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America’s War Against Heart Disease

75 years after it started, we’re losing the battle against our number 1 killer. Here’s why and what will help

heart on a pedestal, stylized illustration
Chad Hagen

Lori Kubitz’s eyes popped open at 4 a.m. “like an alarm went off in my brain.” She could barely breathe. The pain in her chest felt like a bonfire. Her jaw hurt so much that she thought it would explode. As the sun rose over her lakeside cabin in Pelican Rapids, Minnesota, her husband rushed her to the nearest hospital, some 30 minutes away.

“I was scared,” she says. Her father had died of a heart attack.

But Kubitz was just 54 years old. She didn’t smoke. Her cholesterol was normal, her weight and blood pressure “just a little” high. “I thought heart attacks happened to heavy smokers, people who were 50 pounds overweight and people in their 70s and 80s,” she says.

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When she reached the hospital, blood tests and heart scans confirmed her worst fear. Her left anterior descending artery, the heart’s largest, was 99.9 percent blocked. “They were wheeling me into surgery,” she recalls. “I thought, Am I going to die? 

Kubitz’s out-of-the-blue heart attack illustrates a scary new reality. After decades of steady decline, heart disease — long America’s number 1 killer and the third-leading cause of disability — is screaming back with life-changing and often fatal consequences.

Return of the killer

It was 1948 when President Harry Truman signed the National Heart Act, establishing the National Heart Institute (now the National​Heart, Lung and Blood Institute). Truman also funded the landmark Framingham Heart Study, the world’s longest-running population study of heart disease.

For the next six decades, thanks to the explosion in both research and treatment, we were winning the war on heart disease. Deaths from heart attacks, heart failure, heart rhythm disorders and related conditions fell a stunning 69 percent between 1950 and 2009. But lately, the good news has been overshadowed by major reversals.

“We’re looking at a crisis in terms of lowering life expectancy for the first time in decades,” says cardiologist Sadiya Khan, M.D., assistant professor of medicine and of preventive medicine at the Northwestern University Feinberg School of Medicine in Chicago. News reports might point to COVID and the opioid crisis as the drivers of this shift in overall life expectancy, but a 2022 report from the Centers for Disease Control and Prevention (CDC) also lists the rising rate of heart disease deaths as a major reason for that decline.

Among the new heart-health trends that are deeply concerning to Khan and other cardiologists:

  • Midlife and younger adults are dying of heart diseases more often. Death rates from heart diseases rose 8.5 percent for adults ages 45 to 64 between 2010 and 2020, says Stephen Sidney, M.D., director of research clinics with Kaiser Permanente Northern California.
  • Record numbers of older adults are dying too. Fatalities due to heart disease among 65-plus Americans rose from 475,097 in 2011 to 556,665 in 2020 (more recent data isn’t yet available). Interestingly, the heart-disease death rate fell over those years; however, the big growth in America’s older population means a rise in total deaths.
  • The COVID pandemic injected rocket fuel into the heart disease resurgence. In 2020 and 2021, heart attack deaths increased by up to 21 percent for those 45 to 64 and 17.9 percent for people 65 and older, according to a Cedars-Sinai Medical Center study. That might simply be a side effect of the pandemic’s long-term legacy of weight gain, inactivity and stress. But the virus itself may be playing a direct role: A large 2022 study found lingering heart risks a year after COVID infection. Cleveland Clinic cardiologist Larisa Tereshchenko, M.D., told the journal Science that contracting COVID could emerge as the number 1 risk factor for future heart disease.
James L. Young II in 2011 (left), before he entered the hospital with a heart emergency, and in 2021, a   decade after he quit smoking and started to exercise and eat more healthfully.
James L. Young II in 2011 (left), before he entered the hospital with a heart emergency, and in 2021, a decade after he quit smoking and started to exercise and eat more healthfully.
Courtesy James Young II

Beyond heart attacks

In 2011, graphic designer James L. Young II stood in a Detroit parking lot, gasping for air. He was just 40 years old. But years of smoking, beer and lots of fast food had left him with high blood pressure, type 2 diabetes and kidney disease.

