Reversing CVD trends requires focus on health equity, early interventions
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PHILADELPHIA — CVD trends, particularly for HF, have gotten worse since 2011, and a way to address them may be to focus on health equity and begin prevention early, a speaker said at the Heart in Diabetes CME conference.
“Cardiovascular disease mortality rate declines have decelerated and reversed in certain subtypes such as heart failure, with persistent racial and ethnic disparities,” Sadiya S. Khan, MD, MSc, FACC, FAHA, assistant professor of medicine and preventive medicine, associate program director of the cardiovascular disease fellowship and director of research in the section of heart failure at Northwestern University Feinberg School of Medicine, said during a presentation.
In the United States, CVD declined between 1948, the start of the Framingham Heart Study, and 1978, when the Bethesda Conference was convened to determine the causes of the decline, Khan said.
She said the decline continued until 2011, when CVD rates plateaued, and the rates of ischemic heart disease and hypertension spiked in 2020, the first year of the COVID-19 pandemic. She noted that while 75% of excess deaths in 2020 could be explained by the COVID-19, the leading cause of the remaining excess deaths was CVD.
The CVD decline could be explained by improvements in risk factors such as smoking, BP, cholesterol and physical activity, but also by improvements in treatments, Khan said, noting that BMI and diabetes were contributing to increased risk for CV death even during the decline.
Age-adjusted mortality rates for HF started climbing in 2011, especially in non-Hispanic Black individuals, while age-adjusted mortality rates for CVD and ischemic heart disease did not, Khan said.
“The risk of CVD is increasing, and in younger people,” she said. “Rates of obesity are on the rise, rates of diabetes and prediabetes are on the rise, but what has been less noted is that rates of gestational diabetes have increased 4% per year since 2011.” The increase in gestational diabetes has been most pronounced in the non-Hispanic Asian population, she said. She also said the burden of all adverse pregnancy outcomes has increased.
Between 2011 and 2018, the age of diagnosis of diabetes was 4 years younger in Black Americans and 7 years younger in Mexican Americans compared with white Americans, suggesting that “using a single age as a milestone for screening for diabetes may increase disparities,” she said. She added there are also variations among races and ethnicities in the relationship between BMI and new-onset diabetes, so using a single marker of BMI may also contribute to disparities.
The CARDIA cohort study and other data showed that poor CV heath in late adolescence and young adulthood contributes greatly to premature CVD, she said. In fact, she said, there is evidence that CVD risk begins in utero, as offspring of women with gestational diabetes have increased CVD risk if no early intervention occurs.
Social and economic factors account for approximately 40% of CVD risk, and neighborhood factors contribute greatly to racial differences in incident CVD, Khan said, noting there is a close connection between neighborhoods with a high age-adjusted prevalence of CHD and those with a high social vulnerability index.
Improving health equity must be addressed on the societal, community, interpersonal and individual levels, she said.
“There is exposure on all these levels to interpersonal and structural racism, which we need to remember as we start to consider solutions from health policies, built environment strategies, household and/or work environment, as well as at the health system and health literacy level, to be able to try to bend the curve equitably in cardiovascular disease as well as eliminate disparities,” Khan said. “Bending the curve requires a focus on health equity beginning early in the life course, as early as in utero.”
Reference:
- Ford ES, et al. N Engl J Med. 2007;doi:10.1056/NEJMsa053935.
- Goff DC, et al. Circulation. 2021;doi:10.1161/CIRCULATIONAHA.120.046501.
- Jacobs DR Jr., et al. N Engl J Med. 2022;doi:10.1056/NEJMoa2109191.
- Perak AM, et al. J Am Coll Cardiol. 2020;doi:10.1016/j.jacc.2020.10.002.
- Wadhera RK, et al. J Am Coll Cardiol. 2021;doi:10.1016/j.jacc.2020.10.055.
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Khan SS. Session 1: Joint Symposium with Circulation. Presented at: Heart in Diabetes; June 24-26, 2022; Philadelphia (hybrid meeting).
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