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Trends in cardiovascular risk profiles

December 1, 2017|Cleveland Clinic Journal of Medicine
Samir Kapadia, MD
Author and Disclosure Information

Samir Kapadia, MD
Director, Sones Catherization Laboratories and Head, Section of Invasive and Interventional Cardiology, Department of Cardiovascular Medicine, Heart & Vascular Institute, Cleveland Clinic; Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH

Correspondence: Samir Kapadia, MD, Department of Cardiovascular Medicine, Heart & Vascular Institute, J2-3, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195; kapadis@ccf.org

This article is based on Dr. Kapadia’s presentation at the Sones/Favaloro Scientific Program, “Transforming the Delivery of Cardiovascular Care: Research and Innovation in the Heart & Vascular Institute,” held in Cleveland, OH, November 18, 2016. The article was drafted by Cleveland Clinic Journal of Medicine and was then reviewed, revised, and approved by Dr. Kapadia.

Dr. Kapadia reported no financial interests or relationships that pose a potential conflict of interest with this article.

ABSTRACT

Outcomes for patients with coronary artery disease (CAD) have improved in the past 20 years likely due to advances in clinical care such as angiotensin-converting enzyme inhibitors, antiplatelet agents, and reduced time to cardiac cauterization procedures. But how have the risk factors for CAD changed in the past 2 decades? Analysis of nearly 4,000 patients with ST-elevation myocardial infarction (STEMI) at a tertiary care center found that patients presenting with acute STEMI are younger and more obese than in the past. The prevalence of smoking, hypertension, and diabetes mellitus is also increasing. Primary and secondary prevention and aggressive efforts to modify risk factors for CAD is essential for further improvement in cardiovascular outcomes.

KEY POINTS

  • Advances in treatment of CAD have improved patient outcomes over the past 20 years.
  • Prevalence of risk factors for CAD has increased over the past 20 years in patients presenting with STEMI with patients now more likely to be younger and with higher prevalence of smoking, obesity, hypertension, and diabetes.
  • Emphasis on primary and secondary prevention to reduce CAD risk factors is needed to improve outcomes and reduce the cost of care.

TRENDS IN THE UNITED STATES

To evaluate whether geographic or patient population characteristics could have biased our results, we analyzed mortality and risk factor data from the National (Nationwide) Inpatient Sample (NIS) for patients presenting with STEMI (N = 445,319), non-STEMI (N = 915,341), and stroke (N = 937,425) from 2003 to 2013.4,5

Mortality rates

Consistent with the trend in our data, the 10-year NIS data showed a lower mortality rate in 2003 compared with 2013 in patients admitted with extreme-severity STEMI (22% vs 18%), non-STEMI (13% vs 8%), and stroke (15% vs 10%), as well as in patients with moderate-severity disease.4

Risk factors

NIS data also revealed a reduction in the percentage of patients age 75 and older admitted for STEMI, non-STEMI, and stroke consistent with younger age at presentation and an increased prevalence of CAD risk factors from 2003 to 2013 (Table 1).4 The percentage of female patients admitted is also decreasing, indicating the increasing prevalence of these conditions in males.

Unfortunately, the prevalence of these relatively preventable CAD risk factors is moving in the wrong direction. The prevalence of smoking in patients presenting with non-STEMI, STEMI, or acute stroke is higher than in the past, contrary to the nationwide trend of decreasing rates of smoking.6 The increased rate of obesity evident in our data and the NSI data is consistent with rising obesity rates in the United States, which went from 30% to 37% in adults and from 14% to 17% in youth from 2000 to 2014.7 The percentage of adults with diabetes has increased tremendously in the United States, from 4.4% of adults in 1994 to 9.1% of adults in 2015.8 The rise in diabetes has led to increased rates of CAD, heart disease, and stroke in patients with diabetes.9

OPPORTUNITIES AHEAD

Despite improved STEMI outcomes, trends in cardiovascular risk profiles are deteriorating, emphasizing the critical need to educate people about primary and secondary prevention. Folsom et al10 conducted an analysis of a community-based sample to determine the prevalence of ideal cardiovascular health based on 4 ideal health behaviors (nonsmoking, low body mass index, adequate physical activity, healthy diet) and 3 ideal risk health factors (total cholesterol, blood pressure, and moderate glucose control).10 Each of the 7 behavior and risk factors was defined by ideal, intermediate, and poor characteristics. Very few study participants (0.1%) had ideal levels for all 7 healthy cardiovascular behaviors and risk factors, and over 82% had poor levels for all 7 behaviors and characteristics. The need to educate and improve cardiovascular health exists for both adults and youth. Measures of cardiovascular health in the United States indicate that 18% of adults age 50 or older and 46% of youth (ages 12 to 19) have 5 or more of the 7 health cardiovascular behaviors and risk factors at ideal levels.11

Improvement in primary and secondary prevention measures may also present opportunities to contain or reduce the cost of care. Thus far, according to NIS registry data from 2003 to 2013, the mean adjusted cost of hospitalization for patients with STEMI increased about 14%, remained about the same for patients with non-STEMI, and increased about 3% for patients with stroke.4

CONCLUSION

Advances in clinical care have improved outcomes for patients with CAD during the past 2 decades. These gains have come despite a higher prevalence of CAD risk factors in patients. More emphasis on primary and secondary prevention to reduce CAD risk factors may further improve outcomes and possibly lower the cost of care. Aggressive encouragement of risk factor modification is necessary and should go beyond cardiologists to include primary care physicians, preventive clinics, secondary cardiovascular prevention, and population-based efforts.

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