Backsliding in the Prevention of Cardiovascular Diseases

In 1993 an ETC Task Force on Research in Epidemiology and Prevention of CVD set forth a previously unthinkable goal: elimination of the coronary epidemic in the United States. The task force concluded that enough is known already about the causes of heart attack and stroke that a reduction of risk can be envisioned in this country to the level found in Japan, for example, or to that found among adults here who have low values for all the major risk factors.

Do we have sufficient reason to be so optimistic?

Trends downward in CVD mortality in this country and abroad indicate the potential for much wider prevention. Epidemiologic data illustrate that shifts in CVD rates occur in relation to public health efforts and medical advances. But nothing is automatic or guaranteed about the fall of epidemics. Not all trends are favorable. Disease trends have causes that we need to understand and try to influence.

Those working in cardiovascular diseases have participated with the National Heart, Lung, and Blood Institute (NHLBI) in a health revolution that can be said to have turned back the twentieth-century epidemic of CVD. In three decades, the rate of dying has fallen by more than half for heart attack and by two-thirds for stroke. Death rates both in and out of hospital have plummeted, and survival after a vascular event has greatly improved. Population levels of the major CVD risk factors, cigarette smoking, blood pressure, and blood cholesterol, have decreased steadily. And societal mores have changed favorably in respect to smoking, eating patterns, and leisure-time physical activity.

In fact, this revolution is attributable both to advances in cardiac care and to effective prevention. Both of these, in turn, are based on a sound and balanced NHLBI research program and a strong scientific establishment in this country.

Epidemiologic evidence indicates that risk factor improvement, that is, preventive measures, predominated in the early-mortality decline of the 1970s to mid-80s, and that cardiac care has been proportionately more influential during the period since.

We should, nevertheless, be warned by some current developments that threaten this happy revolution. Epidemiologic observations indicate that a plateau has occurred in certain CVD death rates and in some risk factor levels, while CVD morbidity rates, after a period of decline, are again on the rise.

Efforts at hypertension control are losing ground, and many Americans appear to be backsliding in patterns of healthy lifestyle. Moreover, certain segments of our society, including women, youth, and low-income, low-education groups, have not participated fully in the general improvement these days in risk, lifestyles, and cardiac care. Shifts in national research priorities may threaten the enterprise and the infrastructure of CVD prevention, so effectively built in pioneer efforts by NHLBI. And finally, a type of backlash against health promotion is being encouraged by some forces in industry and in the media.

The promise of continued more substantial CVD prevention, including preventing high risk in the first place, need not be lost. Attention is needed to a continued strong and balanced research program in the laboratory and clinic and in the population, and to tested programs directed to susceptible subgroups of the poor, the elderly, women and minorities, and in developing countries. (Henry Blackburn)

References

Report of the Task Force on Research in Epidemiology and Prevention of Cardiovascular Diseases. USHHS Public Health Service. NIH. 1993

Address on 50th Anniversary of the National Heart, Lung, and Blood Institute by Henry Blackburn, M.D, Mayo Professor Emeritus, University of Minnesota