Fighting Heart Disease in the United States

After surgeries for an aortic aneurysm (when the aorta walls balloon out), two hernias and a problematic leg artery, Steven Rowell got a stern warning from his surgeon: Decades of smoking had damaged his blood vessels. "If I wanted to stay around longer, I had to make some decisions," says Rowell, 63, a hospital-system network engineer from Cape Coral, Florida, who had puffed a pack a day for more than 25 years. "With all the grandkids I have, I wanted to see them grow up."

Rowell began swimming and biking with his wife as she trained for triathlons and began following a more plant-based diet. And he signed up for an innovative test that detects if plaque is clogging the arteries of the heart.

The test, known as a coronary computed tomography angiography (CCTA) is widely used in people with early warning symptoms of heart disease, such as chest pain. But now some cardiologists are using the test with people like Rowell, who have risk factors like smoking but exhibit no warning signs. The idea is to look inside the heart — while there's still time to use medications and lifestyle changes to attack dangerous plaque before a heart attack happens, says James Min, M.D., former director of the Dalio Institute of Cardiovascular Imaging at New York-Presbyterian Hospital.

Min developed an FDA-approved system called Cleerly for evaluating heart plaque in CCTA images and assigning it a risk stage (from no risk to severe risk). "Heart doctors have never actually directly measured heart disease," Min says. "It sounds weird, but we haven't. We have used risk factors, like an abnormal stress test or a blockage." Yet 50 percent of heart attacks happen to people who haven't had any early warning signs.

Cleerly could reduce the risk for those individuals who don't show any outward signs of being at risk, Min says. The screening technique shows not just the amount of plaque but also the type: Hard, calcified plaque is relatively safe, while soft plaques can rupture and spin off heart-menacing blood clots. Seeing the buildup and knowing its type can help doctors write treatment plans. And seeing actual pictures of what's going on inside their own heart may motivate people to stick with medications and healthy habits. "Half the people prescribed statins will not be taking them after one year. And by five years, 90 percent are not taking their medications," Min notes.

The day after his scan, Rowell saw his own coronary arteries for the first time. "It was eye-opening," he says. "I had one artery that was 100 percent blocked. The majority were 30 to 40 percent blocked, and the majority was soft plaque." Seeing the state of his heart prompted his doctor to change his blood pressure and cholesterol medications and inspired Rowell to upgrade his eating habits and get more exercise. His cholesterol and blood pressure numbers dropped into a healthier range, and he's lost 35 pounds. In December he will repeat the CCTA test and hopes to see positive changes.

Not everyone agrees with the idea of CCTA screenings for people with no heart disease warning symptoms. In 2021, the American Medical Association advised consumers that there was "no high-quality evidence to support routine use" and urged the use of exercise stress tests, which identify blockages in the heart. But the American College of Cardiology has recently partnered with Min in his research, and the Cleerly system is covered by some insurance plans. In October, Medicare began reimbursing $950 for the system too.

New uses of CCTA screenings are hardly the only advanced weapon being deployed in the war on heart disease. Exciting recent breakthroughs include advances in surgical techniques, implantable devices and more-effective medications.

New plumbing tools. In 30 percent of the 965,000 artery-clearing heart procedures performed each year in the U.S., cardiologists face a tough problem: a hard, calcium-packed shell covering soft, gooey plaque in blood vessel walls. This hardened shell can resist cardiologists’ efforts to deploy artery-widening balloons and stents to hold arteries open. But a new technique called intravascular lithotripsy, approved by the FDA in 2021, uses shock waves to break up these hardened deposits. It is similar to technology used to break up kidney stones, is easier for interventional cardiologists to use (the device is threaded through arm or leg arteries to the heart) and may work better for hard areas deep within plaque.

