Heart disease is still the top cause of death in the US, but the types of heart disease killing people are changing, a new analysis has found. While deaths from acute conditions such as heart attacks have declined, deaths from other types of heart disease such as heart failure, hypertensive heart disease, and arrhythmias have increased.
And that has important implications for primary care physicians (PCPs), who will shoulder much of the burden for caring for these patients who can survive acute threats such as a heart attack but go on to need care for chronic cardiac conditions, sometimes for decades.
The shift in practice is well known to Brent Smith, MD, a family medicine physician in Greenville, Mississippi, in practice for 14 years and a member of the board of directors for the American Academy of Family Practice.
“When I came through training, we would catch hypertension and treat it, catch heart failure and treat it, catch diabetes and treat it,” he told Medscape Medical News.
All that early diagnosis — along with better treatments — paid off and resulted in survival for patients who years ago would have died from a heart attack or other cardiac condition. However, now a growing number of patients have chronic cardiac conditions that need to be managed, and more of that management falls to the PCPs than in years past.
“It’s a success story for the system as a whole and a success story in a lot of ways for specialty-driven intervention, but it’s creating a system where more and more is placed on our PCPs,” Smith said.
And all this is happening, he said, when the US has a system that he termed “weak” on primary care, citing shortages as one factor. In 2022, there were more than 279,000 PCPs in the US, according to an analysis by the National Center for Health Workforce Analysis, but a projected shortage of 87,150 full-time equivalent PCPs is expected by 2037. And in 2024, 75 million Americans, or 22% of the population, lived in an area classified as a primary care health professional shortage area, with 13,075 additional physicians needed to eliminate the short fall.
Analysis in Detail
The new analysis tracked the age-adjusted rates of heart disease deaths among adults aged 25 years or older from 1970 to 2022, arriving at this scoresheet:
- Death rates from heart disease, overall, have dropped 66%.
- Deaths from heart attacks have declined by nearly 90%.
- Heart disease death rates dropped substantially from 41% of all deaths in 1970 to just 24% in 2022.
- In 1970, heart attacks killed more than half of people who died from heart disease. By 2022, less than a third of heart disease deaths were due to a heart attack.
- At the same time, the age-adjusted death rate from heart failure, hypertensive heart disease, and arrhythmia increased by 81%. While those causes accounted for just 9% of all heart disease deaths in 1970, they were the cause of 47% of all heart disease deaths in 2022.
- Deaths from arrhythmias increased the most — the age-adjusted death rate rose dramatically by 450%. (Even so, they accounted for only about 4% of all heart disease deaths in 2022.) The age-adjusted death rate from heart failure increased by 146%. And the death rate from hypertensive heart disease increased by 106%.
The improved outlook is due to a variety of advances, such as coronary artery bypass grafting, coronary care units, improvements in techniques, such as cardiac imaging, better medical therapies, expedited care to open blocked arteries, and effective therapies to lower lipids.
That changing scenario translates to extreme challenges for the medical community, agreed Sara King, MD, the study’s first author and a second-year internal medicine resident at Stanford University School of Medicine, Stanford, California. Noting the rising mortality from the chronic heart conditions, she told Medscape Medical News: “Prevention and treatment of these conditions start at the primary care level, where clinicians can identify individuals with these conditions, help manage their risk factors and disease, refer them to cardiology for specialized care, and have continuity throughout their lifetime.”
Follow-up of the surviving patients isn’t the only task, she said. Continuing to identify those at high risk and managing their risk factors is also crucial at the primary care level, she said.
PCPs: Changing Conversation, More Coordination
PCPs now need to coordinate more with cardiologists than in the past, Smith said. “We do more in conjunction with specialists than we ever did,” he said. With the growing pool of patients who need care, PCPs manage more of the patients now — patients they would have sent off to the specialists in the past, he said.
“The underlying story of that study is, ‘Someone didn’t die when they were 40 because we intervened,” Smith said. However, part two of the story is that the patient is now living with the consequences of whatever would have previously killed them. And they need ongoing management for those conditions.
Conversations with patients have changed. Smith cites congestive heart failure (CHF) as an example. He calls it the worst-sounding diagnosis because it understandably tends to scare patients. He tells them that while it’s the worst-named disease, “It does not reflect our current understanding of the process.” Then he explains to patients about treatment advances and what they must do to live a full, long live with CHF.
Another common conversation, he said, is educating the patient who survived a heart attack but now has an underlying arrythmia. “Now we are managing that arrythmia for 30, 40, or 50 years. And that longer life requires more care.”
The focus must shift to determine what the best therapy is now for the condition, he said, and to continue to do that, sometimes for decades, as treatments change and the diseases must continue to be managed and monitored.
Cardiology Perspective
The analysis is the good news, but also a wake-up call, according to Keith Churchwell, MD, the past president of the American Heart Association and adjunct associate professor of medicine at Vanderbilt University School of Medicine, Nashville, Tennessee.
For the long-term management of chronic cardiac conditions, he urged a new mindset. “We sometimes think after interventions that patients are ‘cured.’ In actuality, there needs to be a re-doubling of efforts to address their risk profile and the cause of why the MI [myocardial infarction or other issue] occurred.”
He urged PCPs to maintain close oversight of the heart disease patients in many areas — blood pressure, cholesterol management, weight, exercise habits, sleep, and diabetes.
For instance, he said, “heart failure [progression] can be a very subtle thing that can creep up on both the physician and the patient,” worsened by other developments such as pneumonia or a urinary tract infection, he said.
Emphasizing lifestyle management is crucial, Churchwell and King said. The American Heart Association has pioneered Life’s Essential 8, eight factors needed for optimal cardiovascular health.
Guidelines, Guidelines, Guidelines
Managing patients more closely, Smith and Churchwell said, depends on paying even closer attention to guidelines — from the American Heart Association, the American College of Cardiology, the American Diabetes Association, and the American Academy of Family Practice.
Expect guidelines to be updated more frequently, even yearly, Churchwell predicted, to keep pace with new treatments and other advances, and to be easier to access.
The focus must be on detecting conditions early and intervening early to reduce bad outcomes.
“Physicians are going to have to be more willing to seek out the guidelines,” Smith said, rather than passively accepting them as they are issued. The question providers must ask, he said, is “What is the best therapy we can do for this condition?” He noted, too, that with guidelines issued by numerous organizations, there’s not always a consensus.
“Not only do you need to be aware of the recommendations [regarding cardiac health], but you need to be aware of the differences between them and how you manage that.”
How? Don’t depend on a sole recommendation source, he said. Read all the pertinent information. Don’t read just formal recommendations but also white papers, position papers, and medical resources that offer a collection of unbiased, peer-reviewed information.
King, Churchwell, and Smith reported having no disclosures.