A new nationwide study offers both encouraging and sobering news about the nation's leading cause of death. While U.S. adults have made significant progress in reducing deaths from ischemic heart disease over the past three decades, researchers say nearly 9 out of 10 of these deaths are still associated with risk factors that people can often prevent or control.

The study, published in JAMA Cardiology, analyzed more than three decades of data from the Global Burden of Disease Study 2023, examining trends in ischemic heart disease (IHD) mortality across the United States from 1990 through 2023.

Researchers found that age-adjusted death rates from ischemic heart disease have fallen by nearly 59 percent since 1990. However, that progress has slowed considerably during the past decade, while obesity and elevated blood sugar have emerged as increasingly important contributors to heart disease.

According to Sanjeev Kumar Gulati, M.D., executive deputy director of Baptist Health Heart & Vascular Care and the system chief of cardiovascular medicine, the findings reinforce an important message: heart disease remains largely preventable when people address cardiovascular risk factors early in life.

"Nine out of 10 ischemic heart disease deaths are related to modifiable risk factors, and we are overall losing ground on reducing these risk factors — while other risk factors such as obesity and fasting blood glucose are becoming major factors," Dr. Gulati says.

What Is Ischemic Heart Disease?

Ischemic heart disease—also called coronary artery disease—develops when plaque builds up inside the coronary arteries, reducing blood flow to the heart muscle. Plaque is made up of cholesterol, fat, inflammatory cells and other substances that gradually narrow the arteries, a process known as atherosclerosis.

As blood flow decreases, the heart receives less oxygen. This can lead to chest pain (angina), heart attacks, heart failure and, in severe cases, sudden cardiac death.

The study estimated that approximately 473,000 Americans died from ischemic heart disease in 2023, making it the nation's leading cardiovascular killer.

Dr. Gulati notes that the investigators analyzed an enormous amount of data to identify long-term trends. "The study was conducted by analyzing vital records and a broad set of epidemiologic data across all states within the U.S. from 1990 to 2023."

Progress Has Slowed

Overall, the study found encouraging long-term improvements. Age-adjusted death rates declined by approximately 58.7 percent between 1990 and 2023, reflecting advances in emergency cardiac care, cholesterol-lowering medications, blood pressure treatment and smoking reduction.

But researchers also found that the pace of improvement has slowed considerably since about 2010.

"The study found that over 470,000 deaths occurred as a result of ischemic heart disease in 2023,” Dr. Gulati explains. “Overall, mortality declined by 58.7 percent since 1990, but the rate of decline slowed since 2010. Women had a greater decline than men from 2010 to 2023. What was concerning was that middle-aged adults (50 to 59 years old) really had no significant decline in mortality from 2010 to 2023."

The lack of progress among adults in their 50s may reflect increasing rates of obesity, diabetes and other metabolic conditions that offset gains made through better medical treatments.

Nearly 90 Percent of Heart Disease Deaths Were Linked to Modifiable Risks

Perhaps the study's most important finding is that 88.7 percent of ischemic heart disease deaths were associated with modifiable risk factors.

These are conditions or behaviors that can often be improved through lifestyle changes, medications or both. The three largest contributors remained remarkably consistent over the past three decades:

• High blood pressure
• Poor diet
• High LDL ("bad") cholesterol

Other important contributors included smoking, diabetes, physical inactivity, obesity, kidney disease, alcohol use and air pollution.

"The bigger picture finding was that 88.7% of ischemic heart disease was related to modifiable disease," Dr. Gulati says. "The three big factors did not change since 1990 and they are high blood pressure, dietary risk and high cholesterol, especially LDL. However, they also found that obesity and high glucose levels have increased dramatically since 1990."

He adds that the trends are not unique to the United States. "These findings are similar worldwide. There was some good news—tobacco abuse and air pollution decreased as modifiable risks."

Why These Risk Factors Damage the Heart

Although the three leading risk factors have been recognized for decades, they continue to account for most preventable heart disease.

Dr. Gulati explains how each one affects the cardiovascular system. "Hypertension causes the heart to become enlarged and arteries to be stiffer, and it accelerates coronary artery blockages."

High blood pressure forces the heart to work harder over many years. Eventually, the heart muscle thickens while arteries become less flexible and more susceptible to plaque buildup.

Diet also plays a major role.

"Dietary risks — including high processed food, high sodium, and low intake of fruits, vegetables and grains — promote increased hypertension, an inflammatory state and insulin resistance, which all lead to increased coronary artery disease," Dr. Gulati says.

Processed foods often contain excessive sodium, unhealthy fats and refined carbohydrates while providing relatively little fiber or essential nutrients.

