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Why has the rate of heart disease related deaths dropped?
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iride6606 posted:
There have been several discussion concerning the reason heart disease related deaths have dropped so dramatically. The link below is a great paper done by a couple doctors I have bumped into during my career that really breaks things down to the basics. The time period of 1980 - 2000 saw a 40% decrease in the death rates for heart disease, which was the most ever in a 20 year period.

This paper breaks down the reasons for the decrease and found that 40% of the deaths prevented was due to advancement in medical treatment which was preventing deaths. Also, 54% was based on the reduction of risk factors and 6% was unknown.

So with 40% coming from the advancements in treatment, what made up the rest. 30% was due to a reduction in Hypertension, 28% was directly attributed to a reduction in serum cholesterol and 15% in the reduction of smoking. These three areas make up 73% of the deaths prevented from heart disease by cintrolling risk factors. The actual number of deaths prevented by controlling cholesterol was 95K second only to 105K from a reduction in Hypertension.

This is very interesting and I recommend reading it if you have a chance. Don't forget to look at the tables, it is very interesting.

http://www.nejm.org/doi/full/10.1056/NEJMsa053935#t=articleDiscussion
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bobby75703 responded:
Excellent discussion title. I will get back with you after family commitments. But I am glad you brought this up.
 
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bobby75703 replied to bobby75703's response:
This is a 5 star topic. One that I explored for several years.
Thank you for posting this.


Its important to note the authors of the article use the words "may" in the introduction and use "estimated" on the tables.
There is no way to know for certain which changes in risk factors bear exactly which percentage of the credit in the decline in heart disease in the USA, but we can speculate.

I was surprised they only credited 15% of the decline to stopping smoking. While they are entitled to their opinion, I know several physicians who would raise an eyebrow. Smoking has been considered the greatest risk factor. I myself view stopping smoking as bearing the most weight in the decline, but that's just my opinion.

There is no question surgical intervention such as bypass surgery has played a role. Bypass gave my father an addition 24 years, but he eventually died from heart disease.

In search for reasons for the decline, I looked back 100 years in the USA, and explored the world. While the united states and other countries enjoyed a decline in heart disease, other countries were not so fortunate, and today we have places in the world where heart disease is on the rise. I was determined to find out why.


What I found was compelling. A strong association with exposure to toxic air particulate and deaths from vascular disease.


Association does not prove causation, however the association is so vivid, science has launched several studies into air pollution and heart disease. With the results of each study the link between air pollution and heart disease becomes stronger. Even the American Heart Association has made a statement accepting air pollution as a risk factor. Just how much weight that factor bears remains to be seen.






 
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iride6606 replied to bobby75703's response:
My concerns with this are the concerns that are being considered by the scientific community concerning all numbers. The issue is simple, do any of these numbers concerning the data since 1900 mean anything? Many are saying no, in fact the only data the we know is correct is the numbers from the mid 70s on. Let me explain.

If you look at the way deaths were reported since the beginning of the 20th century, there has been no consistent measurement due to the way deaths were reported. For instance, between 1900 and 1920 the data only included a few states and some other areas but no one knows what percentage of the population was being represented so the rates mean nothing. From 1930 through the 1950s there was no standard for reporting causes of death but all states were starting to be represented, however most feel the increase in the death rate was more a result of more deaths being reported that were not reported before. More standardization took place in the 60s but it wasn't until the 70s that we know the numbers to be truly representative of the entire population and all being reported as the same code.

What many postulate is that the graph is not actually a bell curve. There is more and more belief that what we really should have is a flat line until we start seeing the dramatic drop in the 80's Personally I don't think that's the case. In my mind it makes sense that there would be some rate of decline which would be driven by the increase in the life expectancy.

Back to the link, their research is solid and I can follow the math and believe that the numbers are more likely to be correct than not. Mostly because we're talking about the period between 1980 and 2000 for which we know we have good data. It is my opinion that we really can only depend on the most recent data.

My personal belief on the matter.
 
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bobby75703 replied to iride6606's response:
While I agree technology has improved in determining cause of death, I personally would not dismiss the data from the 1970's or write it off as invalid.

Even if we use just 1980-2010, using BOTH rate of decline graph, and the numbers of deaths graph, and draw a vertical red line thru 1987 when statins arrived, I get the same observation.

