Physicians' Academy for Cardiovascular Education

Consequences of rising age and obesity on total CV burden not outweighed by better treatment

Literature - Pandya et al., Health Aff Oct 2013 - Health Aff (Millwood). 2013 Oct;32(10):1706-1714


More Americans Living Longer With Cardiovascular Disease Will Increase Costs While Lowering Quality Of Life.

 
Pandya A, Gaziano TA, Weinstein MC, Cutler D
Health Aff (Millwood). 2013 Oct;32(10):1706-1714
 

Background

While age-adjusted rates for cardiovascular (CV) disease mortality has been declining in the United States over the past decades [1], CV disease remains the leading cause of death and source of health care costs [2].
Improvements in treatment have made CV disease less fatal, but more prevalent [3]. Important risk factors have been reduced, such as high cholesterol levels and high blood pressure, and smoking [4-8], thanks to preventive strategies. At the same time, other risk factors such as a high body mass index (BMI), diabetes, and advanced age, have increased [7,9].
The authors therefore aimed to model the net effect of risk-factor and treatment trends on the incidence and prevalence of CV disease in future years. The model predominantly used data from the National Health and Nutrition Examination Surveys (NHANES). The impact of five ‘upstream’ policy-dependent variables (antihypertensive and lipid-lowering treatment, smoking, BMI and saturated fat consumption) on ‘downstream’ risk factors (total and high-density lipoprotein cholesterol (HDL-c), systolic blood pressure (SBP) and diabetes) were used to predict the risk and prevalence of CV disease.

 
Main results

  • The average ten-year risk of CV disease was 12.7% for men and 6.8% for women in 1991. The authors have calculated that it might rise to 15.1% and 8.6% respectively in 2030.
    When adjusting these averages for age, the risk declines for both sexes from 1991 to 2030.
  • Modelling future CV disease prevalence with keeping mortality at the 2010 rate, predicted a substantially lower mortality in 2030 than in the base-case scenario.
    When smoking or cholesterol treatment were kept constant at the 2030 rates, this yielded an increased CV disease risk and prevalence.
     Reducing treatment effectiveness also increased the risk, but reducing the saturated fat consumption did not significantly alter the predictions.
 
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Conclusion

This study analysed and projected trends in risk factors, prevalence and total (Framingham) risk of CV disease. The net effect of the divergent trends in individual risk factors observed from 1973 to 2010 suggests that the incidence of CV disease in the United States is likely to rise from 2015 to 2030. Age-adjusted risk is, however, expected to decline.
Thus, although major improvements in treatment and prevention of CV disease have been achieved, the positive effects do not outweigh the consequences of the aging population and the rise in obesity on the total risk of CV disease. The predictions models suggest that curbing obesity and improving cholesterol and BP treatment will yield the largest reductions of projected risk and prevalence of CV disease, highlighting the importance of prevention strategies.
 

References

1. National Center for Health Statistics. National Vital Statistics System data. Hyattsville (MD): NCHS; 2012.
2. Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics—2012 update: a report from the American Heart Association. Circulation. 2012;125(1):e2–220.
3. Rosamond WD, Chambless LE,Folsom AR, et al. Trends in the incidence of myocardial infarction and in mortality due to coronary heart disease, 1987 to 1994. N Engl J Med. 1998;339(13):861–7.
4. Gregg EW, Cheng YJ, Cadwell BL, et al. Secular trends in cardiovascular disease risk factors according to body mass index in US adults. JAMA. 2005;293(15):1868–74.
5.  Baigent C, Keech A, Kearney PM, et al. Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90,056 participants in 14 randomised trials of statins. Lancet. 2005;366(9493):1267–78.
6. Law MR, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. BMJ. 2009;338:b1665.
7. Stewart ST, Cutler DM, Rosen AB. Forecasting the effects of obesity and smoking on U.S. life expectancy. N Engl J Med. 2009;361(23):2252–60.
8.  Silverstein MD, Nietert PJ, Zoller JS, Silvestri GA. Predicted impact of attaining smoking reduction goals on mortality. South Med J. 2001;94(2): 176–83.
9. Olshansky SJ, Passaro DJ, Hershow RC, et al. A potential decline in life expectancy in the United States in the 21st century. N Engl J Med. 2005;352(11):1138–45.
 

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