Key takeaways:

• Wide gaps exist in the prevalence, awareness and treatment of many cardiometabolic diseases.
• Recent policy changes have both expanded access to effective therapies for many and reduced access for others.

PHILADELPHIA — Wide gaps exist in the prevalence, awareness and treatment of many cardiometabolic conditions, and policies that expand access and lower drug costs will be key to reducing the burden of disease in the U.S., a speaker said.

At the Heart in Diabetes CME Conference, Rishi K. Wadhera, MD, MPP, MPhil, cardiologist at Beth Israel Deaconess Medical Center, discussed gaps in the “cardiometabolic care cascade” and recent policies that both narrowed and widened that gap.

“One of the great public health successes in the U.S. has been the decline in cardiovascular mortality that we’ve enjoyed for many, many decades. But what’s happened over the last [few years] is that decline has stalled, and we’re starting to see a reversal in cardiovascular mortality in some subgroups, which is very concerning. So the two questions we need to ask ourselves are why is this happening and what can we do about it?” Wadhera told Healio. “A big focus from a public health policy and clinician standpoint has to be the cardiometabolic care cascade.

“When you think about a population that’s at risk, maybe it’s a population with hypertension or diabetes, there are many steps along the care cascade way that patients can fall off. The first step is needing to be aware that you have [a condition]. The second step is then receiving treatment for that condition, and then the third step is achieving control of that condition,” Wadhera said. “One of the issues that we’ve experienced across the U.S. is that patients leak across this cascade and fall off, and that effect can compound, resulting in only a fraction of patients achieving control of a cardiometabolic risk factor like hypertension or diabetes.”

In January, the American College of Cardiology issued its inaugural report on risk factors and CVDs that account for most CV death and disability in the U.S.

The report, published in the Journal of the American College of Cardiology, draws together data national surveys, registries and administrative databases and outlines the prevalence, treatment and impact on mortality from hypertension, diabetes, obesity, LDL cholesterol and cigarette smoking, and coronary heart disease, acute MI, heart failure, peripheral artery disease and stroke.

As Healio previously reported, the report showed that the prevalence of most CVD risk factors and diseases has risen in recent years.

Rishi K. Wadhera, MD, MPP, MPhil, discussed gaps in the “cardiometabolic care cascade” and recent policies that both narrowed and widened that gap.

During the presentation, Wadhera highlighted that despite rising prevalence of diabetes, especially among lower-income adults, only one in three know they have it and just 68% are actually receiving treatment.

Nearly half of U.S. adults are now estimated to have hypertension; unawareness is rising among young adults aged 20 to 44 years; and just one in four people with hypertension have their BP under control, a level that has stagnated over the past 15 years, according to the presentation.

Fewer than one in four patients in secondary prevention met their LDL targets over the past 15 years and the overall prevalence of obesity increased despite availability of effective therapies, suggesting there exists a bottleneck in treatment, Wadhera reported.

In addition, many patients with cardiovascular-kidney-metabolic (CKM) syndrome are unaware they also have kidney disease; many do not receive treatment; and few achieve BP, glycemic or cholesterol control, according to the presentation.

“Disparities are a theme in all of this. They’re not a footnote,” Wadhera told Healio. “When you look by race and ethnicity, by income, by geography, where you live, whether you live in a rural area, has a huge impact on whether or not you are going to fall off these cardiometabolic care cascades, whether it comes to hypertension or diabetes. That’s critically important, because where you live affects how long you will live more than ever, and that gap is only widening.”

Affordability and coverage decide who enters and stays in the cardiometabolic care cascade, making policy decisions important for these patients, according to the presentation.

Wadhera cited a recent study published in JACC in which researchers evaluated the impact of the Inflation Reduction Act on medication adherence among adults with CVD.

Results showed that the Inflation Reduction Act lowered cost via the $35 insulin price cap, the $2,000 Part D cap and Medicare price negotiation, conferring a 25% reduction in medication nonadherence, according to the presentation.

However, in a separate commentary published in Circulation, Wadhera and colleagues discussed the impact of Medicaid cuts under H.R. 1, or “One Big Beautiful Bill Act,” and posited it would be at the front of the cardiometabolic care cascade collapse, due to $1 trillion in Medicaid cuts, coverage loss and coming work requirements for 2027.

“The Inflation Reduction Act was monumental legislation ... that is going to reduce the out-of-pocket costs of prescription drugs for patients. Many of the drugs targeted by this legislation treat cardiometabolic conditions or CVD, and we’re already seeing early evidence that this legislation is improving access and adherence to therapy,” Wadhera told Healio. “One of the biggest headwinds right now is a bill called H.R. 1, which just passed, which will result in $1 trillion of cuts to the Medicaid program. It’s estimated that about 16 million people will lose health insurance coverage as a result, and as you can imagine, that is going to affect the cardiometabolic care cascade at the very start with many patients not having access to affordable care, screening, treatment and not being able to achieve control of their cardiometabolic conditions as a result.”

For more information:

Rishi K. Wadhera, MD, MPP, MPhil, is associate director of the Richard A. and Susan F. Smith Center for Outcomes Research, cardiologist at Beth Israel Deaconess Medical Center and associate professor of medicine at Harvard Medical School and Harvard School of Public Health. Wadhera can be reached at cardiology@healio.com.