​ Cardiovascular Disease

The “Million Hearts” initiative

Addressing heart attacks and strokes

By Stanton Shanedling, PhD, MPH

reventing one million heart attacks and strokes over five years is a powerful call to action­—one that was taken on in 2012 by the U.S. Department of Health and Human Services, and co-led by the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare & Medicaid Services (CMS) under the Million Hearts initiative.

While Minnesota is known as a heart-healthy state, heart disease and stroke are still among our leading causes of death. That’s why the Minnesota Department of Health (MDH) is a partner in the Million Hearts initiative, to further the state’s efforts to promote healthy lifestyles and behaviors, create healthy environments and communities, and increase access to early and affordable detection and treatment.

Minnesota is working alongside 120 official Million Hearts partners, 20 federal agencies, the remaining 49 states, and the District of Columbia. More than 12,000 individuals and organizations have pledged their support to reduce heart attacks and strokes, and more than 50 public and private organizations have made specific, actionable commitments to fight cardiovascular disease.

Goals

The initiative scales up proven clinical and community strategies, bringing together existing efforts and adding new programs to improve health across communities—and, ultimately, to help Americans live longer, healthier, more productive lives.

For the first five years, the initiative had two primary goals:

• Keeping people healthy through healthier habits and environments by ensuring fewer people are smoking, cutting back on sodium in processed and commercially prepared food, and eliminating trans-fat in the food supply.
• Optimizing care by encouraging health systems and professionals to focus on the “ABCS”: Aspirin use when appropriate, Blood pressure control, Cholesterol management, and Smoking cessation.

​The state’s smoking rate is slightly lower than the national average.

ABCS: by the letters

Our focus on ABCS is turning the curve on the impact of cardiovascular disease here in Minnesota. In 2014, CDC and Million Hearts recognized two of the project’s health practices—St. Luke’s P.S. Rudie Medical Clinic and Essentia Health, Duluth—that achieved blood pressure control for at least 70 percent of their adult patients with hypertension.

MDH also partnered with Healthy Northland, a regional public health collaborative, to implement a Million Hearts project to enhance the ability of clinics to identify and manage patients with hypertension using a team-based approach focusing on three main evidence-based strategies from the Guide to Community Preventive Services:

• Measuring blood pressure accurately.
• Adopting a hypertension treatment protocol with clinical decision supports.
• Implementing a home blood pressure monitoring program.

To ensure that Minnesota clinics are better able to identify and manage patients with undiagnosed hypertension, MDH encourages implementation of NQF 18: Controlling High Blood Pressure. We provide support to clinics and their staff in developing a process to pull data that can guide treatment.

Those data points can help clinics to bolster their services based on the ABCS:

Aspirin use. The rates of Minnesotans following an aspirin regimen for optimal diabetes/vascular care are high, according to 2016 dates of service data collected by MN Community Measurement: 99.4 percent of Minnesota patients ages 18–75 with diabetes (both type 1 and type 2) and comorbid ischemic vascular disease (IVD) take a daily aspirin, unless contraindicated, as do 93.4 percent of patients ages 18–75 with vascular disease.

Those local numbers compare favorably with national statistics. The CDC’s 2013 Behavioral Risk Factor Surveillance System (BRFSS) reports the percentages of men ages 45–79 and women ages 55–79 who reported that they took aspirin daily or every other day:

• 26.6 percent overall rate for men and women
• 27.0 percent rate for men
• 26.2 percent rate for women

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Blood pressure. 2015 dates of service HEDIS (Healthcare Effectiveness Data and Information Set) data—calculated from a sample of Managed Care patients and published in MN Community Measurement’s 2016 Health Care Quality Report—show that 76 percent of Minnesota patients ages 18–85 with a diagnosis of hypertension or high blood pressure had adequately controlled blood pressure based on the following criteria:

• Patients ages 18–59 whose blood pressure was lower than 140/90 mmHg.
• Patients ages 60–85 with a diagnosis of diabetes whose blood pressure was lower than 140/90 mmHg.
• Patients ages 60–85 without a diagnosis of diabetes whose blood pressure was lower than 150/90 mmHg.

