The new year is the time for resolutions. In the field of cardiovascular prevention, there is much room for improvement as we head into the new year. Despite better understanding of cardiovascular disease (CVD) risks and steadfast prevention efforts, recent data suggest a worsening trend in CVD risk mitigation in the United States (US).

Diabetes

In June 2021, Fang et al. published a New England Journal of Medicine study from the National Health and Nutrition Examination Survey (NHANES) detailing national trends in diabetes treatment and risk-factor control from 1999-2018 in the US.¹ The study found after steady progress from 1999-2010 among US adults with diabetes, the degree of glycemic and blood pressure (BP) control has since regressed while lipid controlled plateaued. Percent of participants with glycated hemoglobin <7% peaked at 57.4% in 2007-2010 then declined to 50.5% in 2015-2018. Meanwhile, the percent of diabetic adults with BP <130/80 mmHg peaked at 51.2% around 2007-2010 with a decline to 47.7% in 2015-2018. Percent of participants achieving non-HDL cholesterol <130 mg/dL was 25.3% in 1999-2002, improved to 52.3% in 2007-2010, but only increased to 55.7% since then. Based on data from the Center for Disease Control (CDC), the prevalence of diabetes in US adults increased from 9.5% in 1999-2002 to 13.0% or an estimated 34.1 million individuals in 2018.² During this time, a multicenter study of over 3 million youths aged 10-19 years found significant increases in the prevalence of type 2 diabetes from 0.34 per 1,000 youths in 2001 to 0.67 per 1,000 youths in 2017.³ This represented a relative increase of over 95% over 16 years.

Hypertension

The findings mirror trends in BP control among adults with hypertension between 1999-2018.⁴ The estimated proportion of adults with hypertension who had BP <140/90 mmHg increased from 31.8% in 1999-2000 to 48.5% in 2007-2008, remained stable at 53.8% through 2013-2014 but decreased to 43.7% in 2017-2018. During this time, the prevalence of hypertension reached a nadir in 2013-2014 at 41.7% and then increased to 45.4% in 2017-2018.⁵ Meanwhile, obesity prevalence in the US increased from 30.5% in 1999-2000 to 42.4% in 2017-2018 while prevalence of severe obesity (body mass index ≥40 kg/m2) increased from 4.7% to 9.2%.⁶

Potential Solutions

Although data are not yet available beyond 2018, these trends are troubling. The gaps in evidence-based care in the community can be attributed in part to patient non-adherence as well as therapeutic inertia among some medical providers. To this end, we as providers must remain motivated in guiding patients toward cardiovascular health via lifestyle modification and medications when needed.  Part of the issue may lie in the variable interpretation of complex and ever-changing scientific evidence. As Fang et al. postulate in their study, the major randomized trials on intensive versus conservative glycemic control from the late 2000s suggested that more intensive glycemic control did not confer additional cardiovascular benefits but resulted in increased hypoglycemia.¹ In the time after the publication of these trials, there was a shift towards more conservative management of diabetes and relaxation in glycemic control. To overcome potential confusion and misapplication of contemporary evidence, guideline working groups and professional societies should provide clear and concise guidance to clinicians using easy to understand graphics and flow diagrams with the understanding that a portion of providers may not be reading the fine print.  For instance, the American College of Cardiology has created "Guideline Hubs" that provide resources for clinicians and patients.

Concurrently, incorporation of technological innovations in fields such as machine learning, telemedicine, health apps and digital wearable devices can boost CVD prevention efforts. Big data and machine learning have long been buzzwords within cardiology circles. However, there has been increased interest in utilizing information captured from the electronic medical record as well as other data sources to implement actionable interventions in care delivery.⁷ The utilization of big data platforms in the development of clinical decision support and performance indicator tools can help to promote CVD prevention at a health systems level. The use of clinical apps such as online ASCVD calculators can further facilitate objective delivery of inventions in CVD prevention. Meanwhile, the increased adoption of telemedicine and direct-to-consumer technologies have the potential to improve access of care, increased personalization, and better patient engagement in prevention efforts.

