Diabetes, Heart Disease, & Stroke - NIDDK

Decline In Heart Failure Deaths Has Been Undone, Led By People Under 45

Heart failure mortality rates are moving in the wrong direction, a new analysis reports, reversing a decline in deaths that means more people in the United States are dying of the condition today than 25 years ago. The concerning conclusion comes as newer medications are raising hopes for better outcomes in the years to come.

A research letter published Wednesday in JAMA Cardiology tracked U.S. Death certificate data from 1999 through 2021, revealing a steady drop in deaths until 2012, when rates plateaued, then began to rise steadily, and accelerated upward once the Covid-19 pandemic arrived. Disparities between men and women and among racial and ethnic groups moved up almost in lockstep, but there was one glaring exception: age. 

The death rate for people under 45 spiked 906% between 1999 and 2021, compared to increases of 364% for people 45 to 64 years old and 84% for those 65 and older. 

"If we are moving the obesity crisis, the liver crisis, and the diabetes crisis in the United States to younger ages, which is exactly what has been going on in the last decade, that is the result of what we are observing right now: shifting the heart failure incidence curve to a younger age group," said the paper's senior author, Marat Fudim. He is the medical director for the Heart Failure Research Unit and Heart Failure Remote Monitoring at Duke University Medical Center. "Many of the gains, and the acceleration, would actually be attributed to the young individuals with that age under 45."

Heart failure is a chronic, progressive condition in which the heart's ability to squeeze and then pump blood throughout the body weakens. Two main types are defined by a measure called ejection fraction. When the heart relaxes after squeezing normally, it's known as reduced ejection fraction; when it doesn't relax afterward, it's known as preserved ejection fraction. Symptoms can be the same for both groups, split roughly in half, but more medications are effective in treating symptoms for those with reduced than preserved ejection fraction. 

The risk of hospitalization is higher for people with preserved ejection fraction and their quality of life is lower, often making it difficult for them to leave their homes to do basic activities like going grocery shopping or even going to the mailbox. Preserved ejection fraction tends to go along with cardiometabolic disease: obesity, high blood pressure, diabetes, inactivity, "all of those things that we recognize have gotten worse over the last few decades," said Sean Pinney, chief of cardiology at Mount Sinai Morningside. He was not involved in the JAMA Cardiology paper. "We're seeing premature coronary disease in patients who are in their 30s and 40s, which, you know, 20 years ago would have been unheard of." 

Doctors are also seeing medications improve the prevention picture, said Clyde Yancy, chief of cardiology at Northwestern University, making it more urgent to use these and other measures early to control blood pressure, blood sugar, and other risk factors. He was not involved in the study but is deputy editor at the journal.

"We need to move way upstream and think about what we can do a priori to interrupt this process," he said about the data.

Yancy sees three explanations for higher death rates from heart failure: First, the persistence of risk factors and the necessity to intervene there. "That's actionable," he said. Second, the persistence of health inequities. "That is theoretically actionable, but it will require as much public policy as it will require medical therapeutics and lifestyle change." Third is the outsized influence of Covid-19, a phenomenon he said we have yet to understand. 

Over the time period covered in the JAMA Cardiology paper, doctors have gotten better at recognizing heart failure, Fudim and the other experts told STAT. Better testing perhaps contributed to increased heart failure diagnoses, reflected in the dataset from the Centers for Disease Control and Prevention on which the analysis was based. More people are surviving heart attacks now, so more people are living long enough to develop heart failure, which could explain higher prevalence in recent years.

There are limitations to the study's methodology of mining death certificates, the paper's authors note. The cause of death may not be accurate: In the case of deaths from opioid overdoses, for example, heart failure may have been cited when cardiac arrest was the cause, Mount Sinai's Pinney said. The steeper climb in death rates coinciding with Covid could mean people sick enough to be hospitalized and later diagnosed with heart failure were suffering from infection-related inflammation as well as economic distress that limited their health and access to health care, study author Fudim said.

The data preceded wide uptake of the wildly popular new obesity drugs, developed to treat diabetes but also proven effective in improving heart health, among other conditions. These new medications appear to work for heart failure patients across the range of ejection fraction, Pinney said.

"We have to see whether or not these new medications can offset the recent worsening in cardiovascular mortality. But I think the paradox is that at a time that we're seeing these increases in mortality, we also have access to better medications," he said. "We need to do a better job focusing on our systems of care delivery, to get the medications to the patient. If you can get all four classes of heart failure medications into patients with heart failure with a reduced ejection fraction, you can cut mortality in half."

Northwestern's Yancy said he was neither surprised nor sobered by the research letter's findings. 

"This really is quite the new day for those of us that have spent a career focused on heart failure," he said. "We've gone from having very little opportunity to offer hope to a scenario where we can not only offer hope but we can realistically talk about true improvement." 

