The Drastic Cardiovascular Death Decline Beginning in the 1960s…What Was the Cause?

This is one of those “Six Blind Men and the Elephant” exercises where when you ask six doctors/epidemiologists/drug company reps “what has caused heart attack and stroke deaths to drop so rapidly in the last 60 years?”, you’ll get six different answers. The conventional wisdom is that: 1) a large drop in smoking, 2) medical interventions, 3) increases in statin use, 4) A decrease in fatty foods, 5) An increase in blood pressure lowering drugs and 6) A decrease in infectious diseases are responsible, but then #1–#3 largely happened about 20 years after the decline began, while #4 occurred along with an increase in carb use and an obesity epidemic. This leaves #5 (fair enough, a large contributor) and #6, which if fully understood, may be the largest contributor of all! Further, understanding of an infection’s relationship with heart attack/stroke may help fully define long-term Covid-19 risk.

Deaths per 100,000 in the US from 1900 to 2000. Note the drastic increase in heart attack and stroke from 1920 to 1960, and the subsequent drop from 1960 to 2000. What happened to both increase, then decrease the incidence of cardiovascular disease so drastically?

I remember that as a boy (around 1960), it was a different world. People were far more likely to smoke and drink hard liquor (unfiltered cigarettes and cocktails were popular then), there were few vaccines or antibiotics, we ate a lot of fatty deep-fried food, and often you’d hear about a 50 year old guy that “suddenly dropped dead of a heart attack”. The victim was often an apparently healthy guy, not always a smoker. Women were less likely to fall victim (they are now known to have some protective effect from Estrogen). Ten to twenty years later, this epidemic of early cardiovascular death had waned greatly (not fully realized until the 90s), which makes one wonder “what was responsible for the heart attack/stroke epidemic and its demise”. Knowing the answer seems critical to our future health, especially if the cause/effect turns out to be infectious disease (which we’ve clearly not entirely conquered). (Elflein,2023),(Mensah,Wei,Sorlie,Fine,Rosenberg,et al,2017)

Success #1, A Large Drop in Smoking (and Drinking): One would think a large decline in tobacco use would be responsible for a large drop in cardiovascular risk. After all, compromised lungs result in less oxygenation for the blood, constricted vessels, and ultimately heart attack/stroke. A drop in smoking certainly is a public health bonanza, resulting in less incidence of cancer, less dangerous secondhand smoke, and less related diseases such as emphysema and COPD. A related drop in the consumption of hard liquor (in favor of wine and beer, a sort of generational change) has also helped, but is probably more related to liver disease and cancer. There are related factors, including a smoker’s tendency to exercise less and have a poor diet, while much more research needs to be done. The problem with the less smoking = less heart disease theory is that the drop in heart disease preceded the large drop in smoking by about 10–20 years. But let’s give “less smoking” credit for about a 15% drop in cardiovascular mortality. (Roy,Rawal,Jabbour,Prabhakaren,2016)

Success #2, Medical Interventions: The largest purveyor of this theory is…surprise! Heart surgeons! Despite the alleged successes of stents, angioplasty, and heart transplants, there is some growing evidence that these interventions are “solutions in search of a problem”, since the cardiovascular epidemic had been on the wane anyway, and preventative measures (diet, exercise, not smoking, meds) were so successful. There was also the specter of these interventions causing problems of their own, and lining big medical’s pockets while being of limited efficacy. But heck, let’s give them credit for a 10% drop in heart attack mortality (even though these doctors would probably claim 50%). (White,2019)

Much has been made of stents, angioplasty, and other medical interventions, yet they may not decrease cardiovascular deaths any more than less invasive means such as diet, exercise, and meds

Success #3, the Use of Statins : Statins are the perfect pill, not many side-effects, makes money for big Pharma, can claim to lower heart attack risk by 50% or so…but wait a minute! Statins weren’t really invented until the mid-80s,and didn’t start being prescribed massively until the mid 90s. Meanwhile, the big drop in cardiovascular death began in the 60s and the biggest drop took place between the 60s and 80s. There are many that also believe the “statin effect” is oversimplified, as they are just as effective as “anti-inflammatories” as “anti-cholesterol”, which some believe “declogs” the arteries (the same effect you would get by a good diet and exercise). Statins may well be the beneficiary of good timing, as the heart disease drop began prior, which allowed Pfizer and others to take all the credit. I’m not knocking statins as much as putting them in their proper place, let’s say they deserve 15% of the credit for the cardiovascular drop. (Hajar,2011),(Endo,2011)

Success #4 A Decrease in the Use of Fatty Foods: Do you know how your 60 year old wife works out, eats vegetables, and still looks pretty good, while your sweet grandma in 1960 looked like a bag of rocks at 55? This was likely the effect of all that Crisco and trans fat, which has finally been identified and largely banned in favor of things like olive oil. So this is responsible for a big drop in heart attacks, right? Wrong! About the time people stopped eating so much fat in the 90s, they started eating too many Carbs, and an obesity epidemic ensued, brought on perhaps by the introduction of sugar into all those packaged foods. So I’m guessing that any cardiovascular benefit in less fat was wiped out by more carbs, and your good-looking 60 yr old wife is smart to not eat too much of either. Additionally, there is evidence that carrying a higher BMI into old age (lets say 25–28, which is considered “moderately obese”), doesn’t result in a great deal of death risk. Finally, scientists are learning that many saturated fats are actually good. As such, I’m only giving less fat a 5% contribution grade.

