Guest Editorial: To Stop the Rise in Cardiovascular Deaths, We Must Take Action outside the Clinic

Introduction

As healthcare professionals, we devote our careers to service. We hope to make a lasting impact for each of our patients. Our advancements in treating and preventing cardiovascular disease over the past few decades have made a clear impact, one patient at a time. As a nation, between 1981 and 2010, we were able to achieve a consistent long-term decline in cardiovascular deaths.1 Astoundingly, we are now seeing that the declining trend in cardiovascular deaths has reversed (Figure 1) and is on the rise again.¹

How can this be? While a new cause of death, COVID-19, entered the top ten causes in 2020, any overlap with that disease does not fully explain the cardiovascular deaths trend. Age-adjusted death rates from atherosclerotic cardiovascular disease (ASCVD), the most common and deadliest form of cardiovascular disease, had started to rise preceding the pandemic, and in 2020, ASCVD was an underlying cause of death for 416,096 Americans², killing more people than COVID-19.

Unfortunately, as we look deeper, while some demographics have seen continued improvement in cardiovascular outcomes, the burden of disease now falls disproportionately on underserved groups. Racial and ethnic minorities, women, and rural populations bear an outsized portion of poor cardiovascular outcomes. For example, Black Americans experienced the highest age-adjusted death rates among all races and ethnicities.³ Inequities in access to care and treatment, as well as the social determinants of health, have been shown both by research and our own experiences as clinicians to be powerful contributors to the increased cardiovascular risk factors existing in these populations.⁴

Take Health to Heart 

The urgency to better understand and make a greater impact on cardiovascular disease brought together the National Medical Association (NMA), the largest and oldest national organization representing African American physicians and their patients, and the Foundation of the National Lipid Association (FNLA). Our organizations realized that to truly make progress in reversing these alarming trends, we must advocate for public policy changes that address barriers outside the clinic doors – and to do that, we must educate policymakers and the public about the ongoing and deadly impact of cardiovascular disease. That is why we have joined forces to launch Take Health to Heart, a collaborative education and advocacy initiative. Our goal of stopping the rise in cardiovascular deaths may seem lofty, but we believe several achievable action steps can help us make progress towards that goal.

Education 

Our first step involves education. We hope to educate patients on the diagnosis and treatment of risk factors that lead to the development and progression of atherosclerotic cardiovascular disease (ASCVD). We also plan to educate elected officials and encourage them to prioritize ASCVD as a critical focus of their health policy agendas in state legislatures across America. We are convening a series of webinars discussing the impact of ASCVD on specific populations to elucidate the challenges we face as a nation and how the data translates to our everyday experiences; these discussions can help shape our policy efforts moving forward.

Quantifying the Burden of Disease

Our next step is to further investigate the current state of ASCVD in the United States. To help quantify the magnitude of the burden of ASCVD, the initiative released the State of the Heart, a new resource that estimates the prevalence of and mortality from the disease at the state and national levels. The resource also includes a first-of-its-kind analysis, that graded each state’s performance against the U.S. Department of Health and Human Services’ Healthy People 2030 targets for coronary heart disease and stroke mortality.⁵ It found that the nation received a near-failing grade of D on these two deadly manifestations of ASCVD. Equally alarming is that more than half of states and the District of Columbia received Ds (14) and Fs (13), indicating they are more than a 20-percent improvement away from reaching expert-recommended targets (Figure 2). Individual fact sheets for each state and D.C. are also available to help clinicians, patients, and policymakers better understand the burden of ASCVD and its risk factors in their own communities. Through this set of resources, we hope to draw attention to the urgency of the problem across the country. 

Policy Advocacy

Educating and raising awareness about the problem, however, is not a complete solution. We know that factors outside of our control as clinicians can impact our patients’ ability to maintain healthy hearts and avoid poor cardiovascular outcomes. Health behaviors and lifestyle decisions contribute to cardiovascular risk, and those are shaped by a complex set of societal barriers which contribute to the social and physical environment^6,7 – many of which are themselves rooted in structural inequities that amplify the wide disparities in ASCVD and other health outcomes we see today in underserved communities. Thus, improving access to care through policy advocacy is crucial.

This underscores the importance of reaching patients as early as possible and addressing these social determinants a key priority of Take Health to Heart. One program that is taking a strong step in improving access is the CDC’s Well-Integrated Screening and Evaluation for WOMen Across the Nation (WISEWOMAN) program. WISEWOMAN provides low-income, uninsured, and underinsured women ages 40-64 years with risk-factor screenings and services that promote healthy behaviors to reduce the risk for heart disease and stroke.⁸ Through our policy advocacy, Take Health to Heart calls for increasing funding for this program and encouraging more states to participate.

Breaking Down Barriers to Care

Even when patients reach our clinics and seek the care they need, we as clinicians face barriers caring for them. We experience a growing burden of complex paperwork to meet prior authorization requirements from insurers, with no guarantee that our patients will get the treatment they need. Even if they do, it could come weeks or even months later – time that could have been used to initiate treatment for the patient, lower their cholesterol levels, and thus mitigate the chances of a serious adverse event occurring. For lipid-lowering therapies, this disproportionately burdens populations who are already at risk for poorer ASCVD treatment and outcomes, like women and Black and Hispanic patients.⁹ Potential reforms to prior authorization policies may vary by state – as some dedicated healthcare provider advocates have already made tremendous progress on legislation – but what they have in common is ensuring a speedy, efficient, and comprehensive process that mitigates the administrative burden on providers and, most importantly, allows both treatments and services to patients in a timely manner.