He ended up in a hospital emergency room. “The cardiologist on staff said, ‘If you’d waited one more week to come to this facility, we’d be talking about you in the past tense.’ That’s a wake-up call.”

Young wasn’t suffering a heart attack. He had congestive heart failure, a condition in which the heart is unable to pump blood efficiently. Doctors recommended implanting a pacemaker. “What’s option B?” Young asked. The cardiologist gave him about a month to improve his heart function by losing weight and exercising. He swapped breakfast bacon for sautéed kale, quit smoking and drinking, gave up fast food and started walking. At first he made it just a quarter of the way around a local high school track. But he soon built up to 10 to 12 miles a day as he listened to house music through his earbuds.

VIDEO: How I Discovered I Had Heart Failure

Over time, Young lost weight, reduced his medications, ran a couple of half-marathons and returned to college. Now 51, he’s a graduate student in public health at Purdue University and an American Heart Association national ambassador, telling his personal story and serving on an AHA committee that awards funds to heart-disease researchers. “Drinking, smoking and heavy eating were my Band-Aids,” Young says. “I had to learn to value myself as a human being.”

As Young discovered, cardiovascular disease isn’t just about heart attacks. It’s a broad category of disorders that covers the blood vessels, muscle, electrical system and valves, as well as the functioning of the heart. (That’s why clots in your leg veins are technically a type of cardiovascular disease.) That said, the primary forms of heart disease include:

  • Coronary artery disease (CAD), when plaque narrows or blocks blood vessels that deliver oxygen and fuel to your heart muscle; this is the classic cause of heart attack.
  • Heart rhythm problems (such as atrial fibrillation, or A-fib), when the heart’s natural electrical system stops functioning​normally, making heartbeats erratic, too fast or too slow.
  • Heart valve malfunctions and heart failure, which is when the heart loses its capacity to pump efficiently, often due to damage from a heart attack, high blood pressure, diabetes or CAD.

Cardiovascular disease also includes stroke, which is caused by blockages or bleeding in blood vessels in the brain. All told, cardiovascular disease is expected to have killed more than 650,000 Americans in 2022. (That’s roughly 1 in every 5 deaths.). Each year, 2.5 million of us are expected to have a heart attack or undergo a procedure to open or bypass clogged coronary arteries, and 7 million more will live with chest pain triggered by narrowing of those blood vessels, according to the CDC.

Overall, 77.5 percent of men and 75.4 percent of women ages 60 to 79 have some form of cardiovascular disease, according to a 2021 report from the American Heart Association; among those of us 80 and older, 90 percent have it.

Victory and loss

Heart disease wasn’t always a major killer. In fact, it was relatively uncommon in the U.S. in 1900, when life expectancy was a cruel 47.3 years and pneumonia, flu and other infections were the top killers. But with the discovery of vaccines and antibiotics, everyday infections and injuries became less lethal. At the same time, another health-related seismic shift occurred: the rise of unhealthy living. During World War II, Americans began to smoke more, sit more at work, eat more saturated fat­ — and we became enamored with sugar and processed foods. The result: Untold millions of Americans upholstered their coronary arteries with gunky, fatty plaque.

Between 1940 and 1948, heart disease deaths soared by 20 percent. That emerging crisis prompted President Truman to fund the National Heart Act and the Framingham Heart Study. When researchers began the study, so little was known about heart disease that their budget, ironically, included money for office ashtrays.

The early findings of this new research push were bombshells: Smoking, high blood pressure, diabetes and being overweight all contributed to heart attack risk — obvious today but groundbreaking information in its day. And so a worried nation slowly began changing its habits. Heart disease death rates began dropping in 1968 — so fast that in 1978, the National Institutes of Health held a conference to determine whether the improvements were for real.

An avalanche of heart disease discoveries was helping to turn the tide. Among them: Open heart bypass surgery began saving lives in 1960. ACE inhibitors, among the most widely prescribed blood pressure drugs today, were approved in 1981. The first cholesterol-lowering statin — a type of drug now taken by more than 35 million Americans — was approved by the U.S. Food and Drug Administration in 1987. In 1970, 38 percent of older adults hospitalized with a heart attack died; in 2010, just 7 percent did.

