‘Troubling numbers’ reveal pandemic’s toll on CVD deaths, widening race disparities
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In 2020, heart disease remained among the leading causes of death, even amid the COVID-19 pandemic, which may have exacerbated preexisting CVD morbidity-related racial and ethnic disparities.
As the initial wave of the COVID-19 pandemic began, more than 3.3 million overall deaths were registered in the U.S., which exceeded the 2019 figure by more than 500,000 deaths, according to the American Heart Association’s annual Heart Disease and Stroke Statistics update.
CVD-related deaths in the U.S. increased from 874,613 in 2019 to 928,741 in 2020, the highest single-year occurrence of CVD deaths since 2003, according to the AHA’s 2023 report (Infographic on page 10).
While the total number of CVD-related deaths increased from 2019 to 2020, more startling to the authors was that the age-adjusted mortality rate increased by 4.6%, meaning the normal aging of the population, which has been increasing, did not account for the heightened deaths.
“Considering the impact of the pandemic, unfortunately delayed care for acute CV conditions such as heart attacks and strokes has taken a toll,” Cardiology Today Editorial Board Member Seth S. Martin, MD, MHS, FAHA, cardiologist at Johns Hopkins Hospital, professor of medicine at Johns Hopkins University School of Medicine and volunteer chair of the statistical update writing group, said in an interview. “Another important factor to consider is the interruption in CVD prevention services. There is an enormous burden of CV risk factors in our country, including hypertension, hyperlipidemia, obesity and diabetes, particularly among underrepresented minority populations. We were not getting the job done in controlling CV risk factors before the pandemic, and now this situation only worsened.”
The pandemic also cast a glaring spotlight on disparities in care for people from underrepresented groups, who were significantly more likely to be infected with SARS-CoV-2 and have underlying CV risk factors and were more likely to have barriers to accessing care. The result was a statistics report that shows a stark difference in CVD deaths based on race and ethnicity.
“The pandemic highlighted the underlying current of problems within our social structures in the U.S.,” Connie W. Tsao, MD, MPH, FAHA, assistant professor of medicine at Harvard Medical School, attending staff cardiologist at Beth Israel Deaconess Medical Center in Boston and volunteer past chair of the statistical update writing group, told Healio | Cardiology Today. “Those who study such disparities already knew this. For the lay public, it was not in everyone’s consciousness. This pandemic was a wakeup call to recognize that underlying disparities among marginalized groups are now getting worse.”
CV deaths during early pandemic
The 2023 statistical update details decades of population research in CV events and mortality, featuring updated data regarding health behaviors, health factors and other risk factors, CVDs and outcomes in the U.S.
The most recent update highlights the continued impact of the COVID-19 pandemic on public health and provides details on its effects on CVD and CVD-related mortality.
As of July 1, 2022, the cumulative number of COVID-19-related deaths in the U.S. was more than 1 million, translating to approximately 306 deaths per 100,000 Americans. As a result, the committee reported that life expectancy in the U.S. decreased from 78.8 years in 2019 to 77 years in 2020.
“A majority of the population did not have as good access to CV care” Michelle A. Albert, MD, MPH, FAHA, the Walter A. Haas-Lucie Stern Endowed Chair in cardiology, professor of medicine at the University of California, San Francisco, and AHA volunteer president, told Healio | Cardiology Today. “Hospitals were cancelling non-urgent procedures. People were afraid to go to the hospital. When they showed up, they had more advanced conditions. MI was more likely to be accompanied by cardiogenic shock, for instance.”
In 2020, 207.1 per 100,000 people died of CVD and stroke, causes that continued to rank ahead of annual deaths from cancer and chronic lower respiratory disease combined.
Researchers estimated that 19.05 million CVD deaths occurred globally in 2020, an 18.71% increase from 2010.
Overall, the crude prevalence of CVD was 607.64 million cases in 2020, a 29.01% increase from 2010; however, the age-standardized rate increased just 0.73% from 2010, according to the statistical update.
The rise in CVD deaths between 2019 and 2020 represents the largest single-year increase since 2015, according to the statistical update.
