The CFA Perspective

Coronary Artery Disease Epidemiological Update

Posted by John W. Meyer, LFACHE

2/13/20 10:00 AM

Amidst the constant barrage of clinical diagnosis and treatment news impacting coronary artery disease (CAD), and the delivery of related services, it is always instructive to be aware of the epidemiological news as well. Several news articles recently came to my attention that I wanted to pass on.

 These items are particularly relevant from a broad population health perspective, as proactively addressing CAD (as well as the social determinants of health) will continue to be a significant issue for all hospitals, physicians and payer organizations. Everyone should be cognizant of these underlying trends, as they will impact all providers, directly or indirectly, and their overall strategy and resource allocation decisions, for many years to come.

CAD Trends are Changing

CAD is the single leading cause of death in the U.S., accounting for about one of every three deaths. It is estimated that more than 17.6 million Americans have diagnosed CAD. It is slightly more prevalent in men than women and increases with age. However, despite these significant facts, the risk of death from CAD declined by 29.2 percent from 1996 to 2006. The risk of death and number of people dying from aged 40 to 60 has been declining. The risk of deaths among people in their 30’s has been stable. CAD used to be an older person’s disease. But it is changing! CAD used to be rare in the young. In the U.S., the average age for a first heart attack in men is 65. That is why CAD is thought of as a disease of senior citizens. But as many as 4 percent to 10 percent of all heart attacks occur before age 45, and most of these strike men.

Heart Disease Increasing in the Middle-Aged Populations

A recent article in the Wall Street Journal documents the fact that even in historically healthy communities, there is an increasing trend towards rising rates of CAD among 45 to 64 year old’s. The WSJ documents that death rates in three Colorado metro areas (Colorado Springs, Fort Collins, and Greeley) rose 25%. Similar reports of increasing death rates among these younger age cohorts are widespread. Their analysis of the changes in Cardiac-disease death rates among middle-aged people in metro areas concluded that:

“The underlying causes of CA disease are universal and difficult to address, public-health officials and doctors say. While the South and some other parts of the nation have perpetually high rates of death from heart disease and strokes, middle-aged CA deaths rates are rising even in places where these rates have been historically low.”

Causal factors include rising rates of obesity and diabetes, high blood pressure, drug and alcohol abuse, stress, and lack of physical activity (plus underlying genetic disposition to CAD).

…And in the Younger Populations as well

As reported by Harvard (refer to https://www.health.harvard.edu/heart-health/premature-heart-disease), premature deaths from CAD among young adults is also on the rise. The historical disease of senior citizens is trending downward.

In older men, nearly all heart attacks are caused by atherosclerotic blockages in coronary arteries. Conventional CAD also predominates in young adults, accounting for about 80% of heart attacks. About 60% of these young patients have disease of just one coronary artery, while older patients are more likely to have disease in two or three arteries.

The lion's share of heart disease in young adults is caused by the same risk factors that cause coronary artery disease in older men. The culprits include a family history of heart disease, smoking, high cholesterol, hypertension, abdominal obesity, diabetes, the metabolic syndrome[1], lack of exercise, hostility, and elevated levels of C-reactive protein. The opioid epidemic has also been singled out as a major underlying cause in both young and middle age.

Implications

In summary, CAD is no longer a disease of seniors, but is increasing among the young and middle aged. Overall trends in healthcare, and CAD in particular, are important reflections on goals, priorities and resource allocation. While the prevention, diagnosis and treatment of CAD has always been the triple aim of all healthcare practitioners, prevention and early diagnosis has historically been the greatest challenge. As hospitals and physicians continually assess their approach to prevention in particular, (the earlier in life the better since atherosclerosis can — and does — start in youth) they will need to be ever more cognizant of trends that impact their efforts, inclusive of epidemiological shifts and the social determinants of health, inclusive of multiple factors, including income levels.

Prescription

Every hospital will need to assess its approach to prevention, from early screening and education of (ever changing) targeted groups, through new and evolving screening and diagnostic programs, services and technologies. Tools such as CT Calcium Scoring programs have been highly successful in many communities. Early screening and detection programs are attempting to rule-out congenital issues in high school athletes. Church and other civic groups have formed weight control support groups, provide periodic blood pressure monitoring, stress management classes, smoking cessation and other relevant services with support from healthcare professionals. Traditional health fairs and community screenings continue to reveal at-risk people within larger populations. As population health approaches and digital health technologies continue to develop, additional targeted opportunities will likely be identified and healthcare providers will need to step-up.

If you are interested in learning more about any of this important issue or in cardiac services strategic development, service expansion and/or other programmatic needs for cardiovascular or other services, please contact CFA at (949) 443-4005 or by e-mail at cfa@charlesfrancassociates.com.


[1] Metabolic syndrome is a cluster of conditions that occur together, increasing the risk of heart disease, stroke and type 2 diabetes. These conditions include increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels.