Case-Based Evidence for Cardiovascular Risk Reduction - Episode 2
Deepak Bhatt, MD, MPH: Jamie, can you discuss with the audience exactly what the prevalence is of cardiovascular disease associated with hypercholesterolemia overall? Also, can you talk about this specifically in different ethnic and geographic groups, socioeconomic disparities, and so forth?
James A. Underberg, MD: That’s a great question, and I think part of what makes that a complicated answer is what we just heard from my copanelists. These are the comorbidities that play into the role that cholesterol has in driving cardiovascular risk. We know that the impact of cholesterol on heart disease risk is often driven by other risks associated with that patient. For the patients with preexisting heart disease or hypertension or diabetes, what is elevated cholesterol for them is different for what is considered elevated for patients who have fewer risk factors or lower risk in general.
We can take a closer look at the data, let’s say from 2018, and the American Heart Association for heart and stroke statistics. If we look at patients who simply have a total cholesterol over 200 mg/dL, it’s somewhere between about 35% and 48% of the population. If you break that down into different ethnic groups, the group that seems to lead the way with cholesterol issues, are Hispanic patients—men more than women—followed by non-Hispanic whites and then non-Hispanic blacks. Why is this such a concern? It’s a concern because cardiovascular disease prevalence was going down for a very long time, and death and mortality from heart disease had really dropped over the last 15 or 20 years.
But you know as well as I do that over the last about 5 years, there’s been a bit of a U-turn. Things have started to progress back upward. If you look at cholesterol control in general, it has gotten better. We’ll talk about some of the gaps in that and get further along in our program. But the accumulation of other cardiovascular risk factors—especially diabetes, obesity, inactivity, diet—drive part of the complication of this. If you look at socioeconomic features, it is exactly what you would expect, right?
This is in regard to those who have less access to health care, those who are less likely to be able to exercise, less likely to eat a heart-healthy diet, and less likely to have access to appropriate screening programs—those who do not do as well as those who do have access. If you look at the shift in heart disease globally, it’s moving from the more developed Western countries to those that are less developed. If you look even within the United States, if you look at a map of heart disease in this country, it’s exactly, again, what you would expect.
In areas of this country where people tend to be more obese, have less healthy diets—in the Southeast, in part of the central part of the South like Oklahoma, and even a little further north into Indiana, we have much higher rates than we see on the East and West Coast of the United States. There is much to be learned from looking at these ethnic and socioeconomic diversities and disparities that drive heart disease risk and informs us on who we need to be focusing on going forward.
Deepak Bhatt, MD, MPH: Those are all really great points. In parts of the coronavirus pandemic in New York brought light to racial disparities that are affecting African Americans.
James A. Underberg, MD: Absolutely.
Deepak Bhatt, MD, MPH: You mentioned geography too. There has been a lot written recently. In fact, there was a paper published in JAMA just about a month or 2 ago highlighting rural health care disparities as it pertains to cardiovascular medicine, whereas in rural parts of this country cardiovascular disease is making a comeback like there is no tomorrow.
It is really something that we all need to be vigilant about and not feel like we’ve won the battle against heart disease. It’s certainly encouraging all the scientific advances that have occurred, but with a lot of work to do in terms of implementation, science, and making sure all patients benefit from these advances. That was really an interesting discussion about cardiovascular risk in general.
Transcript Edited for Clarity