We also face a challenge in the form of quality measures that grade us on process – the number of prescriptions written for statins – rather than clinical benchmarks that measure outcomes, such as reaching healthy cholesterol levels or targets which would indicate that patients are actually using their medications. We know that cumulative, prolonged exposure to high cholesterol is a critical risk factor for ASCVD, specifically heart attack, stroke, and death¹⁰; re-establishing LDL-C measures as a performance metric can help us better manage the disease, especially for the highest-risk patients. Take Health to Heart supports current efforts by our colleagues to update quality measures including re-introducing the measurement of LDL-C.¹¹

When barriers like these interfere with the clinical decision-making process, it undermines our ability to provide optimal care for our patients. And while we as clinicians are reminded of these barriers daily, policymakers, the public at large, and even our own patients are often unaware of the broad challenges outlined. Our education and advocacy efforts are key to addressing these barriers and thus tackling this population health challenge with the urgency it deserves. We are committed to developing resources that clarify that urgency to patients and policymakers in a comprehensible way.

Conclusion

In states across the country, legislative efforts to address these challenges are underway. As clinicians on the front line of the fight against ASCVD, we have seen the debilitating impact of the condition and the human toll it takes – and we are among those best-equipped to advocate for change. We are in a unique position to raise our collective voice for changes that will better serve our patients and improve cardiovascular outcomes for all Americans. By working together to create a more efficient and transparent prior authorization process, change the conversation around what quality looks like when it comes to ASCVD prevention, and better recognize and address the social determinants of health, we can make lasting progress towards stopping and reversing the rise in cardiovascular deaths.

The Take Health to Heart digital hub has a full suite of resources, including materials on our policy priorities and state-specific fact sheets on the burden of cardiovascular disease, to equip clinicians like us with invaluable tools to advocate for our patients and our communities on these critical issues. Visit TakeHealthtoHeart.org to learn more and to sign up for alerts to make your voice heard and help us turn the tide on cardiovascular health in the United States. 

Take Health to Heart is an advocacy and education initiative of the Foundation of the National Lipid Association and the National Medical Association. Take Health to Heart is made possible through sponsorship from Novartis Pharmaceuticals Corporation.

The Foundation of the National Lipid Association is a non-profit organization focused on providing education and resources to help patients and their families manage and overcome lipid-related health problems that may put them at risk for a heart attack or stroke.

The National Medical Association is the largest and oldest national organization representing African American physicians and their patients in the United States, serving as the collective voice of more than 50,000 physicians nationwide.

Dr. Liebeskind has no financial relationships to disclose. Dr. Collins has no financial relationships to disclose. 

References

1. U.S. Centers for Disease Control and Prevention (CDC). Leading Causes of Death Reports, 1981 – 2020. Last updated February 20, 2020. Accessed December 2022. https://wisqars.cdc.gov/fatal-leading (Cardiovascular disease deaths estimated as the combined total of all “Heart Disease” deaths and all “Cerebrovascular” deaths for each year between 1999 and 2020)
2. CDC. Mortality in the United States, 2020. National Center for Health Statistics. December 21, 2021. Accessed March 17, 2023. https://www.cdc.gov/nchs/products/databriefs/db427.htm 
3. Take Health to Heart. State of the Heart: Cardiovascular Disease Impact and Outlook in the United States. February 28, 2023.
4. Jilani MH, Javed Z, Yahya T, et al. Social Determinants of Health and Cardiovascular Disease: Current State and Future Directions Towards Healthcare Equity. Curr Atheroscler Rep. 2021;23(9):55. doi:10.1007/s11883-021-00949-w.
5. U.S. Department of Health and Human Services Office of Disease Prevention and Health Promotion. Heart Disease and Stroke. Healthy People 2030. n.d. Accessed March 16, 2023. https://health.gov/healthypeople/objectives-and-data/browse-objectives/heart-disease-and-stroke
6. CDC. Causes of Obesity. Last updated March 21, 2022. Accessed March 16, 2023.https://www.cdc.gov/obesity/basics/causes.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fobesity%2Fadult%2Fcauses.html
7. Danese A and Tan M. Childhood maltreatment and obesity: systematic review and meta-analysis. Mol Psychiatry. 2014;19:544-554. doi: 10.1038/mp.2013.54.
8. CDC. Division for Heart Disease and Stroke Prevention. WISEWOMAN. Last updated February 10, 2020. Accessed March 16, 2023. https://www.cdc.gov/wisewoman/
9. Partnership to Advance Cardiovascular Health. Rejected: How Life-Saving Heart Medication Eludes Women, Southerners & People of Color. June 2020. Accessed March 16, 2023. https://www.advancecardiohealth.org/resource/rejected-how-life-saving-heart-medication-eludes-women-southerners-and-people-of-color
10. Brandts J and Ray KK. Low Density Lipoprotein Cholesterol-Lowering Strategies and Population Health: Time to Move to a Cumulative Exposure Model. Circulation. 2020;141(11):873-876. doi:10.1161/CIRCULATIONAHA.119.043406.
11. Virani SS, Aspry K, Dixon DL, Ferdinand KC, Heidenreich PA, Jackson EJ, Jacobson TA, McAlister JL, Neff DR, Gulati M, Ballantyne CM. The importance of low-density lipoprotein cholesterol measurement and control as performance measures: A joint Clinical Perspective from the National Lipid Association and the American Society for Preventive Cardiology. J Clin Lipidol. 2023 Mar-Apr;17(2):208-218. doi: 10.1016/j.jacl.2023.02.003. Epub 2023 Feb 27. PMID: 36965958.