Heart and stroke

Since the 1960s the fall in deaths from heart disease and stroke was the main driver of rising life expectancy in high-income countries. Since 2011, cardiovascular mortality at ages under 75 has been flat or falling only slowly, with some evidence of rises in younger adults in the United States. Heart attacks are fewer. In contrast, heart failure and atrial fibrillation are more common. That is partly because more people survive to the ages where these occur, and partly because obesity and diabetes have risen in the cohorts now reaching those ages.

Detection has improved unevenly. Blood pressure and cholesterol are measured routinely. That said, in most countries a large share of high blood pressure is still undiagnosed or untreated, and the health-check programmes meant to find it fail to reach those most at risk. Newer tools are in trials rather than in population use: lipoprotein(a) testing, polygenic scores, and algorithms that read electrocardiograms.

Treatment and prevention carry the strongest evidence. Statins, blood-pressure drugs and the decline of smoking account for most of the gains already made. The GLP-1 trials add a drug class that reduces cardiovascular events in people with obesity, and whose effect has not yet appeared in any national series. As yet, there is still no cross-country consensus on how best to decompose the different contributory factors.

The deaths themselves say two things. The pandemic disrupted diagnosis and treatment for two years, and produced excess deaths at home from cardiovascular causes in 2020 and 2021. The post-pandemic years are the test: whether improvement resumes at its earlier rate, continues at the slower one, or has been reset.

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