October 10th, 2013

Prevalence of Cardiovascular Disease Likely to Increase Despite Gains in Treatment

It is the best of times and the worst of times in the battle against cardiovascular disease. On the one hand, mortality rates from cardiovascular disease in the U.S. have dropped by more than half in the last 30 years, likely due in large part to improvements in treatment for elevated blood pressure and cholesterol levels and big declines in smoking. On the other hand, it is uncertain whether these gains will continue, and many experts think that cardiovascular disease may well be on the rise once again, largely due to the aging of the population and to increases in obesity and diabetes.

In an article in Health Affairs, Ankur Pandya and colleagues (including cardiologist Thomas Gaziano of Brigham and Women’s Hospital in Boston) forecast cardiovascular disease trends through the year 2030 using data from the National Health and Nutrition Examination Survey. They project that although the age-adjusted risk for cardiovascular disease is likely to continue to decline through 2030, the overall incidence of cardiovascular disease will increase because of an aging population and the increase in obesity.

The authors considered various scenarios relating to control of obesity, high blood pressure, and cholesterol. One important unknown factor is whether the recent stabilization in obesity will continue. If the trend holds, they write, 1.6 million fewer people will develop cardiovascular disease in 2030.

The authors warn that “the United States should expect to see a sharp rise in the health care costs, disability, and reductions in quality of life due to increases in the prevalence of cardiovascular disease.”

The study may also have an impact on the often controversial question of whether resources are better devoted to treatment or prevention: “our findings suggest that substantial reductions in incidence are crucial: Otherwise, improvements in mortality from cardiovascular disease (along with aging and obesity trends) will lead to a troubling increase in prevalence.”

They recommend the adoption of policies to reduce obesity and improve treatments of high blood pressure and cholesterol “to curb the imminent spike in prevalence of cardiovascular disease.”

One Response to “Prevalence of Cardiovascular Disease Likely to Increase Despite Gains in Treatment”

  1. Vimal Ramjee, MD says:

    Thanks for this important post Larry. I am certain that many cardiologists – particularly our preventive colleagues – find this study in line with their time-proven suspicions: Our health rests dominantly in our own initiative and anything short of this is merely a bandaid that is destined to fall off.

    Panyda and colleagues nicely re-hash through what is known to be a true problem not only in the United States, but increasingly throughout the world. They interrogate a well-established national source – NHANES – over the course of the past four decades to define and project forthcoming trends in cardiovascular disease. Interestingly, their findings mirror those sequentially published by the Center for Disease Control for obesity over the past 20 years (http://www.cdc.gov/obesity/data/adult.html). Many of us are familiar with these geographically sobering figures (once a US covered in beige, now wearing yellow and orange), demonstrating a true transformation from what used to be an endemic disease to an epidemic problem, and currently what most would consider a growing pandemic.

    As I contemplate these findings – recapitulating those of our past decades’ work – I believe the most important question is: What do we do next? We can give ourselves some credit for more efficacious therapy evidenced by an increase in treatment rates, however, as the authors point out, this is unlikely to keep on par with the exponential burden of CVD that we will see in the coming two decades.

    I believe the root of the problem needs to be emphasized in order to discover an enduring and powerful solution. To date, however, the dominant groundwork of our therapeutic interventions (self-improvement campaigns aside) have focused on reactive strategies – in other words, fixing or solving CVD after a given event; thereby, allowing for a growing incidence of disease.

    There is good literature on anthropological evolutionism, which is a science that notes our physiologic capacity (and therefore, our biochemical and metabolic capacity) is a cumulative accrual of inheritance from ancestors over millions of years – a miniscule of which occurs following the advent of the agricultural revolution. Our genetic composition, expression cues and physiologic processing capabilities have been primed by a lifestyle of our ancestors (i.e. hunter-gatherers, and the like). With the agricultural revolution came highly concentrated and refined foods in an unending tendency toward our palate, and therein we created our greatest problem: A world in which our genetic capacity is overwhelmed by the very foods we have intellectually created. Add to this, national self-reported physical inactivity (i.e. sedentary lifestyle) rates of 25-50%, and we have a good handle on the source of the CVD pandemic, as well as the unsurprising predicted growth potential noted by Pandya and colleagues.

    Noting these important considerations, it is evident that the only way we will really accomplish a tangible reduction in burden of disease is by helping people help themselves. We need to take personal initiative, which includes discerning equipoise in our eating habits with a very high threshold for what we put in our bodies, and ongoing physical activity of at least moderate nature. This simple recipe – a ‘defensive’ strategy, if I may – will reduce our burden of CVD, albeit over a long period of time (perhaps the same time it took to cause all of this damage). Until then, we will be dependent on reactive strategies and therapeutic alternatives to curb the hit. We have our work cut out for us.