Yet Another US Report Shows Stalled Progress Against CHD

Clinicians should keep in mind social determinants of health and other barriers to care for their patients, one expert says.

Yet Another US Report Shows Stalled Progress Against CHD

Progress in the fight against coronary heart disease (CHD) has largely stalled in the United States, Centers for Disease Control and Prevention (CDC) data confirm. An annual phone survey conducted by the agency shows no shift between 2011 and 2018 in the proportion of people reporting a diagnosis.

Sourbha S. Dani, MD (Beth Israel Lahey Health, Burlington, MA), whose own work has tracked similar trends, said what stands out about the new study—which includes data on more than 3.5 million people spanning an 8-year period—is its scope. “The results are not surprising,” he said. “The findings are not new.”

Yet the analysis, published online in JAMA Cardiology, still offers insights, Dani added. For one thing, CHD prevalence has actually increased slightly for younger adults, perhaps due to traditional risk factors but also possibly related to societal issues such as the rural/urban divide and the opioid epidemic, he suggested.

Sophisticated approaches to PCI, novel devices, and pricey medications are appealing tools to curb CHD, Dani said, but they don’t answer what he believes are salient questions for clinicians: “Have we addressed the social determinants of health? Have we addressed the barriers they have?”

Even if patients are prescribed guideline-directed medical therapy, for example, they may not be taking their pills or doing so in a timely fashion. They may lack insurance or the money to buy the medicine in the first place. “In a 15-, 20-, 30-minute visit, all of these questions will have to be addressed,” said Dani, who added that these concerns also must be dealt with at a policy level.

Clinical trialists, too, have a role to play in better understanding disparities, Dani said, suggesting that studies be designed to gather information on social determinants of health from the outset. This would enable investigators to more accurately measure the performance of new therapies across diverse groups.

Geographic, Age Differences

Led by Yi-Ting Hana Lee, MPH (CDC Division for Heart Disease and Stroke Prevention, Atlanta, GA), the researchers analyzed publicly available data on more than 3.5 million people from the Behavioral Risk Factor Surveillance System, an annual telephone survey of noninstitutionalized adults across all 50 US states, the District of Columbia, and US territories.

Participants, as part of the survey, were asked whether a healthcare professional has ever told them they had angina or coronary heart disease or had experienced a heart attack (or myocardial infarction).

Overall, there was no change in CHD prevalence between 2011 and 2018 (P = 0.22), although there were small geographic differences. Prevalence dropped by around 1% in Utah (P < 0.001) and trended in that direction for Washington, DC, California, and Nebraska. On the flip side, there were increases in Oregon and West Virginia of approximately 1% and 2%, respectively.

Adults 65 and older saw an absolute decrease of 1.82%, whereas those ages 18 to 44 had an increase of 0.34% (P < 0.001 for both). For college graduates, prevalence dropped by 0.35% (P = 0.002).

Analyses focused specifically on 2018 showed men were more likely than women to report CHD (7.7% vs 4.6%), and demonstrated other differences related to age, race/ethnicity, education, and income. Insurance status had no impact. That year, CHD prevalence ranged from a low of 4.0% in Washington, DC, to a high of 10.6% in West Virginia.

Unlike the findings from 2011 to 2018, a prior analysis using the same database for the years from 2006 to 2010 showed a decrease in self-reported CHD, from 6.7% to 6.0%. The researchers caution, though, that the two studies can’t be compared directly, in part due to the advent of mobile phones in later years. Neither include people living in institutionalized settings like nursing homes.

But it would appear that declines in CHD prevalence are slowing, they suggest. “Trends in risk factors such as obesity, type 2 diabetes, high sodium intake, and hypertension may have important implications for the trajectories of CHD prevalence and mortality.”

The CHD Gap

As for social determinants of health, Dani cited factors such as low income and low education, noting that the term “marginalized populations” soon may not suffice across the board. “I don’t know if we should call them marginalized or not,” he pointed out, “because Hispanics and Asians will become the most predominant populations by 2050 or so.” The smallest group in the current study, American Indian or Alaska Native, amounted to only 62,989 participants but had a much higher CHD prevalence, hovering at around 10% to 11% over the years, than the other racial/ethnic groups. Another vulnerable group, Dani noted, are individuals living in rural areas.

Medicaid expansion starting in 2016 could also explain some of the disparities. “Many of the Southern states were very late in approving [this],” leading to poor risk factor control among their residents, said Dani. “That could have aggravated things.”

As risk factors—and social determinants of health—continue to accumulate differentially between the various populations, gaps in CHD prevalence will only grow wider, he predicted. The CDC survey could well underestimate the scope of the problem, he added, since people in underserved populations might not have access to phones or participate as easily.

  • Lee and Dani report no relevant conflicts of interest.