The (Post-COVID) Future of Cardiovascular Disease Prevention: At A Crossroads? Laurence S. Sperling, M.D., FACC, FACP,FAHA, FASPC Katz Professor in Preventive Cardiology Founder, Emory Center for Heart Disease Prevention Professor of Global Health Emory University Executive Director, Million Hearts CDC / NCCDPHP / DHDSP/CMS Past President , American Society for Preventive Cardiology Co-Chair ACC Diabetes & Cardiometabolic Working Group Chair World Heart Federation Roadmap on Prevention of CVD Among People Living with Diabetes About the Presenter
Laurence S. Sperling, MD DISCLOSURES No potential conflicts related to this presentation
Opinions expressed do not necessarily reflect the opinions of the US Dept of HHS, the Public Health Service, the Centers for Disease Control and Prevention, or the presenters affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above. (Post-COVID) Future of CVD Prevention
• Past • Present • The Future (Post-COVID) Future of CVD Prevention
• Past – BC (Before COVID) • Present • The Future Father of CV Prevention: Paul Dudley White
• Advocate for prevention of heart disease • Major impetus behind Framingham HS • Helped oversee creation of NHLBI & AHA • Eisenhower’s physician following 1955 MI • “Exercise more. Eat healthy. Learn your family’s medical Hx” Paul Dudley White’s last fellow at MGH
• J. Willis Hurst • Chair Emory’s DOM 35 yrs • Hurst’s The Heart, 14th Ed. • AHA President • Lyndon Johnson’s physician , MI April 9, 1972 • Encouraged start of Prev Card at Emory • 2011 (90 yo) “ In 1961 with just two words, Bill (Kannel) helped to change our understanding of the underlying causes of heart disease and stroke, and with two words, the entire field of preventive cardiology was born.” Daniel Levy Current Framingham Heart Study Director
Wong N., Sperling L. , Baum S. The ASPC: Our 30 Year Legacy, Clinical Cardiology, 2016 Concept of cardiovascular “risk factors”
Age, sex, hypertension, hyperlipidemia, smoking, diabetes, (family history), (obesity) Kannel et al, Ann Intern Med 1961 “We cannot be a strong nation unless we are a healthy nation…”
Franklin D. Roosevelt Dedication of NIH Campus Bethesda, MD October, 1940 “CVD is the biggest epidemic (pandemic) ever known to mankind- We need strategies to address epidemics…” Salim Yusuf President WHF Europrevent 2013, Rome
“Secondary Prevention is urgent….” Valentin Fuster WCC 2016, CDMX Epidemics / Pandemics Our World Has Changed Since January 2020…… (Post-COVID) Future of CVD Prevention
• Past • Present • The Future Bidirectional Interaction Between CVD and COVID-19
Nishiga M, et al. Nature Reviews Cardiology 2020; 17: 543-558 CMR in Patients Recovering from COVID-19
• 100 pts Frankfurt, Germany • Median 71 days from COVID • Cardiac involvement 78% • Active myocardial inflammation 60% • hs-TnT detectable 71% • Independent of preexisting conditions, severity • Bx with severe findings- acute lymphocytic infiltration
Puntmann VO, et al. JAMA Cardiol. Online July 27,2020 Impact of COVID on CV Care (4/25/20)
• Impact of COVID (MMWR)
Lange SJ, Ritchey MD, Goodman AB, et al. Potential Indirect Effects Stokes EK, Zambrano LD, Anderson KN, et al. Coronavirus Disease 2019 Case Surveillance — United States, January 22–May 30, of the COVID-19 Pandemic on Use of Emergency Departments for 2020. MMWR Morb Mortal Wkly Rep 2020;69:759–765. DOI: Acute Life-Threatening Conditions — United States, January–May http://dx.doi.org/10.15585/mmwr.mm6924e2 2020. MMWR Morb Mortal Wkly Rep. ePub: 22 June 2020. DOI: http://dx.doi.org/10.15585/mmwr.mm6925e2 https://www.cdc.gov/mmwr/i ndex.html Delay or Avoidance of Medical Care Because of COVID-19-Related Concerns-U.S., June 2020