Success #5 Blood Pressure Lowering Drugs: I’m going to say that this was a big factor, as the invention of hypertension meds coincide almost EXACTLY with the drop in cardiovascular deaths. In 1958, the first hypertension drug, a diuretic called Diuril, was made available, and soon after many were being treated for high blood pressure. But this still doesn’t explain all those seemingly healthy men that were suddenly dropping dead in their early 50s. In any case, I’m giving hypertension drugs 25% of the credit for offsetting the epidemic. (Wu,Hu,Chou,Hwang,Chou,et al,2016)

Success #6, Fighting Infectious Disease: So this leaves 30%, and I’m sorry but this goes to successes in fighting infectious diseases (and the aftermath of infectious disease) which I believe had a HUGE effect on cardiovascular health. First, people don’t realize the severity of infectious disease in the early 20th Century (it was the biggest cause of mortality until about 1930). Subsequent advances in vaccines, antibiotics, and fighting epidemics, began taking hold in the 60s, about the time the cardiovascular diseases began to subside. However, cardiovascular deaths took an upward turn in the 40s and 50s, even after we got smarter about infection. Why? Well this is the most interesting part of the article, because of the 1918 Influenza cohort (the generation affected by that flu and/or its aftermath). This is more or less bore out by the numbers, and implies that “major” disease outbreaks (such as the 1918 Spanish Flu and, gulp, Covid-19) may have a long-term compromising effect on our cardiovascular systems. If this is true (and if we can’t find a remedy), we might expect the cardiovascular epidemic to return as victims of Covid-19 age. This phenomenon is not fully understood (which is why the 1918 flu is not often implicated in the higher and lower cardiovascular death numbers), but simply put, bad infections may attack the epithelial cells of our vascular systems, making them less supple and more prone to infection/clogging later. Actually, even milder infections can affect one’s heart health (example Rheumatic fever), and I guess we can thank epidemiologists, vaccines, and antibiotics for softening the blow of infection. In fact some believe that an increase in allergies and decrease in heart disease may be linked to extensive antibiotic use (a kind of good news/bad news scenario, mostly good). (Tate,Namkung,Noyer,2016),(Arnott,Neal,Cham,2022),(heart.org,2018)

When all is known, infectious disease may be a leading factor in cardiovascular disease and death. This may mean more aggressively preventing and treating epidemics such as the “Spanish Flu” and Covid-19.

Conclusions: We will end this with the usual “more study is needed to confirm these theories”, but the advantage of hearing this from me is, I HAVE NO BIASES OR ALLEGIANCES TO ANY INDUSTRY, INCLUDING PHARMACEUTICAL, MEDICAL, OR FOOD. I’m just a guy that wants to know the truth and live a long time. Besides, I have no liability as I use wiggle-words such as “may”, “might” and “maybe”. I’m assuming though that conclusions in this direction will force people to take epidemics like Covid-19 more seriously (ie more willing to wear masks and get vaccinated), while searching for anti-viral and other remedies that nip these diseases in the bud.

I’m going to go out on a limb and say that the 1918 Spanish Flu epidemic messed up many people’s cardiovascular systems, hypertensive drugs in the 60s “unclogged” much of the resultant damage, and later anti-smoking and anti-trans fat campaigns, statins, and medical interventions helped lower cardiovascular death further, but not nearly as much as the Spanish Flu cohort die-off and the invention of hypertensive drugs. Meanwhile, Big Pharma and Big Medical (and to a lesser degree anti-smoking and public health advocacies), wish to take disproportionate credit.

All considered, this might be the lines of defense (in order of priority):

1. Prevent and cure infectious disease (especially the severe ones like Spanish Flu and Covid-19). Search for agents that repair infectious disease damage to the cardiovascular system.
2. If possible, avail yourself of good diet and exercise, don’t smoke and limit alcohol consumption. Particularly, avoid trans fats and sugary drinks.
3. If you are hypertensive, take blood pressure lowering drugs.
4. If your cholesterol is high, take Statins. Also consider drugs that lower inflammation. Anti-inflammatories may preclude the need for Statins.
5. If all else fails or there is an emergency, consider medical interventions, including stents, angioplasty, and heart transplants.

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