State-by-State Stats Show Disparities, Lost Ground in CVD

Megan Brooks

April 24, 2018

The burden of cardiovascular disease (CVD) improved in all 50 states from 1990 to 2016, but large disparities exist between states, and the total burden of CVD increased in several states from 2010 to 2016, in a new analysis by the Global Burden of Cardiovascular Diseases Collaboration.

Most of the CVD burden is from atherosclerotic disease and 80% can be attributed to known modifiable risk factors, such as poor diet and high blood pressure.

These new estimates of CVD burden by state "can provide a benchmark for states working to focus on key risk factors, improve health quality, and lower health care costs," the researchers say.

"This study tells us which states are doing better and why, which is important for policy and program development," Ali Mokdad, PhD, from the Institute for Health Metrics and Evaluation, University of Washington, Seattle, who worked on the analysis, told theheart.org | Medscape Cardiology.

"What is really shocking," he said, "is we see a lot of disparities among our states that we shouldn't have in a country like ours, the United States, where we spend more money than anybody on health."

Their findings were published online April 11 in JAMA Cardiology.

A Call to Action for "Alarming" Trend

In a statement, Eduardo Sanchez, MD, chief medical officer for prevention and chief of the Centers for Health Metrics and Evaluation, American Heart Association (AHA), said the increasing burden of CVD in some states is "even more troubling in light of other unsettling trends that have been observed across our country in recent years. For example, life expectancy among women has decreased in some counties, and several studies have noted increasing all-cause mortality for some subgroups."

"We've celebrated a decline in overall mortality from CVD over the past 50 years, due largely to advances in prevention and treatment, but the benefits have been unequal across economic, racial, and ethnic groups. And the revelation of recent increases in the CVD burden in some states may signal that the favorable overall trends could be in jeopardy," said Sanchez.

"These statistics serve as a call to action to seize opportunities to renew tested public health and clinical approaches, forge new partnerships, and test innovative interventions to prevent and control CVD," he noted.

Mokdad and colleagues determined state-by-state levels and trends in CVD disability-adjusted life-years (DALYs) from 1990 to 2016 as well as the relative contribution of different risk factors underlying the levels and trends in DALYs, which describe the number of years lost due to ill health, disability, or early death.

Between 1990 and 2016, age-standardized DALYs for CVD decreased in all US states but the rate of decline varied widely.  Of note, it took 25 years for states with the largest burden of CVD to achieve levels observed among the healthiest states in 1990, the researchers say.

"States with the highest burden of CVD in 1990, such as Kentucky, West Virginia, Alabama, Arkansas, Louisiana, Tennessee, and Oklahoma, are only now achieving the 1990 levels of CVD burden in Massachusetts, Connecticut, and New Jersey," they report. Mississippi continues to lag as the state with the largest CVD burden. 

Sanchez said it's "not surprising" that the greatest CVD burden was observed in the a group of states reaching from the Gulf Coast to West Virginia, citing previous reports showing that many residents in these states fail to achieve the AHA's Life's Simple 7 cardiovascular health metrics: avoiding tobacco, eating a healthy diet, being physically active, and maintaining a healthy weight and healthy blood pressure, cholesterol, and blood sugar levels.

What's particularly concerning in the new analysis, the researchers say, is the fact that 12 states saw increases in the total burden of CVD from 2010 to 2016. This suggests that long-term decline in CVD may be ending. "New clinical or public health interventions delivered earlier in the life course may be required to alter this alarming trajectory," they point out.

Modifiable Risk Factors Driving Trends

Diseases caused wholly or in part by atherosclerotic vascular disease (ischemic heart disease, stroke, peripheral artery disease, or aortic aneurysm) made up the largest portion of CVD in all states. Most of this burden was due to ischemic heart disease. CVD DALYs remain twice as large in men as in women.

The researchers say several modifiable risk factors are driving the trends in CVD burden in the United States. The biggest one is diet, followed by high systolic blood pressure, high body mass index, high total cholesterol levels, high fasting plasma glucose levels, tobacco smoking, and low levels of physical activity.

"Now that we can better quantify the degree and drivers of regional variation in the CVD burden, we can intervene with more targeted strategies in the places that need it the most," said Sanchez.

Wayne Rosamond, PhD, Grillings School of Public Health, University of North Carolina at Chapel Hill, agrees. The fact that 80% of CVD burden could be attributed to known modifiable risk factors is a "potentially encouraging finding if we are to prevent the reversal of the decline in CVD burden across the United States. How to implement change in these risk factors at the population level remains a challenge," Rosamond writes in a related editorial.

This report by the Global Burden of Cardiovascular Diseases Collaboration is a "major step forward in the study and measurement of the burden and trends of CVD and may indeed provide benchmarks for regions committed to creating positive change and preventing a reversal of decades of favorable trends in CVD burden across the United States," Rosamond adds.

Mark D Huffman, MD, MPH, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, and associate editor, JAMA Cardiology, says the reported heterogeneity in this analysis is "striking and informative." 

Diet is the leading cause of health loss due to CVD and remains a "critical target for population- and individual-level interventions," he writes in an Editor's Note.

The recent rise in CVD burden in some states is a "major cause for concern given the extended period of decline in the CVD burden in the United States during the past half century. Do these states foretell a new normal for the rest of the country?... Estimates such as these, imperfect though they are, will be important for informing such decisions now and in the future," Huffman concludes.

The study was funded by the Bill and Melinda Gates Foundation. Mokdad has disclosed no relevant financial relationships. Disclosures for the coauthors are listed in the paper.  Rosamond has disclosed no relevant financial relationships . Huffman receives funding from the World Heart Federation to serve as its senior program advisor for the Emerging Leaders program, which is sponsored by Boehringer Ingelheim and Novartis. He also receives support from the AHA, Verily , and AstraZeneca for work to develop a surveillance system for the US food supply.

JAMA Cardiol. Published online April 11, 2018. Full text, Editorial, Editor's Note

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