COVID-19 spotlights the threat that cardiovascular disease poses to Americans; new technology may help address risk factors at the population health level.
Although it is a new disease, COVID-19 has a way of peeling back layers and bringing other medical issues to the surface. For example, research has shown that people with high blood pressure are more likely to become seriously ill. A study published in the April 22 issue of JAMA of 5,700 patients hospitalized with COVID-19 in the New York City area found that 56% had hypertension, making it the most common comorbidity.
The death rate from cardiovascular disease has been declining, but it remains the leading cause of death in the United States. According to the CDC, 647,457 Americans died of heart disease and 146,383 of stroke in 2017. (Of course, this year COVID-19 has scrambled the usual list of the leading causes of death in this country.)
“(Cardiovascular disease) has to be a priority of health systems and the government. We haven’t really attacked it as well as we should have,” says Martha Gulati, M.D., M.S., FACC, FAHA, division chief of cardiology at the University of Arizona College of Medicine in Phoenix and editor-in-chief at CardioSmart.org, a website run by the American College of Cardiology aimed at educating patients about heart disease. “The whole population has to be involved in this,” with a focus on preventing cardiovascular disease, Gulati says.
More than 100 million American adults, or almost half the country’s adult population, had hypertension in 2018, according to the American Heart Association (AHA). But that proportion grew significantly in 2017, when the AHA revised its definition of high blood pressure. Previously, high blood pressure was defined as a reading of 140/90 mm Hg or higher. Now it is defined as a reading of 130/80 mm Hg, a change that increased the percentage of Americans with high blood pressure from 32% to 46%.
Blood pressure often increases with age, but for people who reach age 50 with normal blood pressure, “the chance of developing cardiovascular disease and stroke immensely decreases,” notes Mariell Jessup, M.D., FAHA, the AHA’s chief science and medical officer. The AHA campaign Life’s Simple 7 highlights seven modifiable risk factors for heart disease, such as losing weight and increasing physical activity. “By working on the risk factors, we can change the overall outcome of the population,” Jessup says.
Cardiovascular disease risk translates into expense. A study of more than 9,000 employees of Baptist Health South Florida, a health system in Coral Gables, collected information on diet, physical activity levels, blood pressure and several other risk factors. Researchers then classified the participants as having optimal, moderate or low cardiovascular health. Results of the study published in Mayo Clinic Proceedings in 2017 showed that the average annual healthcare expenditure for people with low cardiovascular health was $2,021 more than for those in the optimal category and $940 more for those in the moderate one.
‘Bringing the program to you’
The prevalence of diagnosed and undiagnosed hypertension among adult African American men (59% using the new 130/80 threshold) and women (56%) is among the highest in the world. Many programs to address the problem have been launched, with mixed results. A study published in Circulation: Cardiovascular Quality and Outcomes in 2018 involved black churchgoers in New York who had uncontrolled hypertension. One group received “therapeutic lifestyle change” and motivational interviewing about healthy habits, such improving their diet, increasing physical activity and losing weight, along with religious and personal encouragement. The second group received standard health education. At six months, the difference between the two groups was significant. The systolic blood pressure of the therapeutic lifestyle group was, on average, 5.79 millimeters of mercury lower than the health education group. At nine months, there was still a difference, but it was narrow and didn’t meet the usual standard for statistical significance.
In many cases, improving hypertension requires the involvement of community partners, notes Jessup, because most people go to the doctor just once or twice a year. Through programs such as the one conducted at New York churches, “we’re bringing the program to you, rather than making people come to the program,” she says. But it takes money and people to make such programs work, Jessup says.
Gulati points a finger at fee-for-service reimbursement that pays providers more for, say, implanting a stent than for helping a patient keep their blood pressure and cholesterol under control. “We’re a ‘sick care’ system,” she says. “We’re not so good at preventing cardiovascular disease.”
Providers instead need to focus on educating patients on cardiovascular risk and screening those who may be at risk, Gulati says. They also need to get patients engaged in caring for their own health by encouraginghome monitoring ofblood pressure and adherence to hypertension medication prescriptions. By doing so, the healthcare system can “save money by spending money upfront,” Gulati says.
The overlap between the risk factors for serious COVID-19 illness and cardiovascular disease is remarkable. Obesity, diabetes and hypertension appear on both lists. Gulati says COVID-19 has helped shift the conversation to why a healthy population is important.
Telehealth may help
For physicians and nurses involved in the care of people with cardiovascular disease or its many risk factors, telehealth can yield clues about their patients’ exercise and dietary habits. “Seeing a patient in their home environment tells so much about the patient’s life,” Gulati says. There has been a surge in patients using telehealth during the COVID-19 crisis. Not-for-profit FAIR Health analyzed its database of private insurance claims and reported that telehealth jumped more than 4,300% in March compared with March 2019. But oo keep that in perspective, the March 2020 telehealth claims still were only 7.5% of all insurance claims that month.
Hospitals have reported a steep drop in patients experiencing heart attacks and strokes since the pandemic began. Data from Kaiser Permanente Northern California showed a 48% drop in hospitalizations for heart attacks in early April compared with earlier in 2020. Explanations vary. Some people may be dying at home or having relatively mild heart attacks that will lead to more serious problems later.
Mitchell Kaminski, M.D., MBA, a family physician and director of the population health program at Thomas Jefferson University in Philadelphia, says the surge in virtual visits may mean more providers are managing patients with medication rather than referring them to the hospital for a procedure such as cardiac catherization.
“Medication management might sometimes be safer for some categories of patients. We may learn less is more when we analyze all the data,” Kaminski says. “(The COVID-19 pandemic provides) a unique opportunity to step back and analyze data and see what we can learn from it to provide better care for our population.”
Susan Ladika is a health and business writer in Tampa, Florida.