure their patients know about it.

“Any cardiologist who has a clinic sees patients after an event or in prevention of an event,” Eckel told Cardiology Today. “They just need to make these simple steps along this pathway of prevention much more important in their clinical practice.”

Regardless of the specialization, cardiologists need to know the importance of reducing risk before more events occur in patients aged 35 to 64 years.

“I’m very concerned that we’re going to see a resurgence of heart disease if we don’t act,” Goldberg said. – by Darlene Dobkowski

References:

• CDC. Preventing 1 million heart attacks and strokes. Available at: www.cdc.gov/vitalsigns/million-hearts/. Accessed Oct. 22, 2018.
• CDC. Current cigarette smoking among adults in the United States. Available at: www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm. Accessed Oct. 22, 2018.
• Gaziano JM, et al. Lancet. 2018;doi:10.1016/S0140-6736(18)31924-X.
• McNeil JJ, et al. New Engl J Med. 2018;doi:10.1056/NEJMoa1805819.
• Ritchey MD, et al. J Am Heart Assoc. 2017;doi:10.1161/JAHA.117.006021.
• The ASCEND Study Collaborative Group. N Engl J Med. 2018;doi:10.1056/NEJMoa1804988.

• For more information:
• Robert H. Eckel, MD, can be reached at Cardiac and Vascular Center-Anschutz, 12605 E. 16th Ave., 3rd Floor, Aurora, CO 80045; email: robert.eckel@ucdenver.edu.
• Nieca Goldberg, MD, can be reached at NYU Langone Joan H. Tisch Center for Women’s Health, 207 E. 84th St., New York, NY 10028; email: nieca.goldberg@nyumc.org; Twitter: @DrNieca.
• Robert Rosenson, MD, FACC, FACP, FAHA, FESC, can be reached at Mount Sinai Comprehensive Health Program Downtown, 275 Seventh Ave., 12th Floor, New York, NY 10001; email: robert.rosenson@mssm.edu.
• Anne Schuchat, MD, can be reached at Centers for Disease Control and Prevention, 4770 Buford Highway NE, MS F-73, Atlanta, GA 30341; email: acs1@cdc.gov.
• Karol Watson, MD, PhD, can be reached at Cardiovascular Center, 200 UCLA Medical Plaza, Suite 365, Los Angeles, CA 90095; email: kwatson@mednet.ucla.edu; Twitter: @kewatson.
• Janet S. Wright, MD, FACC, can be reached at Centers for Disease Control and Prevention, 4770 Buford Highway NE, MS F-73, Atlanta, GA 30341; email: janet.wright@cms.hhs.gov.
• Eugene Yang, MD, can be reached at UW Medicine Eastside Specialty Center, 3100 Northup Way, Box 356005, Bellevue, WA 98004; email: eyang01@uw.edu; Twitter: @DrEugeneYang.

Disclosures: Eckel, Rosenson, Watson and Yang report no relevant financial disclosures. Goldberg reports she received honoraria from Bristol-Myers Squibb. Schuchat and Wright are employees of the CDC.