As death rates continued to decline, experts predicted heart disease would become America’s number 2 killer, behind cancer, as early as 2013.

But then things changed.

heart monitor, stylized illustration
Chad Hagen

Twin epidemics

“I don’t think we’ve ever really won the war on heart disease,” says Andrew Freeman, M.D., director of cardiovascular prevention and wellness at National Jewish Health in Denver. “Despite excellent medical therapies, the most powerful of all treatments we have is lifestyle. And we’ve paid lip service to lifestyle for decades.”

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America’s obesity and diabetes epidemics took off in 1985. Twenty-five years later, heart disease deaths began inching upward. Today, 42 percent of Americans are obese (generally defined as having a body mass index above 30), and another 30 percent are overweight (a BMI between 25 and 30), according to the National Institutes of Health. More than 37 million have diabetes and 96 million more, including 48 percent of older adults, have prediabetes, according to the CDC.

“We have more cases of heart disease because important drivers of cardiovascular disease — obesity, diabetes, hypertension, metabolic syndrome — are growing more and more prevalent in this society,” says Anekwe Onwuanyi, M.D., professor of medicine and chief of cardiology at the Morehouse School of Medicine in Atlanta.

And in the fight against heart disease, we are moving in the wrong direction. Rates of well-controlled diabetes fell from 57 percent to 50 percent between 2007 and 2018. Deaths due to high blood pressure increased by about 50 percent between 1999 and 2017. In contrast, the prevalence of high cholesterol fell about 42 percent between 1999 and 2018, likely due to the widespread use of statins. “Major reasons for this are limited access to health resources, the ever-expanding number of Americans with obesity, and reduced access to heart-healthy food,” says Nicholas Ruthmann, M.D., a staff cardiologist at the Cleveland Clinic.

The neglected majority

Ten days before her 55th birthday, Vonnie Gaither, a high school career counselor and mother of two, boarded a plane in Salt Lake City bound for her home in Anchorage, Alaska. “I buckled my seat belt, talked to the person sitting on my left, and that’s the last thing I remember,” she says. Flight attendants found her slumped in her seat minutes later, unconscious and without a pulse.

Flight attendants performed CPR and used a defibrillator to shock her heart so it would beat again. She woke up from an induced coma a day later to find her family gathered around her hospital bed. Her surgeon explained that she had suffered a heart attack; three stents had been inserted into her heart to open a major blockage.

Back home a week later, her daughter threw a “55 and Alive” party for Gaither, then accompanied her on walks three times a week on a local middle-school running track. Gaither rediscovered broccoli and spinach, bought fruit salads at Costco and switched to turkey burgers, ground turkey in spaghetti sauce and turkey bacon at breakfast. “I love steak, but I eat it about once a month now,” she says. “It’s a celebration.” She took medications to lower her cholesterol, control her blood pressure and reduce the risk for heart-threatening clots, and she went to cardiac rehab exercise classes. But she still required triple bypass surgery a few months later due to a new buildup of plaque.

Today, at 70, Gaither is retired and spends her time painting, bowling and socializing with friends and family. And she wonders about her heart risk. There’s a family history, she says.

But there’s more. Gaither is a Black woman, and that elevates her risk in two ways.

For decades, women were underrepresented in clinical trials and their heart attack symptoms dismissed in emergency rooms as stomach pain or even emotional problems. The American Heart Association published its first treatment guidelines for women in 1999, but it’s taken longer for science to discover that the anatomy and electrical pathways of the female heart are unique, which may help explain why a woman’s heart attack symptoms can be different from a man’s.

Yet women’s heart health is still under-studied, according to a 2022 review of research in the journal Circulation Research, and women’s heart attack warning signs are too often overlooked. In fact, in 2019, just 44 percent of women in a national survey identified heart disease as the top killer of women, and the vast majority were unable to identify many of the symptoms of a heart attack.