Population-based health initiatives present yet another approach to improve cardiovascular risk factor control and affect large scale change. For instance, the recently published SSaSS clinical trial of 20,995 participants in rural China demonstrated the efficacy of a 75%/25% sodium chloride/potassium chloride salt substitute as a cost effective but potent strategy of reducing BP and risk for cardiovascular disease.⁸ Over a follow-up of 4.74 years, the group receiving the salt substitute had a mean reduction of systolic BP of 3.34 mmHg compared with control and importantly demonstrated significantly less strokes (primary endpoint) as well as major cardiovascular events and death. Similar large-scale initiates may be translated to the US setting. Regulations within the food industry can aim to curtail the amount of sodium content or high fructose corn syrup used in food preparation. Such initiates are not without precedent. For instance, the US Food and Drug Administration (FDA) designated partially hydrogenated oils, the primary dietary source of artificial trans fats in processed foods, as not Generally Recognized as Safe (GRAS) beginning in 2015.

The ongoing COVID-19 pandemic has no doubt diverted attention and resources away from the epidemic of heart disease. However, now more than ever, attention must be placed on CVD prevention not in spite but because of COVID, given the increase in morbidity and mortality among patients with clinical heart disease and elevated CVD risk.⁹ The means toward reversing the negative trends seen in the last few years likely necessitate a concerted effort by multiple stakeholders including patients, providers, public health and government entities, and the tech sector, among others. The campaign will be waged on multiple fronts. But the stakes are high enough that it will be a resolution worth fulfilling.

References

1. Fang M, Wang D, Coresh J, Selvin E. Trends in diabetes treatment and control in U.S. adults, 1999-2018. N Engl J Med 2021;384:2219-28.
2. National Diabetes Statistics Report (CDC website). 2020. Available at: https://www.cdc.gov/diabetes/library/features/diabetes-stat-report.html. Accessed 01/03/2022.
3. Lawrence JM, Divers J, Isom S, et al. Trends in prevalence of type 1 and type 2 diabetes in children and adolescents in the US, 2001-2017. JAMA 2021;326:717-27.
4. Muntner P, Hardy ST, Fine LJ, et al. Trends in blood pressure control among US adults with hypertension, 1999-2000 to 2017-2018. JAMA 2020;324:1190-200.
5. Ortchega Y, Fryar CD, Nwankwo T, Nguyen DT. Hypertension prevalence among adults aged 18 and over: United States, 2017-2018. NCHS Data Brief 2020;364:1-8.
6. Hales CM, Carroll MD, Fryar CD, Ogden CL. Prevalence of obesity and severe obesity among adults: United States, 2017-2018. NCHS Data Brief 2020;360:1-8.
7. Nasir K, Javed Z, Khan SU, Jones SL, Andrieni J. Big data and digital solutions: laying the foundation for cardiovascular population management (CME). Methodist Debakey Cardiovasc J 2020;16:272-82.
8. Neal B, Wu Y, Feng X, et al. Effect of salt substitution on cardiovascular events and death. N Engl J Med 2021;385:1067-77.
9. Cenko E, Badimon L, Bugiardini R, et al. Cardiovascular disease and COVID-19: a consensus paper from the ESC Working Group on Coronary Pathophysiology & Microcirculation, ESC Working Group on Thrombosis and the Association for Acute CardioVascular Care (ACVC), in collaboration with the European Heart Rhythm Association (EHRA). Cardiovasc Res 2021;117:2705-29.

Clinical Topics: Cardiovascular Care Team, COVID-19 Hub, Dyslipidemia, Prevention, Lipid Metabolism, Hypertension

Keywords: Cardiovascular Diseases, Glycated Hemoglobin A, Nutrition Surveys, Potassium Chloride, Sodium Chloride, Diabetes Mellitus, Type 2, Blood Pressure, Body Mass Index, COVID-19, Conservative Treatment, Cost-Benefit Analysis, Decision Support Systems, Clinical, Electronic Health Records, Glycemic Control, Obesity, Morbid, Obesity, Morbid, Pandemics, Patient Participation, Public Health, United States Food and Drug Administration, Risk Factors, Hypertension, Hypoglycemia, Evidence-Based Medicine, Stroke, Heart Disease Risk Factors, Centers for Disease Control and Prevention, U.S., Patient Compliance, Machine Learning, Wearable Electronic Devices, Heart Diseases, Telemedicine, Life Style, Lipids, Sodium, SARS-CoV-2

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