A day before my 47th birthday last month, I took the subway to Manhattan’s Upper East Side for a coronary artery calcium scan (CAC).
For those who haven’t entered the valley of middle age, a CAC is a specialized CT scan that looks for calcium deposits in the heart and its arteries. Unlike in your bones, having calcium in your coronary arteries is a bad thing, because it indicates the buildup of plaque comprised of cholesterol, fat, and other lovely things. The higher the calcium score, the more plaque that has built up — and with it, the higher the risk of heart disease and even heart attacks.
A couple of hours after the test, I received a ping on my phone. My CAC score was 7, which indicated the presence of a small amount of calcified plaque, which translates to a “low but non-zero cardiovascular risk.” Put another way, according to one calculator, it means an approximately 2.1 percent chance of a major adverse cardiovascular event over the next 10 years.
2.1 percent doesn’t sound high — it’s a little higher than the chance of pulling an ace of spades from a card deck — but when it comes to major adverse cardiovascular events, 2.1 percent is approximately 100 percent higher than I’d like. That’s how I found myself joining the tens of millions of Americans who are currently on statin drugs, which lower levels of LDL cholesterol (aka the “bad” cholesterol).
I didn’t really want to celebrate my birthday with a numerical reminder of my creeping mortality. But everything about my experience — from the high-tech calcium scan to my doctor’s aggressive statin prescription — explains how the US has made amazing progress against one of our biggest health risks: heart disease, and especially, heart attacks.
A dramatic drop in heart attack deaths
A heart attack — which usually occurs when atherosclerotic plaque partially or fully blocks the flow of blood to the heart — used to be close to a death sentence. In 1963, the death rate from coronary heart disease, which includes heart attacks, peaked in the US, with 290 deaths per 100,000 population. As late as 1970, a man over 65 who was hospitalized with a heart attack had only a 60 percent chance of ever leaving that hospital alive.
A sudden cardiac death is the disease equivalent of homicide or a car crash death. It meant someone’s father or husband, wife or mother, was suddenly ripped away without warning. Heart attacks were terrifying.
Yet today, that risk is much less. According to a recent study in the Journal of the American Heart Association, the proportion of all deaths attributable to heart attacks plummeted by nearly 90 percent between 1970 and 2022. Over the same period, heart disease as a cause of all adult deaths in the US fell from 41 percent to 24 percent. Today, if a man over 65 is hospitalized with a heart attack, he has a 90 percent chance of leaving the hospital alive.
By my calculations, the improvements in preventing and treating heart attacks between 1970 and 2022 have likely saved tens of millions of lives. So how did we get here?
In 1964, the year after the coronary heart disease death rate peaked, the US surgeon general released a landmark report on the risks of smoking. It marked the start of a decades-long public health campaign against one of the biggest contributing factors to cardiovascular disease.
That campaign has been incredibly successful. In 1970, an estimated 40 percent of Americans smoked. By 2019, that percentage had fallen to 14 percent, and it keeps declining.
The reduction in smoking has helped lower the number of Americans at risk of a heart attack. So did the development and spread in the 1980s of statins like I’m on now, which make it far easier to manage cholesterol and prevent heart disease. By one estimate, statins save nearly 2 million lives globally each year.
When heart attacks do occur, the widespread adoption of CPR and the development of portable defibrillators — which only began to become common in the late 1960s — ensured that more people survived long enough to make it to the hospital. Once there, the development of specialized coronary care units, balloon angioplasty and artery-opening stents made it easier for doctors to rescue a patient suffering an acute cardiac event.
Our changing heart health deaths
Despite this progress in stopping heart attacks, around 700,000 Americans still die of all forms of heart disease every year, equivalent to 1 in 5 deaths overall.
Some of this is the unintended result of our medical success. As more patients survive acute heart attacks and life expectancy has risen as a whole, it means more people are living long enough to become vulnerable to other, more chronic forms of heart disease, like heart failure and pulmonary-related heart conditions. While the decline in smoking has reduced a major risk factor for heart disease, Americans are in many other ways much less healthy than they were 50 years ago. The increasing prevalence of obesity, diabetes, hypertension, and sedentary behavior all raise the risk that more Americans will develop some form of potentially fatal heart disease down the line.
Here, GLP-1 inhibitors like Ozempic hold amazing potential to reduce heart disease’s toll. One study found that obese or overweight patients who took a GLP-1 inhibitor for more than three years had a 20 percent lower risk of heart attack, stroke, or death due to cardiovascular disease. Statins have saved millions of lives, yet tens of millions more Americans could likely benefit from taking the cholesterol-lowering drugs, especially women, minorities, and people in rural areas.
Lastly, far more Americans could benefit from the kind of advanced screening I received. Only about 1.5 million Americans received a CAC test in 2017, but clinical guidelines indicate that more than 30 million people could benefit from such scans.
Just as it is with cancer, getting ahead of heart disease is the best way to stay healthy. It’s an astounding accomplishment to have reduced deaths from heart attacks by 90 percent over the past 50-plus years. But even better would be preventing more of us from ever getting to the cardiac brink at all.
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