Since the 1960s, the U.S. has watched heart disease death rates decline more than 70%, due in large part to decreases in smoking and treating risk factors like cholesterol. But in 2011, that downward trend did an about-face.
Among the 45 to 60 age group, heart disease death rates increased 1.5% from 2011 to 2016, according to an analysis by The Wall Street Journal. That adds up to 129,400 more deaths per year in adults under 65 – people in the prime of their working and family lives.
Even in Colorado, the third heart-healthiest state in the U.S., with a recognizable culture of outdoor exercise and wellness, more patients in their 40s and 50s are having heart attacks, according to the analysis.
What's driving this troubling trend?
Obesity and its related risk factor, type 2 diabetes, are replacing historical culprits for heart disease, such as smoking and high cholesterol. Obesity rates in the U.S. increased 7.2% between 1999 and 2014, up from 30.5% of the population to 37.7%, despite historical lows for smoking and cholesterol levels in the U.S. One consequence of obesity is developing hypertension, which remains a leading driver of heart disease and stroke.
Historically, heart disease care has been more focused on reacting to coronary problems than preventing them. Vast improvements have been made in post-heart attack treatment, including stenting and medications such as statins, but we aren’t doing enough to help patients avoid artery blockages, high blood pressure, type 2 diabetes, and promote a heart-healthy lifestyle.
Preventive cardiology, while still a relatively new field, employs advanced cardiac imaging, genetic testing, nutritional and lifestyle changes to combat the rise in heart disease. At UT Southwestern and through my work as President of the American Society for Preventive Cardiology, we are working to increase patient awareness and change the mindset surrounding heart disease.
Strong family history, genetic factors increase heart disease risk
Having a strong family history of heart disease is partly due to genetics and partly due to other factors. Approximately 10% to 15% of the U.S. population has a strong family history of heart disease. The risks in this group can include family traditions such as preferring sedentary instead of active family time or eating meals that typically include more unhealthy than healthy options.
Additionally, certain conditions that affect heart disease risk, such as high blood pressure or diabetes, tend to run in families. In others, the risk factor levels are OK and individuals are leading a healthy lifestyle, but there still are premature heart attacks in a family. These are the most challenging situations that can benefit from evaluation by a specialist. In fact, if both of your parents had a heart attack before they turned 50, you are seven times more likely to have one yourself.
Our health is strongly tied to our environment – if we have been taught or cornered into a certain way of life, it can become "the norm." Breaking that cycle can be a tough, but it's absolutely possible with a support network and the guidance of a preventive cardiologist.
It seems illogical that a healthy person who is active and strong can have a heart attack. But it happens, and when it does, the cause almost always is a genetic condition that runs in the family.
Familial hypercholesterolemia (FH) is a genetic condition that causes severely high cholesterol, regardless of optimal diet and exercise. It affects approximately 1 in 250 people, often causing no symptoms until the first heart attack or stroke, which typically occurs 10 to 15 years earlier than in those patients without FH.
If left untreated, heart disease risk doubles in patients age 20 to 39. Nearly half of men and 30% of women with FH will have a heart attack by age 60.
Patients with this disorder can take statins or PCSK9-inhibitors to manage their cholesterol. If that is not sufficient, we offer LDL apheresis, an advanced IV therapy that extracts excessive bad cholesterol (LDL) out of the blood. There are many other new treatments being tested for FH, and our patients have access to these clinical trials.
UT Southwestern is a site for the national CASCADE FH registry, in which patients can access the latest care options and information.
Related reading: 10 truths about statins and high cholesterol
The usual suspects: 5 controllable risk factors
Heart disease is almost always caused by more than one issue. According to the American Heart Association, 47% of U.S. adults have at least one of three key risk factors: smoking, hypertension, and diabetes.
More than 20% of 12- to 19-year-olds in the U.S. are considered obese, which can translate – without intervention – into a lifetime of health problems. And obesity keeps bad company, such as type 2 diabetes, high cholesterol, and high blood pressure – all factors that increase the risk of heart attack.
Whether inherited or not, type 2 diabetes rates are rising in the U.S. Approximately 10% of U.S. adults have been diagnosed with type 2 diabetes. Another 3.7% likely have it but are undiagnosed, and astonishingly, nearly 38% have prediabetes.
Less healthy diets and sedentary lifestyles are at the root of this increase, and the disease is developing earlier in many adults.
3. High blood pressure
Blood pressure tracks with weight. As the population gets heavier, hypertension rates also increase. As of 2016, 46% of U.S. adults have the condition. In 2016 alone, more than 82,000 people died as a direct result of high blood pressure.
The American Heart Association estimates high blood pressure will cost the U.S. approximately $220.9 billion by 2035.