In 2020, CHD was the leading cause of CVD death in the U.S., representing 41.2% of all CVD deaths, followed by stroke (17.3%), other minor CVD causes (16.8%), hypertension (12.9%), HF (9.2%) and diseases of the arteries (2.6%), according to the document.
“These total CVD death numbers mean that, based on 2020 data, on average someone dies of CVD every 33.9 seconds in the U.S.,” Martin said. “This translates to over 2,500 deaths from CVD each day. These are indeed troubling numbers, and they begin to give us a glimpse into the pandemic years.”
The CVD death toll increased in women and men, Martin said. The largest increases in CVD mortality were observed among Asian, Black, and Hispanic people, he said.
“We are deeply concerned by what we are seeing overall and in specific subgroups,” Martin said.
Risk varies by race
The AHA report highlighted a decrease in the rate of decline of CVD-related deaths in recent years, which varied by race and ethnicity.
In 1999, the death rate from CVD among Black adults was 337.4 per 100,000 people compared with 156.5 per 100,000 people for Asian or Pacific Islander adults. In 2020, the rate of CVD-related death in the U.S. was 258.6 per 100,000 men and 125 per 100,000 women.
In 2020, the rate of CVD-related death among Black adults continued to be more than twofold of that of Asian or Pacific Islander adults, with 228.6 per 100,000 Black individuals compared with 90.1 per 100,000 Asian or Pacific Islander individuals.
Albert said people from minority backgrounds are more likely to have risk factors that elevate their risk for CVD.
“We know that hypertension and obesity — and 60% of Black or Hispanic adults have those conditions by age 60 years — elevates their likelihood of higher morbidity and mortality,” Albert said. “Then, throw in the social factors, including largely economic factors that tie into where people live and work and their ability to practice social distancing. If you are Black or Hispanic, chances are you are less likely to have the resources to be able to stay at home. If members of your family or community are more likely to be infected, that heightens your risk of being infected also.”
Many so-called essential workers were most exposed to the virus, exaggerating disparities already seen from social determinants of health when it comes CVD and CV deaths, according to Salim S. Virani, MD, PhD, FAHA, vice provost for research and professor at the Aga Khan University and staff member and adjunct professor at the Texas Tech Heart Institute and Baylor College of Medicine.
“These disparities had already existed, and the virus widened that gap even further,” Virani told Healio | Cardiology Today. “A classic marker is life expectancy. That gap was narrowing among races. Now, it is widening again.”
A ‘cascade in motion’
Experts agree pandemic conditions have exacerbated the worsening CVD trends; however, a return to pre-pandemic conditions is not enough to reverse the numbers.
“The reversal will come, but it will not be a rapid turnaround,” Tsao said. “During the past year, we have already seen vast improvements. Fortunately, the disease seems to be fairly under control. This is not over, but we have good vaccines, fairly widespread vaccination uptake and immunity at this point. The variants are less severe. That allows us to re-venture into the world of preventive care for everyone. It also gives us time, now that we are not in emergency mode anymore, to really think about how to make major changes for the future.”
For many people, conditions brought about by the pandemic —lifestyle changes, economic instability, job loss, the loss of family members and mental health challenges — will persist for many years, Albert said. Those issues complicate the effort to improve CV health.
“Once you set the cascade in motion pathophysiologically, by having worsened risk factors, unless those risk factors are attended to appropriately, then these numbers are not going to be a blip on the radar,” Albert said. “Additionally, we have a mental health crisis, and that mental health crisis is happening in tandem with corporations across the country laying off workers. People are silently quitting. There is inflation. The economic factors at play, coupled with the mental health factors, set the stage for a worsening situation. There is a relationship between stress and CV health. All of that has escalated.”
In a commentary published in Circulation in April 2020, Virani wrote that future waves of COVID-19, which are likely to continue for years, will “depict the mental health and economic fallout of this epidemic, which directly and indirectly influences the peak of the other curves.”
“Subsequent waves over the next 8 to 10 years will not be related to the virus itself,” Virani said. “They will be related to the indirect effects of this virus. Whatever we have lost in terms of BP control, diabetes, weight gain, poor lifestyle — this all affects future waves. People seeking care, adherence to lifestyle and medications, those things carry risk.”
