February is American Heart Month, a significant time for me, both personally and professionally.
My fascination with the heart started long before I entered medical school at Einstein. I was always interested in biological electricity, including the type that powers the heart’s steady beat. I chose cardiology as my career and focused my research on biological electricity and how it can sometimes go wrong, leading to arrhythmias, and how technology, such as implanted cardiac defibrillators, can correct this life-threatening condition. I consider myself extremely fortunate to have had the opportunity to care for patients while pursuing my interest in the lab.
But my interest in the heart is also personal. While I was still a resident, my mother received a heart transplant at age 49, only the second woman to receive one at Brigham and Women’s Hospital in Boston. (The first was a woman who lived around the corner from her, strangely enough.) That personal experience helped solidify my decision to enter the field. It also demonstrated the power of research—to break through the status quo, harness curiosity, and leap over seemingly insurmountable hurdles to accomplish the miraculous.
There are many others who, like me, have had a loved one stricken with heart disease. In fact, it is the No. 1 killer of men and women in the U.S., surpassing cancer.
The good news is that we have made remarkable advances in the past 40 years. Since 1978—the year I began medical school—we have seen a particularly sharp decline in the death rate from coronary heart disease; it has been cut by a remarkable two-thirds. This is the result of a range of advances gained from rigorous research, particularly those focused on prevention, which includes better understanding of high blood pressure and high cholesterol as risks for disease and the development of medications to treat those conditions. Advancements in surgical treatments, such as bypass and angioplasty, have also had an enormous impact.
While these dramatic interventions tend to grab the headlines, equally important was a growing awareness, first among researchers, and later among physicians and the public, of heart-healthy behaviors. During the past four decades, increasing attention has been paid to the dangers of cigarette smoking and the recognition of diet and exercise in maintaining heart health, as well as effective public policy to encourage positive behaviors. Such behaviors influence not only the prevalence of heart disease but many other non-communicable chronic diseases, including cancer, type 2 diabetes, lower respiratory disease, and osteoarthritis.
While we celebrate these advances, there are new and lasting areas of great concern. For example, we now understand that obesity, poor sleep, and too much stress can increase the risk for heart disease and lead to worse outcomes for those who develop it.
Factors That Influence Health
We are also learning more about the social determinants of health, which are complex social structures and economic systems that are responsible for most health inequalities. Factors such as: living in high-poverty neighborhoods, lower income levels, lower education levels, less access to services, poorer social networks, or being a member of a minority or disadvantaged group are all connected to notably higher rates of disease and worse health outcomes.
It is difficult for researchers to untangle these various factors and determine how they intersect and overlap to influence health. But it is clear that they are linked to the prevalence and mortality rate for heart disease. The 2019 annual report from the American Heart Association (where I was honored to serve as president in 2011), details many of the ways socioeconomic status and background influences the seven health and behavioral contributors to heart health. (Learn about the American Heart Associations’ Life’s Simple 7.)
Let’s look at smoking, for example. Among its many deleterious effects on the body, it is a major risk factor for heart disease, which can lead to heart attack, heart failure, and death. While smoking has dropped dramatically in the United States in the past few decades, significant disparities exist between groups. Higher smoking rates are observed in LGBTQ+ populations, those with low socioeconomic status, those with mental illness, active-duty members of the military, American Indian/Native Alaskans, and those with HIV who are receiving medical care.
Another major risk factor for heart disease is hypertension, or high blood pressure. In a meta-analysis of 51 studies, increased risk for hypertension was associated with lower socioeconomic status. Lower-educated individuals had double the risk of hypertension than higher-educated individuals. And racial segregation seems to have a significant effect as well. Not only is living in a highly segregated neighborhood linked to hypertension prevalence, but a study found that when African Americans moved from a highly segregated area to one with lower segregation, high blood pressure rates fell.
Einstein Montefiore Changes
Tackling the social determinants of health will not be easy, as they result from systemic forces beyond the control of individual physicians and patients. Yet, I am hopeful. Many are taking up the challenge, including my home institution. As befits a college with a long and robust history of social justice, Einstein and its clinical partner, Montefiore Health System, are targeting socioeconomic factors that contribute to health disparities.
For example, Montefiore has implemented a social determinants of health screening program for patients with the goal of connecting individuals to resources. Montefiore made headlines for a program that focused on housing homeless patients, demonstrating that doing the right thing can dovetail with healthcare savings. And Einstein has been home to researchers focusing on the topic, including how to train physicians to identify and address the social determinants of health.
So, I take heart (pun intended) during this auspicious month. As the past four decades of progress—and my own mother’s remarkable history—have shown, we shouldn’t underestimate our chances against a seemingly unsurmountable challenge.