"Coronary artery disease patients in their late 60s, 70s, 80s and older will generally have calcium in their blockages, so this is an important tool for treating heart disease in older persons, particularly the very elderly," says Quinn Capers, M.D., a cardiologist at the University of Texas Southwestern Medical Center in Dallas. In the clinical trial of 384 people with hard plaque, 92 percent of them were able to receive a stent after lithotripsy, with no heart attacks within 30 days. Meanwhile, doctors are now deploying stents that are stronger, safer and more flexible, providing a variety of new options for patients. On the horizon are biodegradable stents that keep arteries open only long enough for medications and lifestyle interventions to work; when the artery heals, they dissolve.

Advanced heart drugs. When sodium-glucose transporter 2 (SGLT-2) inhibitors burst onto the research scene, scientists thought this new class of drugs would be great at lowering blood sugar. They got a big surprise.

"They really reduce episodes of heart failure in the patients with diabetes. Because of this, and because the drugs don't lower blood sugar if it is not elevated, we tested SGLT-2 inhibitors in people with heart failure without diabetes, and the drug is effective in those patients too," says cardiologist Nancy K. Sweitzer, M.D., professor and vice chair for clinical research in the Department of Medicine at the Washington University School of Medicine in St. Louis, and editor in chief of the journal Circulation: Heart Failure. In a 2022 analysis of five major studies, SGLT-2 inhibitors cut the risk of hospitalization or death from heart failure by 33 percent.

Meanwhile, there are new options for people who can't tolerate statins or who eventually just stop taking them. Cholesterol-smashing medications called PCSK9 inhibitors are given by injection every three or six months at your doctor's office or a hospital. They block the breakdown of LDL receptors so more bad cholesterol is shunted to your liver for disposal. They lower LDLs by 50 to 60 percent, and they also reduce the odds of a heart attack by 15 to 20 percent more than statins alone.

Effective new implants. Until 12 years ago, older and sicker adults with stiff, diseased heart valves were considered "inoperable" — getting a new valve was deemed too risky because it required open heart surgery. Since then, cardiologists have developed a heart-valve delivery method called transcatheter aortic valve replacement (TAVR).

"Now patients can have their aortic valves repaired in a procedure where a new valve is implanted using a catheter inserted into the femoral artery in the groin," Capers says. "Some patients are discharged from the hospital after an overnight stay, with a bandage on their groin." In 2019, Cleveland Medical Center researchers found that deaths from diseased heart valves in older adults fell suddenly starting in 2013, at the same time that the number of TAVR procedures was increasing in the U.S. The new procedure may be the reason, they note.

Today, TAVR is more common than open heart surgery for replacing the aortic valve. "It's an amazing advance over the past 20 years," says interventional cardiologist B. Hadley Wilson, M.D., executive vice chair at Atrium Health's Sanger Heart and Vascular Institute in North Carolina and president-elect of the American College of Cardiology.

Perhaps the best news about our heart health crisis is that when it comes to your own personal risk, the key to prevention is in your hands, says Michelle McMacken, M.D., executive director of nutrition and lifestyle medicine for NYC Health + Hospitals/Bellevue in Manhattan. "A suboptimal diet is responsible for almost half of the deaths from heart disease, stroke and type 2 diabetes," McMacken says. "Even among those who are living at high genetic risk, a healthy lifestyle can actually reduce the risk of developing heart disease by half."

But according to the American Heart Association, just 11 percent of people in their 40s and 50s and 4 percent 60 and older are taking these essential personal steps. While 72 percent of adults in a recent Harris Poll said they want to talk more about self-care with their doctor, 78 percent of physicians in another survey said they don't have time during the typical 17-minute appointment. One in 4 doctors didn't feel confident they could give advice. And in a survey of 1,000 cardiologists that National Jewish Health's Freeman conducted for the American College of Cardiology, nearly 90 percent had little training or education in day-to-day nutrition.

That has to change, Freeman says. "You have to ask patients about lifestyle — and keep revisiting the topic. If we incentivize doctors to spend more time on it, if we show doctors the value of it, these would be extraordinary efforts. If and when we win the battle against heart disease, it will no longer be the number 1 killer."

Sari Harrar is an award-winning reporter and contributing editor to AARP publications who writes on health, public policy and other topics.

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