May 3, 2024 – More Americans die of heart failure today than in 1999, reversing years of progress in reducing death rates.
This is the powerful message of a new JAMA Cardiology studywhich finds that the present death rate from heart failure is 3% higher than it was 25 years ago. Based on death certificate data, the study says, the death rate dropped significantly from 1999 to 2009, then stagnated for a couple of years before rising sharply from 2012 to 2019. During the pandemic years of 2020 and 2021, the most recent 12 months for which data is offered, deaths from heart failure increased.
“These data are remarkable,” said Veronique Roger, MD, MPH, director of Epidemiology and the National Heart, Lung and Blood Institute's Division of Public Health. “They really represent an urgent call to action to reverse this trend.”
Roger, who was not involved within the study, noted that death rates from heart problems declined within the 2000s and have now stabilized, largely on account of the soaring rise in deaths from heart failure. “This paper shows that not only are we not making progress, but our gains are being undone. So it's a big deal.”
According to the National Institutes of HealthToday, about 6.7 million Americans suffer from heart failure. Of course, that's only a snapshot: About one in 4 Americans will develop heart failure of their lifetime, the NIH said. About half of those affected die inside 5 years of diagnosis.
People who're 65 or older have a far higher risk of dying from heart failure than younger people. But the relative increase in death rates was most pronounced amongst younger Americans, in response to the study. Among people under 45, there was a ninefold increase in deaths from heart failure from 2012 to 2021, and amongst people ages 45 to 64, there was an almost fourfold increase.
Comorbidities result in heart failure
Study co-author Marat Fudim, MD, an associate professor of cardiology at Duke University in Durham, NC, said the rise in heart failure deaths amongst younger people is probably going related to the proven fact that obesity and diabetes are more common in young adults. It's not surprising, he said, that more individuals with these conditions are developing heart failure in middle age.
Otherwise, he said, “the reversal of [heart failure mortality] The trends appear to have affected men and women and the different races in a very similar way. They did not distinguish in this respect, nor between rural and urban dwellers. Although there were large differences in death rates from heart failure between racial groups and between rural and urban dwellers, the reversal trend is very similar in all these groups.”
“What we see in practice is that comorbidities cause heart failure,” said Fudim, whose own cardiology practice specializes in the disease. “Heart failure is rarely a single disease problem. Typically, heart failure patients have obesity, diabetes, coronary artery disease and hyperlipidemia – all of these diseases cause heart failure, which leads to death.”
The increase in mortality from heart failure was already evident before the COVID-19 pandemic, but COVID accelerated the increase in deaths from this disease. From 2012 to 2019, the average annual percentage change in mortality was 1.82%; in 2020 and 2021, it was 7.06%.
According to Fudim, there were two reasons for this. First, patients hospitalized for COVID-related pneumonia had about a 20% higher risk of developing heart failure than other people, considering their health status. In addition, COVID exacerbated health disparities based on race and income level, causing the health care system to focus on COVID-related care rather than heart failure prevention or treatment.
Factors for the increase in mortality rate
A co-author of an earlier paper showing an increase in heart failure deaths agreed that COVID is “adding fuel to the fire” in terms of heart failure mortality.
Sadiya S. Khan, MD, the Magerstadt PProfessor of cardiovascular epidemiology at Northwestern University's Feinberg School of Medicine in Chicago, Khan also agreed that the rise in the number of middle-aged people dying from the disease is likely related to comorbidities they developed earlier in life. Khan added kidney disease to the list of possible conditions linked to deaths from heart failure. And, she said, she is also seeing an earlier onset of heart failure.
Khan's research group published a study showing that death rates from heart disease caused by hardening of the arteries – known as ischemic heart disease, which often leads to heart attacks – have declined, while death rates from heart failure have increased. They attribute this mainly to better treatment options for the underlying heart disease.
“In ischemic heart disease, there have been great advances in the event of effective therapies, particularly related to stents and effective lipid-lowering therapies with statins and a few latest therapies. In heart failure, we've not seen the identical progress.”
Another factor that may have contributed to the increased mortality rate is the prevalence of heart failure. If more people develop heart failure, more will die from it. On the other hand, Roger and Fudim say, a higher mortality rate could also result from patients with heart failure being sicker than they used to be, even without increased prevalence. According to Fudim, the data show that the heart failure rate is relatively stable but gradually increasing.
Where did we go incorrect?
Khan's 2019 study suggested that the earlier decline in deaths from cardiovascular disease reflected the success of measures to better control blood pressure and cholesterol, together with higher numbers of people quitting smoking and effective medication use.
“However, the prevalence of obesity and diabetes has increased dramatically, the decline in deaths from heart problems has stalled, and deaths from heart failure are rising,” the paper says.
If so many of the right things were being done, why did the trend of deaths from heart failure reverse?
Roger does not blame the doctors because, in her opinion, they are still doing the right thing.
“What we've not done right is our failure to handle obesity and diabetes. Diabetes goes hand in hand with obesity, so if we focus solely on obesity, the alternatives you and I and everybody else make about food usually are not made by the doctor,” Roger said.
“I feel we've done one of the best we are able to with the things we are able to do,” she said. “But that's being offset by the obesity trend that's related to the consumption of highly processed foods, sugar-sweetened beverages, etc.”
Fudim, however, believes the health care system is at least partly responsible for reversing the trend in heart failure mortality. He said this is partly due to deficiencies in primary care, with access to care limited in many areas, underemphasis on prevention and chronic care, and some heart failure patients not receiving the care they need.
Roger agreed, citing the much higher death rate from heart failure among blacks as evidence that “each difficulties in accessing health care and the standard of health care play a task.”
On the other hand, she said, health systems have prioritized improving care for heart failure patients, in part because of Medicare incentives. The rise in heart failure deaths despite all these efforts, she said, should be “an urgent wake-up call. There are latest avenues in research, prevention and clinical practice that needs to be brought together to handle or mitigate this trend, because we cannot let it proceed.”