• Estimated 41% of U.S. adults delayed or avoided care (12% urgent / emergent; 32% routine) • Greater in those with 2 or more medical conditions (aPR =1.9) • Might contribute to reported excess deaths directly or indirectly related to COVID-19 • Inform approaches and communication encouraging safe routine, urgent and emergency care
MMWR. September 11, 2020/ 69(36); 1250-1257 Curve Curve #5 Curve Curve Curve #4 #1 #2 #3 Delays in Urgent Care, Iterative COVID- Neglected Chronic Mental Health and Acute COVID-19 Lack of Guideline- 19 Infections Conditions, Rehab/LTAC Economic Burden Infections
Directed Care Care Morbidity Morbidity and Mortality
Weeks to Months Years Decades Months Adapted with permission from Victor Tseng, MD Kohli P, Virani SS. Circulation. 2020 Jul 14;142(2):98-100. Recommendations for Patient Visits During COVID-19 Pandemic • Don’t defer patient visits • use telehealth including telephone if at all possible • At each visit: -Ask about symptoms -Encourage EMS/ER for acute symptoms -Remind patients about safety -Ensure adequate medication refills and access -Inquire about physical activity and nutrition habits -Use the full care team to enhance patient care
Khera A, et al. Am J Prev Card;Volume 1: March 2020 Influenza Vaccination for CV Prevention
• AHA/ ACC Class I Recommendation for Secondary Prevention (LOE B) • MI’s 6 X greater within week of influenza • IV reduces burden of influenza-associated illness including CV events (15-45%- similar RRR as other GDMT) • Readiness for upcoming influenza season needed – Health systems and team-based approaches
cdc.gov/flu/high risk/ heart disease Davis MM, et al. Circulation 2006;114(14) Kwong JC, et l. NEJM 2018;378(4) MacIntyre CR, et al. Heart 2016; 102(4) Cardiovascular Health, Prevention, and CV Care Must Remain a Priority during the Pandemic Concerning Directional Change Heart Disease and Stroke Trends 1950-2015
• CVD leading cause of mortality since 1910, (with exception of flu pandemic 1918-1920) • Racial/ ethnic disparities persistent in CVD mortality since 1968 • Current stagnation- upward trends
Mensah GA, Wei GS, Sorlie PD, et al. Decline in Cardiovascular Mortality – Possible Causes and Implications. Circulation Research. 2017;120:366- 380. Sidney S, et al. JAMA Cardiol 2016;1:594-9 Van Dyke M, et al. MMWR Surveill Summ. 2018; 67:1-11 Alarming Mortality Rate Changes Among Adults Aged 35–64
Percent change in heart disease rate, 2010–2017 (% of counties)
Percent change in stroke rate, 2010–2016 (% of counties)
Ritchey MD et al. Trends Cardiovasc Med. 2019;pii:S1050-1738(19)30134-3. Hall EW et al. Stroke. 2019;50(12):3355-3359 Missed Opportunities to Prevent Cardiovascular Events
9.0 M not taking aspirin as recommended 40.1 M with uncontrolled HBP 39.1 M not using statins when indicated 54.1 M combustible tobacco users + 70.9 M who are physically inactive 213.1 M missed opportunities
55% of these opportunities are in adults aged 35–64 years
Wall HK, Ritchey MD, Gillespie C, Omura JD, Jamal A, George MG. Vital Signs: Prevalence of Key Cardiovascular Disease Risk Factors for Million Hearts 2022 — United States, 2011–2016. MMWR Morb Mortal Wkly Rep 2018;67:983–991. DOI: http://dx.doi.org/10.15585/mmwr.mm6735a4. Additional Cause for Concern-Projected U.S. State Level Prevalence of Adult Obesity / Severe Obesity
• 48.9% obese by 2030 • 24% with severe obesity • “given the difficulty achieving meaningful wt loss, findings highlight importance of prevention”
Ward ZJ, et al. NEJM 2019 Social Determinants of Health: Zip Code vs. Genetic Code?