STAT's coverage of chronic health issues is supported by a grant from Bloomberg Philanthropies. Our financial supporters are not involved in any decisions about our journalism.

The Slowly Evolving Truth About Heart Disease And Women

A century ago, so little was known about heart disease that people who had it resigned themselves to years of bed rest or, worse, an early death. Even less was known about how heart disease affected women – because nobody thought it did. Heart disease was considered a man's disease. If women had a role to play, it was in taking care of the men in their lives. Even the American Heart Association hosted a conference in the 1960s themed "How Can I Help My Husband Cope with Heart Disease?" and published a nutrition pamphlet titled "The Way to a Man's Heart." That attitude persisted throughout the 20th century, a time when questions about a woman's health were centered on the parts of her body under her bikini, said Dr. Gina Lundberg, clinical director of the Emory Woman's Heart Center and a professor at Emory University School of Medicine in Atlanta. "It was, 'Get a pap smear and a mammogram and you're good,'" she said. "We left out all the things we were checking men for, like diabetes and cardiovascular disease. But between a woman's breasts and her reproductive organs is her heart." Women were believed to have some natural protection from heart disease until their hormone levels dropped during menopause, Lundberg said. After menopause, it was believed that hormone replacement therapy could prolong that protection, a premise since amended to apply only to women who take it during the early stages of this transition. It wasn't until the turn of the century neared that evidence began to slowly emerge that women, as well as men, faced a substantial risk from heart disease, beginning at a much earlier stage in life and with sometimes differing symptoms than men. Left out of the research It wasn't until the mid-1980s when anyone began looking at how heart disease might affect women. That's when the Framingham Heart Study, the first in-depth, long-term cardiovascular investigation in the U.S., began reporting sex-specific patterns of heart disease, questioning whether the magnitude of this condition in women was being overlooked. The researchers noted that heart attacks were less likely to be recognized in women than in men. They also pointed out that prior investigations had failed to adequately assess sex differences in heart disease because an insufficient number of women were included in the research. Since heart disease was thought to predominantly affect men, only men were being studied. This started to change in the 1990s, after Atlanta cardiologist Dr. Nanette Wenger and others led a push for the equitable inclusion of women in National Institutes of Health-funded research. Doing so became NIH policy in 1989 and was written into law in 1993. But Wenger later said the legislation amounted to little more than a directive, falling short of achieving parity. "It had no teeth," she recently told The Fuller Project. Meanwhile, the prevention and treatment of heart disease in women was based on evidence that came from studies of predominantly middle-aged men, said Dr. Jennifer Mieres, a professor of cardiology and associate dean for faculty affairs at the Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York. "We thought that you could treat men and women the same," said Mieres, who was the first woman to be a full-time faculty cardiologist at Northwell Health's North Shore University Hospital. "We had great advances in treatment strategies, but we were applying a one-size-fits-all approach and clearly that wasn't working." A landmark 2001 report from the Institute of Medicine, a nonprofit policy research organization now known as the National Academy of Medicine, highlighted the underrepresentation of women in clinical trials and sex biases in medicine, calling for a better understanding of differences in how men and women were affected by disease. Mieres said women often failed to meet the criteria for clinical trials because their signs and symptoms didn't match assumptions about what constituted cardiovascular risk. "Our research criteria were customized to men as the gold standard." This realization led to a push for sex-specific clinical trials, allowing researchers to focus exclusively on how cardiovascular disease develops in women, she said. And that led to the discovery that heart disease caused by narrowed heart arteries is more complex and behaves differently in women than in men. Beyond the bikini: A new picture of women's health One of the biggest questions driving the push for more research was why, despite developing heart disease about 10 years later than men, more women were dying from it. And why were women under 65 twice as likely to die from a heart attack as their male peers? As researchers began to dig, a new picture of women's health emerged. One problem was health care professionals were doing less to protect women from heart disease, according to a 1999 report from the AHA and American College of Cardiology, the first women-specific clinical recommendations for the prevention of heart disease. For example, women were less likely to be counseled by health care professionals to reduce their cardiovascular risk factors, such as by losing weight, eating a healthier diet or becoming more physically active. They also were less likely than men to be referred to cardiac rehabilitation following a heart attack or bypass surgery. Mieres said it became clear that women needed better information so they could take control of their own health decisions. So, the AHA established Go Red for Women, a national campaign to raise awareness of heart disease and stroke as leading killers of women and to advance the science of sex differences in heart disease. It also joined forces with the National Heart, Lung, and Blood Institute, which was developing its own campaign, The Heart Truth. The two campaigns were launched back-to-back in 2003 and 2004.

Why The Entire Family Must Know The Signs Of Heart Attack

Don't wait to see if the symptoms go away – it's always better to be safe than sorry

Heart disease is the leading cause of death for both men and women in many countries around the world. A heart attack, which occurs when blood flow to a part of the heart is blocked, is a major event associated with heart disease. Recognizing the signs of a heart attack and acting quickly can significantly improve the chances of survival and minimize damage to the heart muscle. This is why it's crucial for everyone in the family, regardless of age, to be familiar with the signs and symptoms of a heart attack.

