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”

Kannel et al, Ann Intern Med 1961

Age, sex, hypertension, hyperlipidemia,

smoking, diabetes, (family history), (obesity)

“We cannot be a strong nation

unless we are a healthy nation…”

Franklin D. RooseveltDedication 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 FusterWCC 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)

•

Lange SJ, Ritchey MD, Goodman AB, et al. Potential Indirect Effects

of the COVID-19 Pandemic on Use of Emergency Departments for

Acute Life-Threatening Conditions — United States, January–May

2020. MMWR Morb Mortal Wkly Rep. ePub: 22 June 2020. DOI:

http://dx.doi.org/10.15585/mmwr.mm6925e2

Impact of COVID(MMWR)

Stokes EK, Zambrano LD, Anderson KN, et al. Coronavirus Disease 2019 Case Surveillance — United States, January 22–May 30, 2020. MMWR Morb Mortal Wkly Rep 2020;69:759–765. DOI: http://dx.doi.org/10.15585/mmwr.mm6924e2

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

Weeks to

Months

Morb

idit

y a

nd M

ort

alit

y

Curve

#1Acute COVID-19

Infections

Curve

#2

Months Years

Curve

#3

Curve #5

Decades

Delays in Urgent Care,

Lack of Guideline-

Directed Care

Neglected Chronic

Conditions, Rehab/LTAC

Care

Curve

#4

Iterative COVID-

19 Infections

Mental Health and

Economic Burden

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)

Ritchey MD et al. Trends Cardiovasc Med. 2019;pii:S1050-1738(19)30134-3. Hall EW et al. Stroke. 2019;50(12):3355-3359

Percent change in

stroke rate, 2010–2016 (% of counties)

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

Missed Opportunities to Prevent Cardiovascular Events

+

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

ContinuumKnapper JT, Quyyumi AA, Mensah GA, Sperling LS. JACC 2015;66:960-7

Normal

Low risk

Normal

High risk

Pre

disease

Early

disease

Late

disease

Health Promotion & Disease Prevention

Contemporary Medicine

H

E

A

L

T

H

D

I

S

E

A

S

E

Social Determinants of Health: Challenges &

InterventionsSchultz 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

COMMUNITY

Keeping People HealthyOptimizing Care

Priority Populations

Million Hearts® 2022Priorities

Keeping People Healthy

Reduce Sodium Intake

Decrease Tobacco Use

Increase Physical Activity

Optimizing Care

Improve ABCS*

Increase Use of Cardiac Rehab

Engage Patients in

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

•

• Identify vectors / complex causes

• Identify barriers / roadblocks / factors that

propagate

• Goals:

– Control

– Elimination

– Eradication

Approach to Cardiovascular &

Cardiometabolic Epidemics / Pandemics ?

(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