But health professionals seem to have the same difficulty identifying heart disease in women: The same study found that when women suffering heart attacks arrive at an emergency room, they experience longer wait times and are less likely to be seen by a heart specialist or receive an echocardiogram or potentially lifesaving heart drugs. Another study found that women tend to wait longer before calling 911 when they’re having a heart attack — up to 37 minutes longer.

Women are also less likely to receive preventive care such as cholesterol-lowering statins and treatments for heart failure and atrial fibrillation. “Gender biases in medicine still persist,” says cardiologist Emily S. Lau, M.D., of the Corrigan Women’s Heart Health Program at Massachusetts General Hospital in Boston. “There continues to be a pervasive belief — either conscious or subconscious — among health care providers that heart disease is less common among women and that women are less likely to derive benefit from therapies. And we have not trained our health care providers to recognize the unique ways that women experience heart disease.”

Indeed, while men are at greater risk from heart disease when they’re younger, by the time women reach their 70s and 80s, their risk of heart disease actually exceeds that of men.

And recent research shows that high blood pressure or diabetes during pregnancy is an early warning sign of lifelong elevated heart risk, even if the conditions resolved after the women gave birth. But doctors seldom explore this aspect of a woman’s health history.

In the same way, the war against heart disease has been slow to recognize the heart health needs of African Americans, Hispanics and other racial and ethnic groups. According to a 2018 CDC report, heart disease mortality rates for Black adults are 21 percent higher than for whites, and the Black-versus-white death rate gap actually increased by 16.3 percent between 1968 and 2015. Social determinants of health — like education, neighborhood-level poverty and access to healthy food — explained much of this difference in heart disease rates, a 2022 Feinberg School of Medicine study found.

This is important because it refutes the myth that the disparity is unexplained or caused by genetics, says Khan, one of the study authors. Adding to the disparity: Just 3 percent of cardiologists are Black and just 4 percent are Hispanic, according to a 2021 study. Clinical research has shown that seeing a doctor from your own racial or ethnic background “leads to better outcomes — being able to follow recommendations, making lifestyle changes and adhering to treatments,” says Onwuanyi, president of the Association of Black Cardiologists. 

For Latinos, recent studies are puncturing the controversial Hispanic paradox — a belief that Hispanics enjoy protection from heart disease due to strong families, social support, food or perhaps even genetics. A large 2022 University of Miami study found that 6.1 percent of Hispanic women developed heart disease, a higher figure than white women in the study; so did 9.2 percent of Hispanic men, a higher figure than Black and white men. The idea of the Hispanic paradox could be hazardous to the health of Hispanic women and men, Johns Hopkins University researchers warned in a 2022 study, worsening “the existing poor cardiovascular health among the Hispanic population.”

“We as a country need to realize that [heart disease] isn’t happening to everybody equally,” Khan says. “There are significant racial and ethnic inequities. If we don’t turn this around, we’re going to see an exacerbation of those disparities.”

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The latest heart disease breakthroughs

After surgeries for an aortic aneurysm (when the aorta walls balloon out), two hernias and a problematic leg artery, Steven Rowell got a stern warning from his surgeon: Decades of smoking had damaged his blood vessels. “If I wanted to stay around longer, I had to make some decisions,” says Rowell, 63, a hospital-system network engineer from Cape Coral, Florida, who had puffed a pack a day for more than 25 years. “With all the grandkids I have, I wanted to see them grow up.”

Rowell began swimming and biking with his wife as she trained for triathlons and began following a more plant-based diet. And he signed up for an innovative test that detects if plaque is clogging the arteries of the heart.

The test, known as a coronary computed tomography angiography (CCTA) is widely used in people with early warning symptoms of heart disease, such as chest pain. But now some cardiologists are using the test with people like Rowell, who have risk factors like smoking but exhibit no warning signs. The idea is to look inside the heart — while there’s still time to use medications and lifestyle changes to attack dangerous plaque before a heart attack happens, says James Min, M.D., former director of the Dalio Institute of Cardiovascular Imaging at New York-Presbyterian Hospital.