Virani said clinicians must work to create the links they had with patients they were seeing before the pandemic.
“Mental health has declined considerably,” Virani said. “This is tied to physical health and wellbeing. We must look at the totality of what health and wellbeing means. We need to make sure our patients maintain relationships with family and loved ones.”
‘Partner advice with questions’
As the public health emergency recedes, health care providers must help patients access resources that relate to their CV risk factors in a way they have not done in the past, Albert said. That means going beyond telling a person that they need to make lifestyle changes. Instead, assess what might prevent a person from making such changes.
“Take physical activity. If someone lives in a community where they are afraid to walk outside, no matter how much you tell them to walk 45 minutes per day, 6 days a week, they are not able to do that,” Albert said. “You need to partner advice with questions. Ask, ‘What is your community environment like? Where would you go to get your physical activity if you were to do so?’ Then, give them tips. Perhaps there is a local YMCA gym, or the person could partner with a buddy to help keep them accountable.”
Attention to healthy diet, lifestyle and treatment of CV risk factors is critical, according to Eric Stecker, MD, MPH, chair of the Science and Quality Committee of the American College of Cardiology and professor of cardiovascular medicine (electrophysiology) at Oregon Health and Science University.
“Smoking and high BP remain the No. 1 and No. 2 preventable risk factors leading to premature death in the U.S.,” Stecker told Healio | Cardiology Today. “This is the case despite consistent declines in the rate of tobacco smoking in the U.S. over decades. Smoking and high BP are both easily identifiable risk factors with clear clinical guidelines providing direction for doctors, advanced practice providers and patients on how to treat them to improve health. We have no excuse for these remaining major causes of death and disability from heart disease and cancer.”
Martin said the AHA’s research networks are collaborating to bring forward creative solutions, investing in research on health technology and innovation, health equity in the prevention of hypertension and diversity in clinical trials.
“Moving forward, it is my hope that we will develop a stronger ability to efficiently translate research findings into practice,” Martin said. “As cardiologists, we can serve as champions for change. To facilitate change, we need to better align interests across patients, clinicians, hospitals and payors. We need to learn to leverage new digital health and artificial intelligence technology to dramatically scale what we can achieve in delivering CV care and promoting health.”
Widespread partnerships needed
Tsao said reversing CVD mortality and outcomes must result from a widespread partnership effort with multiple organizations.
“The patient has responsibility for their own health, but there is a lot that providers and external entities can do to facilitate positive change,” Tsao said. “Recognition is the first step, understanding the populations to target for intervention. Highlighting health disparities is important for epidemiologists and policy makers.
On a larger scale, cardiologists can use their voices to lobby or advocate for community organizations statewide and at the federal level to urge policy makers to develop programs that improve health.
“Subsidies to provide for basic needs, resources for healthy food, free medications, transportation — a lot of this involves collaboration with organizations that are bigger than any of us alone,” Tsao said. “But if we as health care providers and researchers can highlight these issues for those in government and community organizations, we can begin to work together to make change. A concerted group effort is required. Change will reverse these numbers, but probably more slowly than the converse happened.”
- References:
- COVID toll realized: CVD deaths take big jump, especially among certain populations. newsroom.heart.org/news/covid-toll-realized-cvd-deaths-take-big-jumps-especially-among-certain-populations. Published Jan. 25, 2023. Accessed on April 12, 2023.
- Kohli P, et al. Circulation. 2020;doi:10.1161/CIRCULATIONAHA.120.047901.
- Tsao CW, et al. Circulation. 2023;doi:10.1161/CIR.00000000000001123.
- For more information:
- Michelle A. Albert, MD, MPH, FAHA, can be reached at michelle.albert@ucsf.edu.
- Seth S. Martin, MD, MHS, FAHA, can be reached at smart100@jhmi.edu; Twitter: @sethshaymartin.
- Eric Stecker, MD, MPH, can be reached at steckere@ohsu.edu.
- Connie W. Tsao, MD, MPH, FAHA, can be reached at ctsao1@bidmc.harvard.edu; Twitter: @connietsaomd.
- Salim S. Virani, MD, PhD, FAHA, can be reached at salim.virani@aku.edu; Twitter: @virani_md.
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