Author + information
- Published online April 30, 2018.
- Hena Patel, MD and
- Kim Allan Williams Sr, MD∗ ()
- ↵∗Address for correspondence:
Dr. Kim Allan Williams Sr., Rush University Medical Center, Division of Cardiology, 1717 West Congress Parkway, Kellogg Suite 303, Chicago, Illinois 60612.
The last several decades have witnessed great strides forward in heart failure (HF) therapeutics; however, HF remains one of the leading causes of morbidity and mortality in the United States, and its prevalence continues to increase with an aging population. HF affects 5.7 million Americans, and represents the most common reason for hospitalization among Medicare recipients, costing more than $30 billion annually in treatment expenditures and lost productivity (1). By 2030, an estimated 8 million persons, or 1 in every 33 individuals, will have HF in the United States and medical costs are expected to more than double (2). Although new therapies offer improved quantity and quality of life, with fewer hospital admissions, there has been little attention to actual prevention of HF rather than diagnosing and managing it.
Racial and ethnic health care disparities are a significant problem in the United States. It has been recognized for years that African Americans are disproportionately affected by HF, with a high prevalence at an early age. According to American Heart Association statistics, the annual incidence of HF in whites is approximately 6 per 1,000 person-years, whereas in African Americans it is 9.1 per 1,000 person-years (2). The Atherosclerosis Risk in Communities study found that the incidence of new HF was 1.0 per 1,000 person-years in Chinese Americans, 2.4 in whites, 3.5 in Hispanics, and 4.6 in African Americans (1). Further, the lifetime risk of HF for those age 45 to 75 years was greater for blacks than for whites, and greatest for black females. With good reason, disparities in health care outcomes have become an area of focus for clinicians, researchers, and policymakers. In the current context of increasing health care costs and an increasing prevalence of HF, promoting health equity is a public health priority. Improved HF treatment could generate significant health benefits and reduce health disparities.
In this issue of JACC: Heart Failure, Van Nuys et al. (3) illustrate the potential benefits of effective HF treatment in terms of improved health, greater social value, and reduced health disparities between black and white subpopulations. They adapted the Future Elderly Model to estimate trends in HF prevalence and calculate the savings rendered from a hypothetical cure of HF among middle-aged individuals. The Future Elderly Model is an established economic-demographic microsimulation that incorporates data from 3 nationally represented datasets: the Health and Retirement Study, the Medical Expenditure Panel Survey, and the Medicare Current Beneficiary Survey. With a hypothetical intervention to prevent HF incidence, the authors projected a decrease in mortality and morbidity among the entire population along with a reduction in existing health disparities. The total life-years, quality-adjusted life-years and disability-free life-years with and without the innovation were estimated for both the overall population and for race- and gender-defined subpopulations.
Consistent with previous data, the model projected a lifetime risk of HF incidence of 35% for middle-aged adults. The prevalence of HF among older adults was expected to increase substantially over the next 2 decades, nearly doubling from 4.3% in 2010 to 8.5% by 2030, and affecting blacks more than whites. A diagnosis of HF was found to coincide with significant increases in disability and medical expenditures, again particularly among blacks compared with whites. Using the model, the authors suggest that the effective prevention of HF could improve the health of older Americans and that, despite increases in longevity, such benefits could be achieved with little or no additional lifetime medical spending. Specifically, the model suggests that applying an intervention to prevent HF among those age 51 to 52 years in 2016 would generate nearly 2.9 million additional life-years, 2.1 million quality-adjusted life years, and more than 1.2 million disability-free life years, worth $200 to $400 billion (3). These gains are generally greater among blacks than whites, thereby ameliorating some racial disparities in health outcomes associated with cardiovascular disease.
Although interesting conceptually, 2 issues merit consideration. First, there are many assumptions on dynamics and therapy that may not be feasible. An innovation that completely eliminates HF, as is assumed in the study, is highly unlikely, at least in the near future. Rather, as the authors acknowledge, actual interventions are more likely to reduce the severity and the incidence of HF. Second, this study does not model the social determinants of health that seem to underpin the increased incidence of HF in black patients. These factors are multifactorial and range from the individual level to the social environment. The higher prevalence of systemic hypertension, for instance, underlies the relatively earlier age of onset of HF among African Americans. Further, access to care and medication adherence continue to be lower among black patients, resulting in less effective disease management and greater mortality (4). Other patient-specific barriers include higher poverty and unemployment rates, lesser levels of higher education leading to poor health literacy, poor dietary habits, living in “food deserts,” and a lack of engagement with or distrust in the health care system. For those with access to health care, a lack of effective care coordination, exacerbated by arbitrary reimbursement policies and outdated information technology systems, also likely contribute to these health disparities. Additional systems-level challenges, such as lack of health insurance or inadequate supply of cardiologists in medically underserved areas, may further undermine the provision of quality cardiac care. Provider-specific forces, including biases of physicians in clinical assessment or referral process, combined with uneven application of practice guidelines, also directly contribute to the notable disparity in HF among blacks. Importantly, these social determinants would not allow optimal penetration of a new therapy or innovation to vulnerable populations, such as those in our inner cities.
Limitations notwithstanding, this is an important study that has implications for improving HF outcomes by illustrating the social impact of the disease. Designing initiatives with the overarching goals to increase the number of healthy years and eliminate health disparities are daunting, and require novel approaches.
One such novel approach, given the increasing public health and economic burdens of HF, despite improvements in therapy, is to shift strategies and invest in innovations for the prevention of HF. Efforts have traditionally focused on medical management and device therapies, but there is the potential for broadening interventions to include lifestyle modifications. Epidemiological studies have suggested that a healthy lifestyle, including not smoking, frequent exercise, better nutrition, and optimizing body weight, results in substantial reductions in HF incidence, with recent studies demonstrating a graded relationship between the two (5). A growing body of evidence has also demonstrated an inverse relationship between increased consumption of plant-based foods and incidence of HF. An observational study comparing different diets among participants without known cardiac disease from the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study found that individuals who mostly followed a plant-based diet lowered their risk for HF by 42% (6).
Plant-based nutrition can reduce serum levels of the intestinal microbe-generated metabolite, trimethylamine-N-oxide, which has been tightly correlated with mortality in patients with HF (7). Thus, dietary adjustments may reduce the burdens of HF, and potentially reduce the unsustainable increases in American health care costs. Because much of the evidence related to HF nutrition is based on observational studies, randomized trials studying the effects of modulating various components of diet with a focus on prevention, rather than just treatment, are needed. Furthermore, adopting healthy lifestyles can be challenging on a personal and population level and will require innovative efforts for implementation.
Similarly, a focus on early and intensive treatment for systemic hypertension can reduce the incidence of HF by up to 64% (8). This opportunity is important, given the high incidence and relatively poor levels of control of blood pressure in the African American and Hispanic American populations (9).
Although health systems cannot overcome all the social determinants of health at the root of disparities in HF, targeted interventions that address structural inequalities in education, income, and health insurance coverage through patient empowerment, advocacy, and political involvement may help to decrease the burden of HF and promote health equity among the population.
A shift to move beyond the approach of simply knowing and reacting to actively preventing HF is critical to improve the cardiovascular health of our communities. The human and financial costs of mopping up the floor are staggering compared with that of turning off the faucet. The time for a prevent-driven rather than event-driven focus for HF has come.
↵∗ Editorials published in JACC: Heart Failure reflect the views of the authors and do not necessarily represent the views of JACC: Heart Failure or the American College of Cardiology.
Both authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2018 American College of Cardiology Foundation
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