Min developed an FDA-approved system called Cleerly for evaluating heart plaque in CCTA images and assigning it a risk stage (from no risk to severe risk). “Heart doctors have never actually directly measured heart disease,” Min says. “It sounds weird, but we haven’t. We have used risk factors, like an abnormal stress test or a blockage.” Yet 50 percent of heart attacks happen to people who haven’t had any early warning signs.

Cleerly could reduce the risk for those individuals who don’t show any outward signs of being at risk, Min says. The screening technique shows not just the amount of plaque but also the type: Hard, calcified plaque is relatively safe, while soft plaques can rupture and spin off heart-menacing blood clots. Seeing the buildup and knowing its type can help doctors write treatment plans. And seeing actual pictures of what’s going on inside their own heart may motivate people to stick with medications and healthy habits. “Half the people prescribed statins will not be taking them after one year. And by five years, 90 percent are not taking their medications,” Min notes.

The day after his scan, Rowell saw his own coronary arteries for the first time. “It was eye-opening,” he says. “I had one artery that was 100 percent blocked. The majority were 30 to 40 percent blocked, and the majority was soft plaque.” Seeing the state of his heart prompted his doctor to change his blood pressure and cholesterol medications and inspired Rowell to upgrade his eating habits and get more exercise. His cholesterol and blood pressure numbers dropped into a healthier range, and he’s lost 35 pounds. In December he will repeat the CCTA test and hopes to see positive changes.

Not everyone agrees with the idea of CCTA screenings for people with no heart disease warning symptoms. In 2021, the American Medical Association advised consumers that there was “no high-quality evidence to support routine use” and urged the use of exercise stress tests, which identify blockages in the heart. But the American College of Cardiology has recently partnered with Min in his research, and the Cleerly system is covered by some insurance plans. In October, Medicare began reimbursing $950 for the system too.

abstract symbols of heart and two people with hearts highlighted
Chad Hagen

The fight for new answers

New uses of CCTA screenings are hardly the only advanced weapon being deployed in the war on heart disease. Exciting recent breakthroughs include advances in surgical techniques, implantable devices and more-effective medications.

New plumbing tools. In 30 percent of the 965,000 artery-clearing heart procedures performed each year in the U.S., cardiologists face a tough problem: a hard, calcium-packed shell covering soft, gooey plaque in blood vessel walls. This hardened shell can resist cardiologists’ efforts to deploy artery-widening balloons and stents to hold arteries open. But a new technique called intravascular lithotripsy, approved by the FDA in 2021, uses shock waves to break up these hardened deposits. It is similar to technology used to break up kidney stones, is easier for interventional cardiologists to use (the device is threaded through arm or leg arteries to the heart) and may work better for hard areas deep within plaque.

“Coronary artery disease patients in their late 60s, 70s, 80s and older will generally have calcium in their blockages, so this is an important tool for treating heart disease in older persons, particularly the very elderly,” says Quinn Capers, M.D., a cardiologist at the University of Texas Southwestern Medical Center in Dallas. In the clinical trial of 384 people with hard plaque, 92 percent of them were able to receive a stent after lithotripsy, with no heart attacks within 30 days. Meanwhile, doctors are now deploying stents that are stronger, safer and more flexible, providing a variety of new options for patients. On the horizon are biodegradable stents that keep arteries open only long enough for medications and lifestyle interventions to work; when the artery heals, they dissolve.

Advanced heart drugs. When sodium-glucose transporter 2 (SGLT-2) inhibitors burst onto the research scene, scientists thought this new class of drugs would be great at lowering blood sugar. They got a big surprise.

“They really reduce episodes of heart failure in the patients with diabetes. Because of this, and because the drugs don’t lower blood sugar if it is not elevated, we tested SGLT-2 inhibitors in people with heart failure without diabetes, and the drug is effective in those patients too,” says cardiologist Nancy K. Sweitzer, M.D., professor and vice chair for clinical research in the Department of Medicine at the Washington University School of Medicine in St. Louis, and editor in chief of the journal Circulation: Heart Failure. In a 2022 analysis of five major studies, SGLT-2 inhibitors cut the risk of hospitalization or death from heart failure by 33 percent.