"Nothing happened that wasn't already happening after statins arrived"


This is part of the reason why I personally believe statins had no role in the decline of heart disease related deaths.


Using 1980-2010 something was causing heart disease deaths to decline for seven years before statins came onto the scene.


After 1987, statins made zero impact on the graph line.


So even if I kick out the data from 1970 -1980, I still get the same answer.
 
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billh99 replied to bobby75703's response:
I have not had time to read the article.

But a quick google on smoking rates show that it had started down in 1980 and was drastically down by 2000.
 
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iride6606 replied to bobby75703's response:

Based on the data presented, you have to look at the sum total of the reasons for the decline. Perhaps the number of deaths eliminated in the early 80's were from the advances in cardiovascular surgery. That leveled off and then the effects of statins kicked in to keep the decline intact. Also, you need to look at the numbers year over year, and not just as part of a 110 year graph which will show an exponential smoothing effect.

Here's another representation from the UK.



Note the increase in the reduction due to smokers. This makes sense as the UK has more smokers per 1,000 population than the US.

Below is the findings from the NIH, very similar;

We applied a previously validated statistical model, IMPACT, to data on the use and effectiveness of specific cardiac treatments and on changes in risk factors between 1980 and 2000 among U.S. adults 25 to 84 years old. The difference between the observed and expected number of deaths from coronary heart disease in 2000 was distributed among the treatments and risk factors included in the analyses.
RESULTS:From 1980 through 2000, the age-adjusted death rate for coronary heart disease fell from 542.9 to 266.8 deaths per 100,000 population among men and from 263.3 to 134.4 deaths per 100,000 population among women, resulting in 341,745 fewer deaths from coronary heart disease in 2000. Approximately 47% of this decrease was attributed to treatments, including secondary preventive therapies after myocardial infarction or revascularization (11%), initial treatments for acute myocardial infarction or unstable angina (10%), treatments for heart failure (9%), revascularization for chronic angina (5%), and other therapies (12%). Approximately 44% was attributed to changes in risk factors, including reductions in total cholesterol (24%), systolic blood pressure (20%), smoking prevalence (12%), and physical inactivity (5%), although these reductions were partially offset by increases in the body-mass index and the prevalence of diabetes, which accounted for an increased number of deaths (8% and 10%, respectively).
 
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iride6606 replied to billh99's response:
I hope you get a chance to read it as I would be interested in your opinion.
 
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bobby75703 replied to billh99's response:
"But a quick google on smoking rates show that it had started down in 1980 and was drastically down by 2000."


My understanding has been that America started its decline in smoking around 1970. As a teenager in the 70's, I clearly remember the 'stop smoking' campaign.


If my memory serves me right, I have seen graphs depicting the smoking decline beginning right after 1968 or 1970. The same time heart disease began its decline.


My thoughts towards the decline in death rates from heart disease since 1968 is that the decline in smoking and decline in smog played a significant role in the decline of vascular disease and heart attacks.


While a healthy diet is vital, the lions share of what enters our arteries and tissues comes from inhalation.


I credit the following to play a significant role in the decline of heart disease in the USA:


* Smoking rates dropping in half.
* Strict public laws restricting second hand smoke.
* Factories cleaning up their emissions.
* Exporting manufacturing jobs to China and other countries.
* EGR valves
* Catalytic converters.
* Development of automotive air conditioning.
* Development of residential central air.

Most people reading this list will be able to relate to stopping smoking. But are probably scratching their heads on the air conditioning part. I will explain the A/C part later in another post.



 
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bobby75703 replied to billh99's response:
Bill, just double checked the smoking data. Per capita consumption of cigarettes peaked in the mid 60's.

All graphs show a gradual decline in smoking rates after the late 60's, with the exception of teenagers in the 90's, however the brief increase in teenage smokers has been snuffed out.
 
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billh99 replied to bobby75703's response:
Exactly.

While smoking is a very high risk factor on an individual level when looked at on a population group, if the number smoking is reduced then it will have a reduced effect on the group.
 
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bobby75703 replied to billh99's response:
100% agreed smoking is a very high risk factor.

As smoking declined, death rates from heart disease declined.


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