Chapter 62
Cardiovascular Disease — 1
At the beginning of the twenty-first century, you might have thought cardiovascular disease was going to take a back seat to cancer as the leading cause of death. Some people projected there would be substantially less need for cardiologists. But to this day, heart disease still accounts for the greatest loss of lives of any disease, not just in the United States but globally.
The extraordinary progress made in my medical specialty is reflected in a graph that has been stuck in my mind since the first time I saw it (and didn’t decide to quit cardiology). While the graph (fig. 5.1a) shows a marked reduction for heart disease over half a century, the latest US data available indicates it has been increasing steadily since 2019 (fig. 5.1b), now with about one hundred thousand more deaths per year from heart disease than cancer (approximately seven hundred thousand vs. six hundred thousand, respectively, about 17 percent more). In 2010, there were eighteen heart disease deaths per ten thousand people; in 2021, that increased to twenty-one per ten thousand people. In contrast, during this same period, cancer death rates decreased to fourteen per ten thousand people. In 2024, most Americans did not know that heart disease was the leading cause of death.
These days, there’s a heart attack about every thirty-four seconds in the United States and a death attributable to these events every eighty-three seconds. Rather than the curves for fatalities from heart disease and cancer coming together, they are diverging. And the data are age-adjusted, which should markedly reduce the potential confounding effect of an aging population.
Figure 5.1a. Reduction in United States deaths from heart disease, 1960 through 2010. Adapted from George Johnson, “Why everyone seems to have cancer,” New York Times, January 4, 2014, https://www.nytimes.com/2014/01/05/sunday-review/why-everyone-seems-to-have-cancer.html?pagewanted=print.
Figure 5.1b. Recent increase in heart disease–related deaths, 2010–2022. AAMR: age-adjusted mortality rate. Adapted from Rebecca Woodruff et al., “Trends in cardiovascular disease mortality rates and excess deaths, 2010–2022,” American Journal of Preventive Medicine 66, no. 4 (April 2024): 582–89, https://doi.org/10.1016/j.amepre.2023.11.009.
What accounts for the reversal of this once promising curve for heart disease? The factors that helped achieve substantially less heart disease fatalities include markedly less cigarette smoking (from 45 percent in the 1950s to about 12 percent today), the use of statins (now in approximately one in four Americans), better control of high blood pressure, and procedures to restore blood supply, whether it be in the midst of a heart attack or in nonurgent settings with bypass surgery or stenting. In addition, various improvements for treating heart failure and serious heart rhythm abnormalities have led to extension of life in these high-risk populations.
It’s hard to pinpoint the reasons our hearts started killing us in greater numbers again. But we know the diabesity epidemic must be one of them. A deterioration across the many facets of lifestyle+ is likely also playing a part. Ironically, unlike other age-related major diseases, 80 to 90 percent of heart disease can be prevented by attention to the lifestyle+ factors discussed in part 1. It is indeed the most preventable of the chronic killers discussed in this part of the book.