While high cholesterol diagnoses increased 6% from 2006 to 2012, high cholesterol levels are declining in the U.S. Among patients taking medication, the average cholesterol reading dropped from 206 mg/dL to 187 mg/dL between 2005 and 2016.
Some of this can be attributed to innovative new drugs such as statins or PCSK9-inhibitors (both of which have roots at UT Southwestern) and therapies for severe cholesterol disorders, such as LDL apheresis.
5. Lack of exercise
From a lifestyle perspective, approximately 27% of people in the U.S. do not participate in leisure-time physical activity. Whether you live in a state like Colorado, where wellness is central to the culture, or somewhere less conducive to exercise, the takeaway is that we can't get healthy by osmosis – we have to participate.
If accessing a gym, trail, or rec league isn't feasible for you, talk with a preventive cardiologist about effective ways to get moving at home with free or low-cost resources. For those with heart disease, a preventive cardiologist can inform about ways to ensure that exercise is safe regardless of what types you enjoy.
Stress: the overarching nemesis
Stress is an umbrella that can influence all five risk factors listed above. Complicated to analyze at a societal level, long-term stress is still an important factor in middle-aged heart health.
Who among us doesn’t know a hardworking friend or loved one who has had a heart attack in their 40s or 50s? Extreme stress can lead to unhealthy coping mechanisms such as smoking, drinking, and other substance use. In these ways, stress-related heart disease can compound heart disease risk and negatively impact individuals, families, and communities.
What's most concerning to me in all these risk factors – both hereditary and environmental – is that self-care has been deprioritized. Proactive, preventive care is a pathway to help reduce heart attack deaths among middle-aged people in the U.S.
Seeing a preventive cardiologist
Cardiology used to operate under the "plumbing" approach: Where's the clog? What's the best way to get rid of it? How can we keep it from coming back? Oftentimes, treatment didn’t begin until a patient had a heart attack.
Today, we know that prevention is more effective than trying to correct the aftermath. And it's potentially more economical – from 2014 to 2015, the U.S. spent $219 billion on heart disease care, medication, and lost productivity. Between 2015 and 2030, these costs are expected to double. Research suggests that wider use of preventive care could drastically reduce these expenditures.
Going forward, we need to focus on preventing the initial artery clog. We can do this in many ways:
- Risk assessment is taking an inventory of a patient's risk factors and the risk of having a heart attack and stroke in the short term (10 years) and long term (lifetime). We want to match how aggressive we are to the patient’s risk.
- Lifestyle interventions including clinical nutrition services to prevent and manage heart disease through proper dietary choices, as well as exercise counseling, weight loss, and smoking cessation.
- Cardiac imaging tests, such as a cardiac calcium scoring, help us detect tiny clumps of cholesterol in the arteries before a significant blockage can form. These tests are currently the best crystal ball about heart disease.
- In some cases, genetic testing is warranted to help detect inherited mutations known to increase heart disease risk, such as chromosome 19 defects, that lead to familial hypercholesterolemia
None of these screenings is one-and-done. We will collate the results with your family history and personal risk factors.
Who is eligible?
With all these preventive services, the questions become who will benefit most and what is the critical age to seek care? The answer is not set in stone and something we continue to test through clinical trials.
Our current recommendation is for anyone with a family member who had a heart attack before age 65 visit with a preventive cardiologist for a personalized screening recommendation. Similarly, anyone with concerns about their cardiac health and those who want to ensure they're on the right track should also consider seeing us.
Do I need a referral?
Approximately half of our patients refer themselves – we love to see patients advocating for their health and seeking preventive cardiology care.
The other half typically are referred by their primary care doctors. Ironically, patients sometimes apologize to me when they visit since they don’t have a problem yet, which is why most people see the doctor. But that's the scenario we hope for – working with patients early to avoid problems down the road in their lifetime.
Occasionally, patients have come to us with a lot of plaque buildup or blockages that they didn't know were there. In cases like these, we have to work extra hard together to change course.
Ideally, we'd like to see you before any problems arise.
Preventive care in 2020 and beyond
The greatest challenge we have in the immediate future is increasing public awareness around preventive services. Here in Dallas, patients can self-refer for guided support to determine their personal risks and work with us to sculpt achievable goals to improve their heart health.
Looking toward the future, we must continue to expand our view of heart disease as a metabolic and endocrine condition as well as a cardiovascular disease. Because the development of heart disease is influenced by so many conditions, the UT Southwestern preventive cardiology team and other cardiologists around the country have adopted the term "diabetocardiologist" to describe the shift in cause and treatments for heart disease.
Particularly in the middle age population, we must become more vigilant and proactive to help patients take control of their heart health. From intercepting genetic heart issues to guidance for making healthier lifestyle choices, we are here to support you.