Despite COVID-19, Heart Disease Remains Top US Killer: AHA

Death and disability from COVID-19 have grabbed the headlines for the past 12 months, but as the American Heart Association (AHA)’s latest statistical update makes clear, heart disease remains the number one killer in the United States.

More than 125 million people, or roughly 50% of all adults in the United States, have cardiovascular disease, which is defined as coronary heart disease, heart failure, stroke, or hypertension. When hypertension is excluded, nearly 10% of the American population, or 26.1 million adults, had a diagnosis of CVD in 2018—the latest available data.

Heart disease and stroke are not affecting everybody equally, however. The AHA report reveals significant differences in the prevalence of all types of heart disease across racial/ethnic lines, with 14.6% of American Indian or Alaskan Native people having coronary heart disease, angina, or any type of heart condition/disease compared with 7.7% of Asian people. The prevalence is 11.5%, 10.0%, and 8.2% among white, Black, and Hispanic/Latino people, according to the AHA.

“Every year, cardiovascular disease and stroke remain the number one killer in our country, but there is a racial/ethnic disparity, as well as a geographic disparity, and the same holds true for risk factors as well,” Salim Virani, MD, PhD (Baylor College of Medicine/Michael DeBakey VA Medical Center, Houston, TX), chair of the 2021 AHA statistical update, told TCTMD. “There is a lot of difference here. We can’t look at the entire population with one lens. We have to look at different subgroups within our population.”

With the release of the 2021 update, the elephant in the room remains COVID-19 and the impact it might have going forward. Virani, for one, is worried.

Not only are there documented direct effects of COVID-19 on the heart and vasculature, but there is a flurry of indirect costs, too. “First and foremost is the deferral of care,” Virani said, highlighting the most recent report of spikes in CVD mortality that occurred in areas heavily hit by the pandemic, such as New York City. “We know that a lot of patients are very scared of coming to the hospitals, and yet we’ve not heard of a major outbreak in a US hospital. The hospitals have learned how to deal with COVID-19, and one important message is that patients should be very comfortable coming in to receive the care they need, just like they were pre-COVID.”

Targeted Interventions to Reach Different Populations

Published January 27, 2021, in Circulation, the AHA report is the culmination of a yearlong effort to provide the most up-to-date look at heart disease and stroke in the US.

Like past updates, the writing committee highlights the worrying and well-documented problem of obesity, diabetes, and physical inactivity in the US. For example, among adults 20 years or older, the age-adjusted prevalence of obesity is 40% in men and women, while one in five youths aged 2 to 19 years are considered obese. Roughly 26 million adults have diabetes, 9.4 million are suspected to have undiagnosed diabetes, and 91.8 million have prediabetes. Only one-quarter of adults meet the US recommendations for daily physical activity.

Among men and women, the prevalence of obesity is lowest in Asian adults, but highest in Hispanic men and non-Hispanic Black and Hispanic women. Across state lines, nearly 40% of adults in West Virginia and Mississippi are obese compared with 23.0% of adults living in Colorado. By region, one-third of people living in the southern and midwestern states are obese. The prevalence of diabetes varies by race and sex, too, and is highest in Hispanic men (15.1%) and lowest in non-Hispanic white women (7.3%). Among Asian subgroups, South Asian people have a significantly higher rate of diabetes (23.3%) compared with the national average.

Over the years to come, I am very worried about what the impact of this pandemic is going to be. Salim Virani

An analysis of the data revealed some positive trends for awareness, treatment, and control of hypertension that were evident in all race/ethnic groups, males and females, the lone exception being Black women. Based on the targets set out in the most-recent hypertension guidelines, though, the age-adjusted prevalence of hypertension is 47.3%, meaning there are a whopping 121.5 million US adults with high blood pressure. Among Black men and women, respectively, 56.6% and 55.3% have hypertension, rates that the AHA says are among the highest in the world. In both sexes, 38.1% have total cholesterol 200 mg/dL or more while 11.5% have levels 240 mg/dL or greater.

Given the disparities, Virani said the solution to combatting heart disease and stroke shouldn’t be a one-size-fits-all approach. Instead, primary and secondary prevention interventions will need to factor in cultural beliefs as well as potentially meet these groups where they’re at, such as a place of worship or barbershop.

“Rather than bringing people to the hospital for interventions, it’s becoming more and more obvious that we need to go out into the community, to meet people where they live,” said Virani. “Most of the work [these days] needs to happen around lifestyle interventions, and lifestyle interventions work much better when they’re part of someone’s routine.”

Smoking and high systolic blood pressure were the number one and two leading risk factors responsible for cutting US lives short. Elevated fasting glucose levels, obesity, and smoking were the three leading risk factors responsible for the most years of life lost to disease. Smoking rates on the whole were relatively stable, with 13.7% of US adults reporting smoking regularly. Most concerning, though, is the rise in the use of electronic cigarettes in young people. Among adolescents, e-cigarette use increased from 1.5% to 27.4% between 2011 and 2019. 

Worried About the Impact of COVID-19

With respect to the AHA’s “Simple 7,” an approach that promotes physical activity; a healthy weight; normal levels of total cholesterol, blood pressure, and fasting plasma glucose; abstinence from smoking; and a heart-healthy diet, Virani said meeting these goals remains a “challenge.” For instance, fewer than 1% of adults have an optimal diet as outlined by the AHA’s Healthy Diet Score, while just 52.4% and 40.8% had “ideal” total cholesterol and blood pressure levels endorsed by the AHA. 

Although ischemic heart disease remains the leading cause of years of life lost (YLL) due to premature mortality in the United States, the age-standardized rate of YLL has declined by 51% from 1990. Nonetheless, the economic costs of CVD remain significant. The average annual direct and indirect cost of CVD in the US is estimated to be more than $363 billion, with inpatient stays accounting for the largest direct cost based on the recent data. The estimated direct costs of CVD have risen, too, up from $103 billion in 1996-1997 to $216 billion in 2016-2017.   

The 2021 AHA statistical update also includes an enhanced focus on the social determinants of health and a new chapter focused on adverse pregnancy outcomes. “There has been quite a bit of work done in the space,” said Virani, noting a woman’s pregnancy history can serve as a marker of future CVD risk. For example, one meta-analysis showed that gestational hypertension was associated with a higher risk of subsequent CVD while preeclampsia was associated with a higher risk of CVD-related mortality. 

As for the long-term implications of COVID-19, Virani pointed out that hospital systems have been stretched incredibly thin this past year and said this might have an indirect impact on CVD rates. At the pandemic’s peak, cardiologists and nurses were pulled in different directions, and Virani worries this might have affected care for other CVD-related emergencies. There are also growing concerns about the morbidity and mortality impact of postponing elective cardiac procedures. “It remains to be seen,” he added, “but there is only so much you can do working in a hospital [during the pandemic].”

Virani predicts there will be an additional mental health impact from the pandemic that will have subsequent effects on CVD risk factors. For example, older people might be fearful of going outside for a walk and limit their physical activity, which could have an impact at the population level. Additionally, healthy diets during COVID-19 have suffered, and drinking habits might have increased given the stresses of 2020 and beyond. COVID-19 has had profound effects on “how we take care of ourselves” that could have a lasting impact, said Virani. “Over the years to come, I am very worried about what the impact of this pandemic is going to be.”