Early action saves lives

During a heart attack, time is crucial. The longer it takes to receive treatment, the greater the potential for heart damage. By recognizing the warning signs and calling emergency services immediately, you can significantly increase the chances of a successful recovery for yourself or a loved one. Even if the symptoms seem mild or atypical, it's always better to err on the side of caution and seek medical attention.

Heart attack symptoms don't always look like the movies

Hollywood portrayals of heart attacks often depict a person clutching their chest and collapsing dramatically. While chest pain is a common symptom, it doesn't always manifest in the same way for everyone. Some people experience no chest pain at all. Here's a breakdown of some of the most common signs of a heart attack, recognizing these in yourself or someone around you can be lifesaving:

Chest discomfort: This is the most common symptom, but it can vary greatly. It may feel like pressure, tightness, squeezing or a burning sensation. The discomfort may come and go or be constant.

Pain or discomfort in other areas: Pain can radiate to other parts of the upper body, such as the arms, back, shoulders, neck, jaw or teeth.

Shortness of breath: Difficulty breathing is another common symptom, often accompanying chest discomfort. It may feel like you can't catch your breath, even when resting.

Nausea, vomiting or indigestion: These symptoms can sometimes mimic heartburn or indigestion, but they can also be signs of a heart attack, especially in women.

Cold sweat: Breaking out in a cold sweat — often accompanied by clammy skin — can be a sign of a heart attack.

Lightheadedness or dizziness: Feeling faint or dizzy can occur during a heart attack, especially if there's a significant drop in blood pressure.

Extreme fatigue: Unusual and unexplained fatigue can be a warning sign, particularly in women.

Remember: Not everyone experiences all symptoms

It's important to remember that not everyone will experience all of these symptoms, and the severity can vary greatly. Some people may only have one or two mild symptoms, while others may have several intense symptoms. If you or someone you know is experiencing any of these warning signs, don't hesitate to call emergency services immediately.

Risk factors for heart attack

While a heart attack can strike anyone, certain factors can increase your risk. Understanding these risk factors can help you and your family take steps to prevent a heart attack:

Family history: Having a close relative (parent, sibling, child) with a history of heart disease increases your risk.

Age: The risk of heart attack increases with age.

High blood pressure: Uncontrolled high blood pressure is a major risk factor for heart disease and heart attack.

High cholesterol: High levels of LDL ("bad") cholesterol and low levels of HDL ("good") cholesterol can contribute to plaque buildup in arteries.

Smoking: Smoking significantly increases your risk of heart attack and other cardiovascular diseases.

Diabetes: Diabetes can damage blood vessels and increase your risk of heart attack.

Obesity: Being significantly overweight or obese increases your risk of heart attack.

Unhealthy diet: A diet high in saturated and trans fats, processed foods and added sugar can contribute to heart disease.

Physical inactivity: A lack of regular physical activity is a risk factor for heart disease.

Stress: Chronic stress can contribute to high blood pressure and other risk factors for heart attack.

Taking action for a heart-healthy family

There are many things you and your family can do to reduce the risk of heart attack:

Know your family history: Talk to your family members about their health history, particularly regarding heart disease.

Schedule regular checkups: Get regular checkups with your doctor to monitor your blood pressure, cholesterol levels, and blood sugar.

Embrace a healthy lifestyle: Eat a heart-healthy diet rich in fruits, vegetables and whole grains. Limit saturated and trans fats, processed foods and added sugar. Aim for at least 150 minutes of moderate-intensity exercise per week or 75 minutes of vigorous-intensity exercise. Manage stress through relaxation techniques like meditation or yoga.

Quit smoking: If you smoke, quitting is the single most important thing you can do to improve your heart health. Talk to your doctor about smoking cessation programs or medications that can help.

Maintain a healthy weight: If you're overweight or obese, losing even a moderate amount of weight can significantly improve your heart health.

Open communication is key

Having open communication within your family about heart health is crucial. Here are some tips:

Family discussions: Schedule regular family discussions about heart health. Talk about risk factors, healthy lifestyle habits and the importance of recognizing warning signs.

Encourage questions: Create a safe space for everyone in the family to ask questions and express concerns about their heart health.

Lead by example: Make healthy choices yourself and encourage your family members to do the same. Cook healthy meals together, get active as a family and prioritize stress-management techniques.

By being informed about the signs of a heart attack, understanding risk factors and taking steps towards a healthy lifestyle, you and your family can significantly reduce the risk of heart attack and promote overall cardiovascular health. Remember, early action is critical. If you or someone you know is experiencing any potential heart attack symptoms, call emergency services immediately. Don't wait to see if the symptoms go away – it's always better to be safe than sorry.

This story was created using AI technology.

---