Deaths from Coronary Artery Disease Have Fallen by Over Half Since 1990, Yet Nearly 90% of Recent Deaths Remain Preventable
Key Insights
Ischemic heart disease (search) deaths in the U.S. fell by 58.7% from 1990 to 2023, driven largely by reductions in smoking and particulate air pollution, according to a JAMA Cardiology study.
Despite progress, 88.8% of the estimated 473,000 coronary artery disease (search) deaths in 2023 were attributable to modifiable risk factors, led by high systolic blood pressure (search) (47.2%), dietary risks (38.6%), and high LDL cholesterol (search) (28.5%).
Deaths linked to high BMI and high fasting blood glucose have risen by 12.5% and 10.5% respectively since 1990, signaling growing challenges from obesity (search) and diabetes (search).
Deaths due to ischemic heart disease (search) in the United States fell by more than half — 58.7% — between 1990 and 2023, according to a systematic analysis published Wednesday in JAMA Cardiology. Yet the same study reveals a sobering counterpoint: an estimated 88.8% of the 473,000 coronary artery disease (search) deaths recorded in 2023 were linked to modifiable risk factors, meaning nearly nine out of ten such deaths could potentially have been prevented.
The findings, drawn from the Global Burden of Disease Study 2023, offer both a testament to decades of public health progress and a stark reminder of the work that remains.
"We are not seeing the progress we should hope for and comparing states helps us to see what can be accomplished in reducing ischemic heart disease (search) mortality, when we compare leading and trailing locations," said Gregory Roth, MD, MPH, director of the Program in Cardiovascular Health Metrics and professor of medicine-cardiology at the University of Washington, who served as lead author of the study.
Progress Driven by Smoking and Pollution Declines
Much of the mortality reduction over the 33-year study period stemmed from declines in two key risk factors: smoking, which fell by 33.3%, and particulate air pollution, which dropped by 74.9%. These gains reflect decades of tobacco control policies and environmental regulations.
However, the pace of improvement has slowed since 2010, when progress on several risk factors began to stall. Against a backdrop of an aging and growing U.S. population, the absolute number of deaths remains substantial.
Metabolic Risks on the Rise
While some risk factors have receded, others are moving in the wrong direction. Deaths attributable to high body mass index increased by 12.5% since 1990, and those linked to high fasting plasma glucose (search) rose by 10.5%. These trends align with the growing prevalence of diabetes (search) and the emergence of cardiovascular-kidney-metabolic (CKM) syndrome, an umbrella term encompassing heart disease, kidney disease, diabetes, and obesity (search).
"This is the fastest rising risk for ischemic heart disease (search)," Roth said of the BMI and glucose trends. "We need to focus attention on how to disrupt this alarming trend."
In 2023, the leading contributors to ischemic heart disease (search) mortality were high systolic blood pressure (search) (accounting for 47.2% of deaths), dietary risks (38.6%), and high LDL cholesterol (search) (28.5%). These metabolic and behavioral factors together accounted for nearly half of all heart disease deaths.
"I think it bears repeating that coronary artery disease (search) is preventable," Roth told STAT. "For those of us who are in the health space, that sounds maybe obvious, but I see patients every week who are not aware that for the leading cause of death in the United States, we know how to modify risk factors so that we could potentially remove 80% or 90% of it."
Stark Geographic Disparities
Where people live made a measurable difference. The highest coronary artery disease (search) death rates were concentrated in Kentucky, Tennessee, West Virginia, Mississippi, and Arkansas. The lowest rates were observed in Massachusetts, Oregon, Hawaii, Colorado, and Minnesota.
Looking back to 1990, Massachusetts, New Jersey, and Minnesota achieved the largest age-adjusted declines, each averaging more than 63% fewer coronary artery disease (search) deaths. States that adopted policies targeting tobacco smoking saw greater improvements in heart disease outcomes.
"We want to communicate with individuals about choices they can make, but we really want to communicate this information to people who are in a position to guide health policy," Roth said.
A Call for Policy and System-Level Action
Robert Califf, MD, a cardiologist, former FDA commissioner, and member of the Duke Clinical Research Institute, authored an accompanying editorial that framed the findings as a call to action on multiple fronts.
"It is ironic that a society with such a surplus of resources is not aggressively addressing this issue when it is overwhelmingly likely that a combination of policy interventions, attention to reliable communication about health in our information ecosystem, and wider use of generic medicines would dramatically reduce the scourge of CKM syndrome," Califf wrote.
He highlighted the shortage of primary care physicians and CKM specialists, conflicting dietary guidance between federal recommendations and the American Heart Association's scientific consensus, and the spread of health misinformation on social media as critical barriers.
"We must join the battle on social media, using modern methods for effectively communicating reliable and useful information to counter the overwhelming volume of misinformation used to sell ineffective, unproven wellness interventions and unhealthy food choices," Califf wrote.
Clinical Implications and Individual Action
Sadiya Khan, MD, professor of cardiovascular epidemiology at Northwestern Medicine, who was not involved in the study, emphasized the need for a comprehensive approach. "Weight loss drugs right now are very, very effective and helpful at reducing cardiovascular risk in the right patient. But let's talk about the food environment and let's talk about our green spaces, making sure that there are safe spaces and places for a healthy lifestyle, opportunities for structured exercise."
Roth stressed that the central message is not about medications but about modifiability. "The main message is not that people need medicines. The main message is that these risk factors are modifiable. I see this all the time where people don't understand the impact that they can have on their health over the long term."
Screening at annual checkups — including blood pressure measurement, cholesterol panels, and blood glucose testing — can detect silent risk factors years before symptoms develop. Medical societies now recommend screening at earlier ages than in the past, potentially leading to statin initiation in one's 30s given that heart disease develops over decades.
Newer obesity (search) medications may feature prominently in the next iteration of the analysis, which Roth said will be extended from 2023 to 2025. "We see very large changes in the way the federal government is deciding on investing in the health of its population by making changes in Medicare and Medicaid. These new medications that we hear about all the time are not reaching most patients, and we need to look holistically across all of the risk factors."