• Health varies at a very LOCAL level
• Life expectancy in Atlanta Status of CV Health Across America
• 2009 BRFSS, > 350K,self report
• 3.3% with ideal CV health (A) ; – 1.2% Oklahoma – 6.9% DC
• 9.9% with poor CV health (B: 0-2 metrics)
• Large disparities by age, gender, education, ethnicity
Fang J, et al. J Am Heart Assoc 2012;DOI.1161 (Post-COVID) Future of CVD Prevention
• Past • Present • Post-Pandemic Future ? March 22, 2020 DocMatter Community
• Cases of COVID-19 Worldwide: 372,147 – Deaths 16,310 U.S. 42,161 – Deaths 508 Cases of COVID-19
Worldwide: Approaching 32M Deaths Approaching 1M U.S.: Approaching 7M Deaths > 200K
Johns Hopkins Coronavirus Resource Center, accessed Sept 23, 2020 Future CVD Prevention ?…. Sperling LS. Circulation 2020 On My Mind doi.org/ 10.1161.120.047059 “risk for COVID-related morbidity driven by interaction of viral illness with unwell population. Need to invest more than ever in ESSENTIAL services like CV prevention, population health initiatives, robust public health programs…”
Sperling LS. Circulation 2020. The (Post-COVID) Future of Cardiovascular Prevention: Unprecedented Times doi.org/10.1161.120.047059 “cardiovascular and cardiometabolic prevention must be a high level priority in the post-pandemic recovery & the era of COVID-19”
“lessons learned during (pandemic) recovery critical to ensure health of population going forward..”
Dhindsa D, Wong ND, Sperling L Cardiovasc Endo & Metabol 2020; 9(3): 125-127 “In the midst of difficulty lies opportunity…”
Albert Einstein THE FUTURE OF CARDIOVASCULAR MEDICINE WILL BE ….. FOCUS ON CV HEALTH & PREVENTION Focus on CV Population Health: The Health/Disease Continuum Knapper JT, Quyyumi AA, Mensah GA, Sperling LS. JACC 2015;66:960-7
Normal Normal Pre Early Late Low risk High risk disease disease disease
D H Health Promotion & Disease Prevention I E S A E L Contemporary Medicine A T S H E Social Determinants of Health: Challenges & Interventions Schultz WM, Kelli HM, Sandesara P, Quyyumi AA, Mensah GA, Sperling LS. Circulation, 2018.137;2166-2178
• The Post-COVID Future ?
• Acceleration of New Care Models – Telehealth / telemedicine • Decreased use of Ineffective, low-value care • Volume to value transformation • Rapid movement to further healthcare integration / consolidation Need for Comprehensive & Complementary Prevention Programs (Focus on where we are born, live & work, learn & play) • Traditional HC…… • Public / Global Health • Industry / workplace • Schools / churches / families/ communities • Media • Environmental engineering/architecture • Government Success Stories • Be There San Diego – Univ. of Best Practices / Right Care Initiative • Nashville Health • Kaiser N. California HTN Control • South Carolina Collaborative • Minneapolis focus on comprehensive CV risk factors
Fremont A, et al. Health Affairs 2018;37(9):1457-65 Egan BM, et al. J Clin Hypertens 2011;13(8):543-550 PRECISION MEDICINE ? POPULATION HEALTH ? Precision Public Health
• Precision Medicine – Providing right treatment to right patient at right time • Precision Public Health – Providing right intervention to right population at right time
Khoury MJ, et al. Am J Prev Med 2016;50(3):398-401 Million Hearts® 2022 Aim: Prevent 1 Million Heart Attacks and Strokes in 5 Years
Keeping People Healthy Optimizing Care
COMMUNITY
Priority Populations Million Hearts® 2022 Priorities
Keeping People Healthy Optimizing Care
Reduce Sodium Intake Improve ABCS*
Decrease Tobacco Use Increase Use of Cardiac Rehab
Engage Patients in Increase Physical Activity Heart-Healthy Behaviors
Improving Outcomes for Priority Populations Blacks/African Americans with hypertension
35- to 64-year-olds
People who have had a heart attack or stroke
People with mental and/or substance use disorders
*Aspirin use when appropriate, Blood pressure control, Cholesterol management, Smoking cessation • Public Health Priorities – Where CDC & partners can make significant progress in relatively short time • Antibiotic Resistance • HIV Elimination • Million Hearts • Opioid Overdose • Vaccine Preventable Disease • Viral Hepatitis The Future? J. Auerbach. J Public Health Manag Pract 2016;22(3): 215-18
• Approach to Cardiovascular & Cardiometabolic Epidemics / Pandemics ?
• Identify vectors / complex causes • Identify barriers / roadblocks / factors that propagate • Goals: – Control – Elimination – Eradication (Post- COVID) Future of CVD Prevention: At A Crossroads? • COVID impacts CV system, CV care, and outcomes • CV Health & Prevention remain a priority in the midst of pandemic • Future- greater need for integration of healthcare and public health at level of community The Future ?? “It’s tough to make predictions, especially about the future” Yogi Berra
“It is not in the stars to hold our destiny but in ourselves.” William Shakespeare thanks