The Changing Profile of Cardiovascular Disease

For decades, the story of heart disease has been dominated by two main characters: coronary heart disease (arteries in heart muscles become clogged with atherosclerosis which can lead to heart attacks) and stroke (clot or bleeding impedes blood flow to part of brain). They were the undisputed leading causes of cardiovascular illness and death. However, recent data reveals a dramatic shift in this landscape. While we've made significant strides against these traditional foes, conditions once considered secondary now command the stage.

The good news is a testament to decades of medical progress. Advances in prevention, from smoking cessation campaigns to cholesterol-lowering statins, and improved treatments have led to a significant decline in atherosclerotic diseases—conditions caused by the hardening and narrowing of arteries. Data from a landmark UK study shows that between 2000 and 2019, the proportion of these diseases as a total of all newly diagnosed cardiovascular conditions fell from 55% to just 39%. Specifically, acute coronary syndromes (heart attacks) dropped from 12% to 9% of the total, while chronic ischaemic heart disease (e.g. angina) was reduced from 24% to 16% (Figure 1). 

As the incidence of atherosclerotic diseases has fallen, other cardiovascular conditions have risen to fill the gap, namely a steady increase in non-atherosclerotic problems. The proportion of arrhythmias, or irregular heartbeats, has surged from 19% to 28% of the total cardiovascular burden. Within this category, atrial fibrillation and flutter (less severe than fibrillation) are now the most common cardiovascular problems diagnosed, climbing from 16% to 22% of all conditions (Figure 1). Furthermore, cases of heart block, another type of arrhythmia, have more than doubled. Alongside these, degenerative conditions like valve disease and thromboembolic diseases (related to blood clots) have also become more prevalent, ensuring that the overall incidence of cardiovascular disease has remained stable since the mid-2000s.

This shift isn't due to a single cause but rather a combination of our successes and ongoing challenges. First, improved survival rates from heart attacks and strokes mean that patients are living longer, but this extended lifespan gives other, often age-related, cardiovascular conditions time to develop. Second, diagnostic tools are more sensitive and awareness is greater, allowing doctors to detect conditions like atrial fibrillation that might have been missed in the past. Finally, a rising tide of risk factors like high blood pressure, obesity, diabetes, and chronic kidney disease across the population is thought to be a major driver behind many of these newly prominent non-atherosclerotic conditions such as the arrhythmias.

A closer look at the data reveals that the progress we've made is not evenly distributed. The significant reduction in heart attacks and strokes has been most pronounced in individuals over the age of 60. In younger populations, there has been disappointingly little improvement, suggesting that the risk factors affecting younger adults may be different or that preventive messages are not having the same impact. Compounding this is a persistent socioeconomic gap. For nearly all cardiovascular diseases, a clear gradient exists where individuals from more deprived backgrounds are at higher risk, a disparity that has shown no sign of narrowing over the past two decades.

This evolving picture has profound implications for how we approach prevention. Current guidelines, which are heavily focused on preventing traditional atherosclerotic diseases, are becoming outdated. To continue reducing the overall burden of cardiovascular disease, we must broaden our focus. Future strategies need to incorporate the prevention of arrhythmias, valve disease, and thromboembolism. This will require more research into the specific risk factors for these conditions. Furthermore, a one-size-fits-all approach is no longer sufficient; prevention must be tailored to address the unique risks faced by younger people and more socioeconomically deprived populations. For example, lifestyle factors such as obesity, physical inactivity, and stress can increase the risk for arrhythmias. 

The challenge of this new landscape comes with exciting therapeutic opportunities. The deeper understanding of disease mechanisms is paving the way for novel treatments. For instance, drugs originally developed for diabetes, such as SGLT2 inhibitors and GLP-1 receptor agonists, have shown remarkable and unexpected benefits in preventing heart failure and arrhythmias. This points towards a future of personalized medicine, where risk assessments are more dynamic and precise, allowing for earlier, targeted interventions across a wider spectrum of cardiovascular conditions.

In summary, the profile of cardiovascular disease has fundamentally changed. The celebrated decline in heart attacks and strokes has been offset by a significant rise in other conditions like atrial fibrillation and valve disease, keeping the overall burden of heart disease distressingly high. This shift is driven by a mix of improved survival, better diagnosis, an aging population, and persistent risk factors. To meet this new reality, we need to broaden our prevention strategies beyond atherosclerosis, address age-related and socioeconomic disparities, and capitalize on new therapeutic opportunities to create a more personalized and effective future for cardiovascular health.

Figure 1. Pie chart showing distribution of cardiovascular diseases from 2000 to 2002 (top) and 2017 to 2019 (bottom). Atherosclerotic diseases are in blue/white; non-atherosclerotic diseases are the other 3 categories in green, red, and white (data from Conrad et al. BMJ, 2024).

Glossary of conditions. (1) Acute Coronary Syndrome (ACS): sudden, reduced blood flow to the heart muscle, usually due to rupture of an atherosclerotic plaque (e.g. myocardial infarction aka heart attack). (2) Chronic Ischaemic Heart Disease: long-term condition where the heart muscle receives insufficient blood supply due to narrowed coronary arteries, often from atherosclerosis (e.g. stable angina). (3) Stroke: blood flow to part of the brain is interrupted or reduced, leading to brain cell death which can be due to a blood clot (ischemic) or to bleeding (hemorrhagic). (4) Peripheral Arterial Disease (PAD): condition where narrowed arteries reduce blood flow to the limbs, typically the legs. (5) Atrial Fibrillation or Flutter: abnormal heart rhythms originating in the atria. Atrial fibrillation is more irregular often with rapid beating of the atria, whereas atrial flutter is more organized often with a regular rhythm. (6) Heart Block: a type of arrhythmia in which the electrical signals from the atria to the ventricles are partially or completely blocked. (7) Aortic Aneurysm: abnormal bulging or dilation in the wall of the aorta, the main artery leaving the heart, that if ruptured, can cause life-threatening bleeding. (8) Aortic Stenosis: narrowing of the aortic valve opening, restricting blood flow from the left ventricle to the aorta. (9) Heart Failure: chronic condition in which the heart is unable to pump enough blood to meet the body's needs. (10) Venous Thromboembolism (VTE): blood clots in the veins. Two examples are deep vein thrombosis (DVT) in deep veins such as the legs and pulmonary embolism (PE) which is a clot that travels to the lungs, potentially fatal.