Coronary Heart Disease Mortality Down, But Prevention Efforts Still Needed

SAN FRANCISCO, CALIF.—In the United States, the marked decline in age-adjusted mortality from coronary heart disease is a “success story,” according to Lee Goldman, MD, of Columbia University, New York. However, increasing incidence of diabetes and obesity are quickly offsetting the improvements made in primary prevention and will continue to contribute to the incidence of CHD.

“This will continue to increase prevalence and continue to put a patient burden on all of us for secondary prevention and treatment,” Goldman said during his presentation.

Changes over time

Lee GoldmanSince the late 1960s, age-adjusted CVD mortalities have declined, with death rates from stroke and CHD decreasing by about 70% and 60%, respectively, according to Goldman. In comparison, although there has been a slight decrease in the number of deaths from cancer in the last 5 years, other causes of death in the United States have remained fairly steady. “This reduction is picking up steam,” Goldman said, noting that from 1950 to 1960, heart disease death rates went up, but leveled out from 1960 to 1970. Since then, he said, there was a 3% annual decline through 1998 and a 5% annual decline since 1999. “This is really a remarkable success story,” he said.

“For most of this time, however, the absolute number of heart disease deaths was increasing; even though age-adjusted death rates were going down,” he said, an expected trend based on the increasing, and aging, population. As a result, overall death rates continue to rise. Since 2000, however, the absolute number of heart disease deaths has begun to decline, Goldman said.

Global death rates on decline

Globally, mortality incidence varies, with CHD death in men highest in Russia and lowest in Japan. But data from a number of studies demonstrate that the annual percent decline in CHD death rates in several European countries is fairly consistent at 3% to 4% per year.

There are a number of reasons for the decline, according to Goldman, including a continual decrease in age-adjusted mortality after acute MI. More aggressive interventions, particularly PCI, are responsible.

Since 1975, the risk for death from acute MI has declined by more than 50%, with therapies such as aspirin, beta-blockers, ACE inhibitors, aggressive therapy, CABG and cardiac rehab cited as ”major contributors in the decline in CV mortality in people who have heart disease,” he added.

Prevention in United States ‘still bad’

In the United States, Goldman reported that the percentage of adults with hypertension or high cholesterol and of those who smoke has decreased over the last 50 years. High cholesterol levels have dropped from 34% in 1961 to 15% in 2007, with most of the changes preceded by the use of statins. Similarly, smoking rates have declined from 39% in 1973 to 25% in 2007, as a result of non-smokers boycotting public smoking areas and nationwide smoking bans. Although the reduction in these risk factors explains 51% of the decline in CHD mortality in the United States, the real message is that the incidence of CHD has not been reduced as much as it should, Goldman said.

“[When it comes to] primary prevention, we’re still pretty bad,” he said. “Most of the benefit here, in terms of reducing heart disease mortality rate, has to [do] with what we as cardiologists do after people already have heart disease.”

Conversely, however, the rate of obesity and diabetes in the United States has increased significantly, with the prevalence of diabetes more than doubling since 1961. With rates like these, according to Goldman, a major reduction in heart disease is not on the horizon. As such, he foresees a continued need for intervention and improvements in secondary prevention.

“I don’t see, especially with the increase of obesity and diabetes, that we’re going to wipe out heart disease as we know it [or] that we’re going to see the incidence plummet. Rather, it’s going to be an ongoing battle of lifestyle changes that we seem to be losing, a battle of available medications that we may win, but it will mostly help us stay even,” he said.

Disclosures
  • Dr. Goldman reports no relevant conflicts of interest.

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