In 1970, someone over the age of 65 hospitalized for a heart attack in the United States had about a 60% chance of leaving the hospital alive. Today, the survival rate is over 90%, with even better outcomes for younger patients.
Those numbers have contributed to a remarkable decrease in the likelihood of dying from any type of heart disease over the last 50 years, according to a new study of heart disease mortality led by Stanford Medicine researchers. In 1970, 41% of all deaths were attributed to ailments of the heart; in 2022, that statistic had dropped to 24% of all deaths.
Most strikingly, the proportion of deaths from acute myocardial infarctions — commonly known as heart attacks — fell nearly 90% during that period.
The decrease is a testament to the leaps and bounds made in our ability to manage and prevent heart attacks, from bystander CPR to artery-opening stents and cholesterol-lowering statins, as well as public health measures that have drastically cut tobacco smoking.
But the researchers also found that more Americans now die from other types of heart disease, including heart failure, hypertensive heart disease and arrhythmias. More deaths from chronic heart conditions are, in part, the trade-off from more patients living beyond events like heart attacks.
"People now are surviving these acute events, so they have the opportunity to develop these other heart conditions," said Sara King, MD, a medical resident and lead author of the new study to be published June 25 in the Journal of the American Heart Association.
The senior author of the study is Latha Palaniappan , MD, a professor of cardiovascular medicine and associate dean for research.
The shifting trends in heart disease mortality revealed by the new study are largely a success story, but they also point to areas that need improvement.
Life-saving innovations
The researchers used nationwide data from the National Vital Statistics System on all deaths in adults 25 and older from 1970 to 2022, which numbered 119 million. The cause of death was determined by standard codes, known as the International Classification of Disease codes, indicated by physicians on death certificates.
Overall, 37 million of those 119 million deaths were attributed to heart disease. The researchers sorted the specific cause of these deaths into two main categories: ischemic, meaning it involved blockage of blood flow to the heart, which includes heart attacks; and non-ischemic, for everything else.
"Ischemic heart disease is caused by plaque building up in the arteries," King said. "It's a common pathophysiology that we have learned can be prevented and treated."
In 1970, nearly all heart disease deaths — 91% — could be attributed to ischemic causes. About half of those were heart attacks.
Every decade since has seen life-saving innovations in the treatment of ischemic heart conditions, and of heart attacks in particular.
In the '70s, bystander CPR and portable defibrillators became more widespread and allowed more people to make it to the hospital alive. Coronary care units, cardiac imaging, the invention of bypass surgery and balloon angioplasty improved the odds of survival. In the 1980s and 1990s, coronary stenting kept arteries open, and medications like aspirin and other anti-platelet therapies averted and treated many heart attacks. In the 21st century, high-intensity statin therapy and new cholesterol and diabetes treatments improved prevention and further lowered mortality.
Moreover, the increasing recognition of heart attacks as a medical emergency that requires rapid intervention — ideally within 90 minutes of arriving at a hospital — has spared many lives.
And beginning with the 1964 surgeon general's report on smoking and health, the public health campaign against cigarette smoking has reduced a major risk factor for cardiovascular disease. In 1970, 40% of Americans smoked, compared with 14% in 2019.
Though the new study did not link specific developments to lower mortality, the big picture is one of advancements.
"Overall, there's been significant progress with every decade," King said.
By 2022, the overall rate of heart disease deaths had decreased 66% from 1970 and ischemic heart disease deaths by 81%. Besides heart attacks, deaths from other types of ischemic heart disease also decreased, though at a lower rate.
"Thanks to sustained public investment, we've seen a remarkable 90% decline in heart attack deaths, a medical miracle made possible by the synergistic power of science, medicine and public health," Palaniappan said.
A sizable shift
"Fortunately, people are dying less from ischemic disease. Now, we need to expand our efforts to non-ischemic causes of heart disease death," King said.
Roughly half of heart disease deaths now are caused by non-ischemic conditions. Among the more common causes are heart failure, hypertensive heart disease, arrhythmias and heart disease from pulmonary conditions. Some of the increase may be attributed to better diagnostics and changing disease definitions under the International Classification of Disease codes.
But it also reflects a rise in risk factors such as obesity, diabetes, hypertension and physical inactivity, the researchers said. An estimated 50% of adults have diabetes or pre-diabetes, and 40% have obesity. The U.S. population is also older — life expectancy in 1970 was 70.9 years compared with 77.5 years in 2022 — giving people more years to accumulate chronic conditions.
"Often it's the passage of time that can lead to conditions such as atrial fibrillation or heart failure," King said. "Finding ways to age healthily is going to be the next frontier of heart care."
The researchers acknowledge that the nationwide trends may obscure significant differences among subgroups. Sex, race and socioeconomic status can affect risk factors for heart disease and access to care, for example.
"A lot of people, unfortunately, who end up in this mortality dataset are people who don't engage with care or who don't have access to care," King said. She plans to look at patterns in specific subgroups next, which could help determine more tailored interventions.
Heart disease remains the leading cause of death in the U.S.
"We have so many tools in our toolbox now, but still, there's a lot more that can be developed and improved," King said. "I hope the numbers just keep getting better."
Researchers from Beth Israel Deaconess Medical Center; the National Heart, Lung, and Blood Institute; the American Heart Association; and Johns Hopkins University School of Medicine contributed to the study.
The study received funding from the National Institutes of Health (grants K24 HL150476, 1K01HL144607 and R01HL168188), the American Heart Association/Harold Amos Medical Faculty Development program and the Doris Duke Foundation.