Meanwhile, there are new options for people who can’t tolerate statins or who eventually just stop taking them. Cholesterol-smashing medications called PCSK9 inhibitors are given by injection every three or six months at your doctor’s office or a hospital. They block the breakdown of LDL receptors so more bad cholesterol is shunted to your liver for disposal. They lower LDLs by 50 to 60 percent, and they also reduce the odds of a heart attack by 15 to 20 percent more than statins alone.

Effective new implants. Until 12 years ago, older and sicker adults with stiff, diseased heart valves were considered “inoperable” — getting a new valve was deemed too risky because it required open heart surgery. Since then, cardiologists have developed a heart-valve delivery method called transcatheter aortic valve replacement (TAVR).

“Now patients can have their aortic valves repaired in a procedure where a new valve is implanted using a catheter inserted into the femoral artery in the groin,” Capers says. “Some patients are discharged from the hospital after an overnight stay, with a bandage on their groin.” In 2019, Cleveland Medical Center researchers found that deaths from diseased heart valves in older adults fell suddenly starting in 2013, at the same time that the number of TAVR procedures was increasing in the U.S. The new procedure may be the reason, they note.

Today, TAVR is more common than open heart surgery for replacing the aortic valve. “It’s an amazing advance over the past 20 years,” says interventional cardiologist B. Hadley Wilson, M.D., executive vice chair at Atrium Health’s Sanger Heart and Vascular Institute in North Carolina and president-elect of the American College of Cardiology.

Your heart in your hands

Perhaps the best news about our heart health crisis is that when it comes to your own personal risk, the key to prevention is in your hands, says Michelle McMacken, M.D., executive director of nutrition and lifestyle medicine for NYC Health + Hospitals/Bellevue in Manhattan. “A suboptimal diet is responsible for almost half of the deaths from heart disease, stroke and type 2 diabetes,” McMacken says. “Even among those who are living at high genetic risk, a healthy lifestyle can actually reduce the risk of developing heart disease by half.”

5 Amazing Facts About the Human Heart

  1. The blood vessels in your heart are the most likely to clog. The reasons: Blood flows in two directions in many arteries, creating turbulence that can damage artery walls—which makes it easier for plaque to set in. And coronary arteries have lots of branches and bends, which are prime real estate for atherosclerosis. ​
  2. Nearly half of all heart attacks have no symptoms, according to a 2016 Wake Forest University study. No-symptom attacks were more common in men but deadlier in women.​
  3. The best food for your heart? It might be bananas. In a 2020 analysis of studies involving more than 4 million people, bananas were associated with 24 percent lower risk for coronary heart disease. But all produce helps; people who munched the most fruit and vegetables had 11 percent less cardiovascular disease than those who ate the least.​
  4. Spare parts for your heart may come from outer space. In 2020, NASA blasted cardiac stem cells into space for an Emory University study seeking to find out whether they would become beating heart-muscle cells faster in zero-gravity conditions. The stem cells became heart cells in just three weeks. Researchers hope to use them for heart failure repairs, a therapy that could require up to 150 million cells per treatment.​
  5. A great sport for your heart? Grab a racket. A study that tracked 80,306 adults for nine years found that tennis and badminton cut risk for fatal cardiovascular disease by 59 percent. Swimming and aerobics lowered the odds by 41 and 36 percent, respectively. Distance running was less effective; some research suggests it could have a negative impact.​

But according to the American Heart Association, just 11 percent of people in their 40s and 50s and 4 percent 60 and older are taking these essential personal steps. While 72 percent of adults in a recent Harris Poll said they want to talk more about self-care with their doctor, 78 percent of physicians in another survey said they don’t have time during the typical 17-minute appointment. One in 4 doctors didn’t feel confident they could give advice. And in a survey of 1,000 cardiologists that National Jewish Health’s Freeman conducted for the American College of Cardiology, nearly 90 percent had little training or education in day-to-day nutrition.

That has to change, Freeman says. “You have to ask patients about lifestyle — and keep revisiting the topic. If we incentivize doctors to spend more time on it, if we show doctors the value of it, these would be extraordinary efforts. If and when we win the battle against heart disease, it will no longer be the number 1 killer.”

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