A forecast of cardiovascular health 30 years from now did not paint a rosy picture. What can healthcare stakeholders do to create a better future for patients?
By Graham Garrison
As a medical student, Dhruv S. Kazi, M.D., M.Sc., M.S., FAHA was fascinated by the physiology of the cardiovascular system – the heart sounds, the cyclical nature, the electrical system of the heart. Halfway through his training, he felt a calling to better understand not only what heart disease does to the individual patient, but what it does to us as a society. It felt intuitive that the two were connected.
“They are,” said Dr. Kazi. “But it’s a different mindset when you try and understand what a disease does to society, both from a health perspective and an economic perspective.”
Dr. Kazi was a recent volunteer vice-chair of American Heart Association advisory writing groups tasked with forecasting what cardiovascular health could look like 30 years from now. The outlook is concerning if current trends continue.
Total costs related to cardiovascular disease (CVD) conditions are likely to triple by 2050, according to projections. At least 6 in 10 U.S. adults (61%) – more than 184 million people – are expected to have some type of CVD within the next 30 years, reflecting a disease prevalence that will have a $1.8 trillion price tag in direct and indirect costs.
What’s causing it?
The AHA’s forecasting exercise projects substantial increases in the burden of cardiovascular disease across all sections of society: young adults, middle-aged adults, older adults, men and women across all racial and ethnic groups, across all categories of insurance coverage, and educational attainment.
Dr. Kazi said there are three drivers of the forecasted increases. First is the fact that the population is getting older. “As our population ages, heart disease increases as we get older. And so, as a population gets older, we see an increase in heart disease.”
The second driver is that the burden of some of these risk factors is going up, in particular hypertension, diabetes, and obesity. From 2020 (the most recent data available) to 2050, projected increases of CVD and risk factors contributing to it in the U.S. include:
- High blood pressure will increase from 51.2% to 61.0%, and since high blood pressure is a type of CVD, this means more than 184 million people will have a clinical diagnosis of CVD by 2050, compared to 128 million in 2020.
- Cardiovascular disease, including stroke, (but not including high blood pressure) will increase from 11.3% to 15.0%, from 28 million to 45 million adults.
- Stroke prevalence will nearly double from 10 million to almost 20 million adults.
- Obesity will increase from 43.1% to 60.6%, impacting more than 180 million people.
- Diabetes will increase from 16.3% to 26.8%, impacting more than 80 million people.
- High blood pressure will be most prevalent in individuals 80 years and older; however, the number of people with hypertension will be highest – and rising – in younger and middle-aged adults (20-64 years of age).
- People aged 20-64 years also will have the highest prevalence and highest growth for obesity, with more than 70 million young adults having a poor diet.
The third driver is that the U.S. population is getting more diverse. Some of the subpopulations and racial ethnic groups have a higher burden of disease than others. Among adults aged 20 and older, projections note:
- Black adults have the highest prevalence of hypertension, diabetes, and obesity, along with the highest projected prevalence of inadequate sleep and poor diet.
- The total numbers of people with CVD will rise most among Hispanic adults with higher numbers also seen among Asian populations.
- Asian adults have the highest projected prevalence of inadequate physical activity.
- The aggregated group of American Indians/Alaskan Natives (AI/AN)/multiracial adults will have the highest projected prevalence of smoking.
- Among children, the projections found:
- Black children will have the highest prevalence of hypertension and diabetes.
- Hispanic children will have the highest prevalence of obesity and the greatest projected growth in hypertension, diabetes, and obesity.
- Asian children and Hispanic children had the highest prevalence of inadequate physical activity.
- AI/AN/multiracial children will have the highest prevalence of smoking.
- Black children and white children will have the highest prevalence of poor diet.
- The absolute increase in each risk factor will be greatest for Hispanic children, reflecting broader trends in population growth.
Past, present and future
Not all the projections were dire. There are several positive developments that forecasters found related to cardiovascular health. For instance, more adults in the U.S. are embracing the healthy behaviors of the AHA’s Life’s Essential 8, as prevalence rates for most are expected to improve:
- Inadequate physical inactivity rates will improve from 33.5% to 24.2%.
- Cigarette smoking rates will drop nearly by half, from 15.8% to 8.4%.
- While more than 150 million people will have a poor diet, that is at least a slight improvement from 52.5% to 51.1%.
Indeed, as the AHA celebrated its centennial in 2024, the organization highlighted some “monumental” accomplishments in the fight against cardiovascular disease which includes all types of heart and vascular disease. Supported by efforts led by the Association, death rates from heart disease have been cut in half in the past 100 years. Deaths from stroke have been cut by a third since the creation of the American Stroke Association in 1998.
Dr. Kazi said we have much to celebrate in terms of the success of science and population health over the past century. Yet, there have been some alarming trends over the past decade that must be addressed. In particular, blood pressure control has declined, while diabetes and obesity have started to rise significantly.
“This contrasts with a long-term decline in blood cholesterol, for instance, that we don’t fully understand,” he said. “A shift to lower saturated fats in our diet has played some role, but this predates any medical intervention. We’ve also made great progress on average on tobacco control. Far fewer Americans smoke today than smoked say 30 to 50 years ago.”
But that progress has been uneven. Some sections of society have made very dramatic progress compared with others. A classic example is tobacco control. It’s very easy for individuals in certain sections of society to not know anyone who smokes, yet, smoking is often clustered in individuals of lower socioeconomic level, lower educational attainment. It’s also rising in certain subpopulations like LGBTQ populations, which are being targeted by ads for products.
