Where do we stand on cardiovascular health in America?
In the first of what the Journal of the American College of Cardiology promises will be annual editions, a new analysis drawn from nationally representative surveys, administrative claims, clinical registries, and vital statistics paints a picture of disease burden, quality of care, and mortality trends.
For each of the five risk factors and five conditions, there are wins, losses, and status quo.
Half of Americans still have high blood pressure, unchanged from 2009 to 2023. Both diabetes prevalence and deaths are growing, particularly among younger adults and people of low income. More than 40% of adults have obesity. Most adults with high “bad” cholesterol aren’t taking statins that could lower it. And while smoking rates are down overall, looking closer at low-income adults reveals rates twice as high as national levels, while young people’s e-cigarette use is climbing.
As for the conditions these risk factors point to, rates of coronary heart disease have been rising since 2019, and only half of people who could benefit from medications are taking them. Hospitalizations for heart attacks have fallen but have gone up among young people. Deaths from heart failure declined from 1999 to 2011, but that drop has reversed and spiked since the Covid-19 pandemic. Peripheral artery disease affects 1 out of 4 adults, but nearly half of the people who undergo corrective procedures leave care without what’s considered full guideline-directed medical therapy. Then there’s stroke, the fifth leading cause of death in the country, which translated into 1 of 20 deaths in 2023. A note of mild optimism from the report: Stroke care has improved but its quality could still be better.
“JACC is creating a consistent benchmark that allows us to track progress over time and ask a simple but critical question each year: Are we actually moving toward better cardiovascular health for all?” lead author Rishi Wadhera, a cardiologist at Beth Israel Deaconess Medical Center and Harvard Medical School, told STAT via email about the report, published Monday in JACC.
Here’s more of the conversation, lightly edited for length and clarity.
Can you tell me what inspired this report?
The motivation behind this report was accountability. Progress depends on clear-eyed understanding — on being honest about where we are, where we’ve made gains, and where we’re falling behind.
Our goal was to make the state of cardiovascular health clear not just to researchers and clinicians, but also to patients, the public, and policymakers who shape decisions that directly affect cardiovascular health.
Do you find the data sobering? Surprising?
Both. The data are sobering because they show that for many major cardiovascular risk factors, such as hypertension, diabetes, and obesity, we’ve stalled or moved in the wrong direction over the past decade. In some areas, mortality is rising again, particularly among younger adults and populations that have historically faced barriers to care.
What’s surprising is how wide the gap is between what we know works and what’s happening in practice. We have highly effective therapies and clear clinical guidelines, yet far too many patients are not receiving treatment or achieving adequate control. That disconnect between scientific progress and real-world outcomes is one of the most striking — and concerning — findings of this report.
Why aren’t we doing better in cardiovascular disease?
We’ve made extraordinary scientific advances, but progress in cardiovascular health isn’t limited by innovation — it’s limited by implementation. Too often, prevention is fragmented, risk factors go undetected or untreated, and care falls apart once patients leave the clinic.
Cardiovascular disease is shaped as much by where people live, work, and eat as by what happens in the health care system. You can’t treat your way out of a prevention problem. When access to insurance coverage, healthy food, safe places to exercise, affordable medications, and continuous care are uneven, outcomes will be uneven, too.
The result is a widening gap between what’s possible and what’s delivered. Until we align our health system, public policy, and community investments around prevention and long-term risk factor control, we’ll continue to see avoidable heart attacks, strokes, and deaths.
How much of this story is unique to the United States among peer nations?
A meaningful part of this story is uniquely American. Many high-income countries are grappling with rising obesity and diabetes, but the U.S. stands out for how consistently those risks translate into worse cardiovascular outcomes, and for how wide the gaps are by income, race and ethnicity, and geography.
Two things are especially distinctive. First, we’re world-class at high-tech rescue care, but far less consistent at prevention and long-term risk-factor control at the population level. Second, the U.S. has a more fragmented health system and a weaker social safety net, with gaps in insurance coverage, affordability of medications, access to primary care, and the environments that make healthy choices feasible.
One doctor told me nearly two years ago that more people are surviving heart attacks long enough to develop heart failure. Does that ring true to you?
Yes, that absolutely rings true. In many ways, this reflects a major success story in cardiovascular medicine. We’ve become much better at getting people through heart attacks and saving lives in the short term. But survival is not the end of the story. For some patients, a heart attack can leave lasting injury to the heart muscle, which increases the risk of developing heart failure over time. At the same time, rising rates of hypertension, diabetes, and obesity are compounding that risk.
What we’re seeing is a shift in the landscape of cardiovascular disease: more people living longer after acute events, but with a greater burden of chronic cardiovascular illness. That’s why prevention, early detection, and long-term management matter just as much as emergency care.
Where are we going backward?
We’re seeing reversals across several foundational drivers of cardiovascular health. Hypertension is a prime example — nearly 1 in 2 U.S. adults now meets criteria for high blood pressure, and many are unaware they even have it. Despite being highly treatable, progress in detection, treatment, and control has largely stalled over the past decade. Diabetes prevalence and complications continue to rise, particularly among younger adults and people with lower incomes, and obesity has reached epidemic levels across nearly every demographic group. And after years of improvement, we’re seeing warning signs in conditions like heart failure and stroke.
What’s most concerning is that these reversals are not evenly distributed. They are concentrated in younger adults and communities already facing barriers to care, setting the stage for a growing burden of cardiovascular disease in the years ahead.
What are some other surprises in the data?
One of the biggest surprises was how little progress we’ve made in treating and controlling common cardiometabolic risk factors like hypertension, diabetes, and high cholesterol, even as therapeutic options have expanded. We have more effective medications and clearer guidelines than ever, yet treatment and control rates for these conditions have barely budged.
Another striking finding was how early cardiometabolic risk and cardiovascular disease are now showing up, particularly among younger adults. That means people are living longer with chronic cardiovascular illness, rather than developing disease later in life.
Finally, what stood out was how consistent disparities were across nearly every risk factor and condition we examined. When the same patterns repeat themselves again and again, it tells us this isn’t about isolated failures — it’s about how the system is working.
Tell me, where there are gains, and then where those gains are offset by disparities in age or income or race and ethnicity. Is that true of each condition or risk factor you examined?
There are real gains, and it’s important to acknowledge them. We’ve seen long-term declines in deaths from coronary heart disease, meaningful improvements in the quality of acute cardiovascular care, and substantial reductions in cigarette smoking overall.
But almost every gain we identified is unevenly distributed. Smoking has declined nationally, yet rates remain far higher among people with lower incomes. Treatment for cardiometabolic risk factors has improved in some populations, yet younger adults, people living in rural areas, and many racial and ethnic minority communities are less likely to receive consistent treatment or achieve good control.
Is there always a downside to the good data?
Yes, there is often a downside even to the good news. Progress at the population level can mask growing inequities beneath the surface. The data make clear that improving averages is not enough. Who benefits from progress matters just as much as whether progress occurs at all. The key takeaway is simple: average improvement is not the same as equitable improvement. If we don’t measure disparities alongside progress, we risk celebrating gains that leave too many people behind.
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.