High LDL cholesterol is another major driver. "High LDL leads to acceleration of the development of atherosclerosis."

LDL cholesterol contributes directly to plaque formation inside artery walls. Over time, plaques can narrow blood vessels or rupture suddenly, triggering a heart attack.

Obesity and High Blood Sugar are Becoming Bigger Threats

One of the study's most striking findings was the growing impact of obesity and elevated fasting blood glucose.

Researchers found that heart disease deaths linked to high body mass index (BMI) increased by more than 54 percent since 1990. Deaths associated with elevated fasting blood glucose increased by nearly 39 percent.

Fasting blood glucose measures blood sugar after not eating overnight. Elevated levels often indicate prediabetes or type 2 diabetes, both of which damage blood vessels over time.

Obesity contributes to heart disease in several ways. Excess body fat increases blood pressure, raises cholesterol, promotes chronic inflammation and makes insulin resistance more likely.

Together, obesity and diabetes significantly increase the likelihood of developing coronary artery disease earlier in life.

These findings help explain why progress against heart disease has slowed despite improvements in medications and medical procedures.

The Importance of Starting Earlier

The study's authors argue that preventing heart disease should begin much earlier than many people realize.

Rather than waiting until symptoms develop or heart attacks occur, they recommend viewing atherosclerosis as a lifelong process that begins decades before clinical disease appears.

Dr. Gulati agrees.

"The authors advocate for a paradigm shift toward viewing atherosclerosis as a lifetime continuum, with early detection and aggressive risk factor modification beginning at younger ages—particularly since even low-risk individuals may harbor subclinical atherosclerosis. I believe this is an important shift."

Subclinical atherosclerosis refers to plaque buildup that has not yet caused symptoms. Many people may have early artery disease for years before experiencing chest pain or a heart attack.

"We need to work early to modify the risk factors to delay or stop the progression toward ischemic heart disease," Dr. Gulati says. "We need to focus education on our children and young adults so we can combat these modifiable risk factors."

Practical Steps to Lower Your Risk

The encouraging message from the study is that many of the leading risk factors are manageable.

"These are modifiable risk factors and therefore can be fully or at least partially controlled by the individual," Dr. Gulati says.

He recommends several evidence-based strategies.

Eat a Heart-Healthy Diet

A Mediterranean-style or largely plant-based eating pattern remains one of the best-supported dietary approaches for cardiovascular health.

Dr. Gulati recommends emphasizing:

• Vegetables and fruits
• Whole grains
• Legumes
• Nuts
• Fish
• Lean protein

At the same time, limit:

• Processed meats
• Refined carbohydrates
• Excess sodium
• Saturated fats
• Sugar-sweetened beverages

Stay Physically Active

Aim for at least 150 minutes of moderate-intensity exercise each week, such as brisk walking or cycling, or 75 minutes of vigorous activity, such as running.

Regular physical activity helps lower blood pressure, improve cholesterol levels, control blood sugar and support a healthy weight.

Control Blood Pressure

Lifestyle measures remain the first step for many people with elevated blood pressure.

Reducing sodium intake, following the DASH (Dietary Approaches to Stop Hypertension) eating plan, exercising regularly and losing excess weight can all help lower blood pressure naturally.

When lifestyle changes are not enough, medications may be recommended to achieve a target below 130/80 mmHg for appropriate patients.

Manage Cholesterol

For some people, healthy lifestyle habits alone may not adequately reduce LDL cholesterol.

Current guidelines recommend statin therapy for individuals with very high LDL cholesterol, adults with diabetes between ages 40 and 75, and others whose overall cardiovascular risk is sufficiently elevated after discussion with their healthcare provider.

Don't Smoke and Maintain a Healthy Weight

The study showed meaningful progress in reducing smoking-related heart disease deaths, demonstrating the benefits of tobacco-control efforts.

Maintaining a healthy weight and controlling blood sugar also become increasingly important as obesity and diabetes continue to rise nationwide.

A Lifetime Commitment to Heart Health

Although medical advances have dramatically improved survival from heart disease over the past three decades, this study highlights that prevention remains the most powerful tool.

Most ischemic heart disease develops gradually over many years, making it possible to slow—or even prevent—its progression through healthy habits and appropriate medical care.

Dr. Gulati believes the findings should encourage people to think about cardiovascular health much earlier in life.

"People should begin to work with their cardiologist to make a plan to modify their risk factors early on in life and develop a healthy cardiovascular lifestyle."

As researchers continue searching for new treatments, the evidence remains clear: controlling blood pressure, cholesterol, blood sugar, body weight and other modifiable risk factors can significantly reduce the likelihood of developing—and dying from—the nation's most common form of heart disease.