“So, I think there’s much to celebrate on average across the country,” said Dr. Kazi, “and yet a word of caution that the trends over the past decade are alarming both overall and in certain subpopulations.”
Making changes
Through its research and advocacy, the AHA hopes this data and forecasting will help both individual clinicians, health systems and policy makers plan better for the health of the populations they serve.
“We have been closely following trends in cardiovascular risk factors over time,” Dr. Kazi said. “Yet, when I looked at recent trends on obesity and diabetes, they were really alarming. It has led me to believe that there is no future of good cardiovascular health in the U.S. that does not go through systematic efforts to address obesity and diabetes. We need to have an honest conversation about what our strategy is to help individuals and society as a whole to beat obesity. Because this is not an individual failing. This is a systematic issue in the country, something fundamentally broken in our food system that leads to such high levels of obesity not seen in many other parts of the world.”
At the individual practitioner level, there needs to be heightened recognition that for many of the conditions that increase cardiovascular risk, there are very effective therapies already available. For instance, effective low-cost therapies for blood pressure have existed for a long time, yet blood pressure control remains poor. Or for individuals with high levels of cholesterol, clinicians can encourage and educate them on ways to do better in nutrition and exercise.
While there has been a general erosion of society’s trust in sources of scientific and health information, whether it’s from the general media, politicians, policymakers, etc., trust in clinicians, physicians, and caregivers remains very high. “That’s bipartisan,” Dr. Kazi said. “So, particularly as we live in a world of political polarization, I think clinicians should take their roles seriously as purveyors of high-quality health and lifestyle information. What can we do to support our patients?”
Not every solution is going to involve a medication or an injection. Some solutions will require lifestyle changes or having a real conversation on how clinicians can help support patients to lose weight or manage diabetes better. Those changes for individuals might mean restricting salt so their blood pressure gets under control or increased physical activity – or even something as basic as more sleep.
“We now have compelling data on what sleep does to heart disease risk,” Dr. Kazi said. “And I think the individual clinician can play a very vital role in communicating this information effectively to patients and families.”
There is a fundamental need to think about how we in the U.S. provide access to high quality preventative care early in life and sustained access to care, because some of these weight trends start early in adolescence. Obesity among children (2-19 years of age) is estimated to rise from 20.6% in 2020 to 33.0% in 2050, increasing from 15 million to 26 million children with obesity; highest increases will be seen among children 2 to 5 years of age and 12 to 19 years of age. The prevalence of inadequate physical activity and poor diet among children is projected to remain high at nearly 60% each, exceeding 45 million children by 2050.
“How do we shift our focus from these high-cost procedures that we’re doing late in life to a more robust primary care system where people can see their physicians, get their blood pressure in control well before they have their stroke or develop heart failure, get their weight under control well before they develop diabetes, for instance?” Dr. Kazi said. “That is going to require systematic strategies both within and outside the health system.”
Within the healthcare system, it includes better access to primary care, and affordable pharmacological interventions that are effective like GLP-1 inhibitors. Outside the health system, it may involve subsidizing healthy foods, disincentivizing unhealthy foods like sugar-sweetened beverages and systematic strategies to reduce tobacco use.
On the healthcare system side, no conversation about the future of heart disease in the U.S. is complete without talking about weight loss drugs like Ozempic and Wegovy, Dr. Kazi said. The AHA recently published some data finding that one in two U.S. adults is eligible for these therapies based on the current indications, and their indications continue to grow over time. These weight loss drugs have the potential to improve the population’s health, but at the same time, they come with a very hefty price tag. Most people who start these drugs stop taking them at one or two years and lose most of the benefits.
“They’re effective, but they’re expensive, and they’re also not a magic bullet,” Dr. Kazi said. “They’re not going to work unless we also invest in other systematic changes to our food supply or primary care system to make sure that patients can make sustainable lifestyle changes.”
Imperatives
Improving cardiovascular health in the U.S. will take both prevention and treatment. If we put all our eggs in the treatment basket and ignore prevention, then we’re not going to be able to make any sustained changes in society, Dr. Kazi said. At some point, it’s going to be too expensive to manage as the population gets older.
The forecasting paper found that as a proportion of the GDP, cardiovascular disease will almost double by 2050 (with inflation already taken into account). When you compare it with GDP, that’s a massive change between 2020 and 2050 if we don’t start addressing it now.
“What we’re trying to say is that there is a health imperative to make change,” Dr. Kazi said, “but also an economic imperative to turn this ship around, because we won’t be able to afford these kinds of expenses as a society if the trends continue.”
Heart disease has been the leading cause of death in the U.S. since the inception of the American Heart Association in 1924. Stroke is currently the fifth leading cause of death in the U.S. Together, they kill more people than all forms of cancers and chronic respiratory illnesses combined, with annual deaths from cardiovascular disease now approaching 1 million nationwide.
Clinically, cardiovascular disease refers to a number of specific conditions, including coronary heart disease (including heart attack), heart failure, heart arrhythmias (including atrial fibrillation), vascular disease, congenital heart defects, stroke and hypertension (high blood pressure). However, while high blood pressure is considered a type of cardiovascular disease, it is also a major risk factor contributing to nearly all types of heart disease and stroke, so for the purposes of these analyses, high blood pressure was predicted separately from all CVD. The American Heart Association said this aligns with its Life’s Essential 8™ – key measures of health factors and health behaviors identified for improving and maintaining cardiovascular health.