Boston—Cardiovascular mortality declined for years until 2008; however, it now appears to have stagnated, according to a new report.
The report in the Journal of the American Medical Association pointed to the worsening of cardiovascular risk factors, including blood pressure and blood sugar control, among U.S. adults. The researchers and colleagues from Beth Israel Deaconess Medical Center (BIDMC) in Boston raise questions about trends in lipid concentration—another major modifiable risk factor for cardiovascular disease.
"Nationally representative estimates of lipid trends and lipid control in the U.S. population have not been recently examined by gender or race and ethnicity, particularly for Asian and Mexican American adults," explained corresponding author Rishi K. Wadhera, MD, MPP, MPhil, cardiologist at BIDMC and section head of health policy and equity at the Smith Center for Outcomes Research. "Understanding contemporary trends in lipid concentrations and control is important, given concerning changes in population-level cardiovascular mortality and persistent disparities over the past decade."
Essentially, the study team set out to determine whether lipid concentrations in the U.S. population changed from 2007-2008 and 2017-2018, and whether those patterns differed across subgroups.
To do that, researchers conducted a serial cross-sectional analysis of 33,040 adults aged 20 years or older, weighted to be nationally representative, from the National Health and Nutrition Examination Surveys (2007-2008 to 2017-2018). The focus was on lipid concentrations among U.S. adults and on rates of lipid control—defined as a total cholesterol concentration of 200 mg/dL or less—among adults receiving statin therapy.
The mean age of the study population was 47.4 years, and 51.4% were women. Of the 33,040 participants, 12.0% were non-Hispanic black; 10.3%, Mexican American; 6.4%, other Hispanic American; 62.7%, non-Hispanic white; and 8.5%, other race and ethnicities (including non-Hispanic Asian).
The results indicated that among all U.S. adults, age-adjusted total cholesterol improved significantly in the overall population, decreasing from 197 mg/dL in 2007-2008 to 189 mg/dL in 2017-2018 (difference, —8.6 mg/dL [95% CI, —12.2 to —4.9 mg/dL]; P for trend <.001). Those results did not appear to vary much between men and women. In addition, black, Mexican American, other Hispanic, and white adults had significant improvements in total cholesterol; however, that was not the case for Asian adults.
For patients on statin therapy, age-adjusted lipid-control rates did not significantly change from 78.5% in 2007-2008 to 79.5% in 2017-2018 (difference, 1.1% [95% CI, —3.7%-5.8%]; P for trend = .27), with little difference between men and women. As for racial and ethnic groups, only Mexican Americans experienced a significant improvement in age-adjusted lipid control (P for trend = .008).
On the other hand, there is still work to be done, according to the authors, who noted, "In 2015-2018, age-adjusted rates of lipid control were significantly lower for women than for men (OR, 0.54 [95% CI, 0.40-0.72]). In addition, when compared with white adults, rates of lipid control while taking statins were significantly lower among black adults (OR, 0.66 [95% CI, 0.47-0.94]) and other Hispanic adults (OR, 0.59 [95% CI, 0.37-0.95]); no significant differences were observed for other racial and ethnic groups."
Overall, the authors advised that lipid concentrations improved across the board in the U.S. adult population from 2007-2008 through 2017-2018, with the exception of non-Hispanic Asian adults. Specifically, the study identified large improvements for black (–8 points), Mexican American (–11 points), other Hispanic American (–7 points), and white (–9) adults. The drop was only –0.2 points for Asian American adults.
In fact, the number of patients who met cholesterol-level goals of 200 mg/dL or less rose an average of just 1% from 2007-2008 to 2017-2018, with larger jumps among Hispanic American and black adults, who historically have experienced poor rates of lipid control. "However, the rates of lipid control among black adults and other Hispanic Americans still remained significantly lower than those of their white counterparts," the researchers wrote.
In the 2007-2008 sample, an area of concern was that the rates of lipid control among women receiving statin therapy were significantly lower than for men, with just more than one-half achieving 200 mg/dL or lower, and that rates of lipid control among women continued to lag behind that of men during the more recent time period.
"Women with high cholesterol were 10% less likely to achieve lipid control and further study is needed to understand why," stated first author Rahul Aggarwal, MD, cardiology fellow at Brigham and Women's Hospital and research fellow at the Smith Center for Outcomes Research in Cardiology, both located in Boston. "In addition, the lower rates of lipid control among black adults and Hispanic adults, compared with white adults, is also concerning, especially because rates of heart attacks and strokes remain high in these groups. Efforts to identify gaps in care and increase and intensify medical therapy are needed, as statin treatment rates in these populations have been low. Further improvements in lipid control could have substantial public health effects."
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