Cholesterol management. 2016 dates of service data on statin use collected by MN Community Measurement show that 90.1 percent of Minnesota patients ages 18–75 with vascular disease are on a statin medication, unless allowed contraindications or exceptions are present.

Smoking. The CDC’s 2016 BRFSS and the 2014 Minnesota Adult Tobacco Survey (MATS) show that the state’s smoking rate is slightly lower than the national average:

• 15.2 percent adult (18+) smoking rate (BRFSS)
• 14.4 percent adult (18+) smoking rate (MATS)

While Minnesotans and their physicians are already following many of the ABCS—and maintaining our reputation as a heart-healthy state—Million Hearts strives to improve outcomes through education and advocacy.

The national impact

According to the Million Hearts Meaningful Progress 2012–2016 report, during the first two years of the initiative, about 115,000 cardiovascular events were prevented. That number is relative to the expected number of events if 2011 rates had remained stable.

​Clinicians and health care systems have an integral role to play.

Although final numbers will not be available until 2019, CDC estimates that up to half a million events may have been prevented from 2012 through 2016. These outcomes were fueled by these achievements by Million Hearts and health care advocates:

Seven million fewer people smoked cigarettes in 2015 than in 2011. Quitting smoking immediately reduced their risk for a heart attack or stroke.

Guidance was drafted and issued in June 2016 for the food industry to voluntarily reduce sodium in processed and commercially prepared food. The intention of this step is to help Americans gradually reduce their sodium intake to the recommended level of less than 2,300 mg per day, which will improve their blood pressure.

Although daily sodium intake has not dropped significantly in the past five years, widespread implementation of healthy food purchasing policies and voluntary industry adoption of recommendations for lower sodium food choices are expected to help all Americans eat healthier in the years ahead.

Partially hydrogenated oils will be removed from the food supply in 2018. This action is expected to prevent thousands of fatal heart attacks every year.

Million Hearts mobilized health care systems to deliver high value care for people at risk of cardiovascular diseases by focusing on the ABCS in clinical quality measures.

A focus on the ABCS has generated slow but steady improvement in aspirin use, blood pressure control, and statin use among people who are eligible, based on current guidelines.

Electronic health records have helped to identify more than half a million people who may have hypertension.

Million Hearts 2022 priorities

The work to prevent heart attacks and strokes is far from complete. Million Hearts is continuing and expanding its priorities to meet the aim of preventing one million heart attacks and strokes by 2022. These actions will align with the development of Healthy People 2030: Objectives for the Nation.

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Million Hearts 2022 will continue focusing on the goals to keep people healthy and to optimize care. The initiative is placing new emphasis on efforts to increase physical activity and focusing specifically on highly affected populations. These populations were selected based on data showing a significant cardiovascular health disparity, evidence of effective interventions, and partners ready to act. These include African Americans 35 to 64 years of age, people who have had a heart attack or stroke, and people who have a mental illness or a substance use disorder.

The role of providers

Clinicians and health care systems have an integral role to play in meeting the goals of Million Hearts, including:

• A commitment to system-wide excellence in the ABCS.
• A focus on team-based care and using technology to effectively measure, report on, and improve ABCS outcomes.
• Partnerships between the medical and public health arenas.

Together we can help ensure a well-informed Minnesota population that recognizes the signs and symptoms of heart attack and stroke. At the same time, we can promote proven practices that prevent heart attacks and strokes from happening in the first place, while also managing risks and using interventions that prevent people from having another event.

While Minnesota is known as a heart-healthy state, health is not shared equally across all populations. MDH is committed to health equity for all Minnesotans, where all communities are thriving and all people have what they need to be healthy. For those who are at higher risk of cardiovascular disease because of economic, racial, or other societal factors, we need to continue identifying strategies that effectively reach these individuals, reduce disparities, and increase opportunities for health.

Stanton Shanedling, PhD, MPH, is the supervisor of the Cardiovascular Health Unit at the Minnesota Department of Health. In this role he advances the MDH agenda to improve cardiovascular health and reduce the burden of heart disease and stroke across Minnesota.