Continued Progress Against Heart Disease Depends on Addressing “Previously Unaddressed Environmental Factors and Re-Imagining Cities and Our Ways of Life”

Measures could make it possible to eliminate heart disease, UH Harrington Heart & Vascular Institute cardiologist and researcher says

Innovations in Cardiovascular Medicine & Surgery | Summer 2021

The next frontier in preventing cardiovascular disease and death across the globe will not come from new drugs or novel devices, but instead in applying what we know and from addressing environmental risk exposures in cities, where 75 percent of the world’s population is estimated to live by 2050, according to a leading cardiologist at University Hospitals Harrington Heart & Vascular Institute in Cleveland, Ohio.

Sanjay Rajagopalan, MD

This notion runs contrary to most beliefs about the causes and risk factors for cardiovascular disease held by the general public, says Sanjay Rajagopalan, MD, Chief of Cardiovascular Medicine at UH Harrington Heart & Vascular Institute.

Ideas about what constitutes the “environment” in terms of heart disease need an overhaul, Dr. Rajagopalan says.

“Environment is everything,” he says. “There are physical environmental factors that you come in contact with, such as heat, temperature, noise, air pollution, light pollution at night. There’s also the social environment. And then there’s the larger environment that we live in as a society in the world, subject to things like climate change.”

“We did some of the earlier studies that contributed to the knowledge that things like air pollution, noise pollution, things like emotional stress, have a domino effective on the cardiovascular system through common pathways that may originate in the way our body processes environmental stress,” he says. “Given that urban environments are a key aggregator of a number of complex environmental and social exposures such as air pollution, chemical toxins, noise pollution, psychosocial, and economic stressors, there is a substantial need to focus health efforts in reducing these exposures.”

Dr. Rajagopalan makes this case in a new review article in the European Heart Journal (EHJ), which presents a compelling narrative of the next transformation in cardiovascular care, combining new understanding in this “exposome” with next-generation technologies and approaches to impact cardiovascular care through innovation in imagining the cities of the future.

“Much of lowering risk for cardiovascular disease in this century will be through a revolution in our approach to the environment, which includes understanding and intervening on complex stressors including emotional, physical and psychosocial stress”, Dr. Rajagopalan argues. “What is very interesting to me is this notion that most of our disease is actually the environment. That gives us an opportunity to modulate the disease and talk about things that we can change so that you can eliminate heart disease. It’s possible, entirely possible that you could eliminate heart disease.”

“When asked what percentage of heart disease they think is from genetic inheritance, most people say half. When they’re told that 90%, if not more, is from the environment and that 10% is from your genetics, they are really surprised,” he adds. “However older notions of gene-environment interactions are changing through knowledge in epigenetics, which is how the environment could help shape the genome. So rather than the Mendelian view of genes being the primary determinant of disease, the environment takes the primary place in shaping the genomic response.”

Dr. Rajagopalan and his EHJ co-authors argue that continued progress in preventing cardiovascular disease will come from re-imagining city design.

A number of new urban concepts are being introduced in various cities that take advantage of the revolution in information technology, sustainable energy sources, sustainable living and a balance between work and play that address the above described problems to variable degrees, such as the compact city, superblocks, 15-minute city, car-free city, or a mixture of these, they write. A superblock is a very large commercial or residential block barred to through traffic, crossed by pedestrian walks and sometimes access roads, and often spotted with grassed malls. In a 15-minute city, being piloted in Paris, work, school, entertainment and other activities are all reachable via a 15-minute walk from home.

“What these models do with variable degree depending on the model is to reduce greenhouse gas emissions, increase consumption of heart-healthy, sustainable foods, increase public and active transportation (walking and cycling), while reducing air pollution, noise, increasing green spaces and increasing physical activity and thereby promoting a holistic view of cardiovascular health,” Dr. Rajagopalan says.

Although these concepts may not immediately come to mind for some when discussing prevention of heart disease, Dr. Rajagopalan argues that it’s time for a paradigm shift.

“I think we need to start thinking about broader constructs for change,” he says. “Taking statins or putting in stents is not the only way we are going to solve heart disease. Those are good solutions. We have made lots of strides in the last 50 years and have reduced cardiovascular disease by over 50%. We have had a major impact in reducing cardiovascular events. But we are at a point where any future increases in life expectancy because of heart disease is going to be increasingly difficult unless we start to go beyond traditional approaches. It’s going to come through sustained changes in the way we live, eat, and play. That’s where the concept of heart-healthy cities comes in because the other environments that we live in generate too much waste as a society, at least in the Western hemisphere, contribute enormously to climate change.”

In making the case for heart-healthy cities to the general public, Dr. Rajagopalan says policy makers and cardiologists will be more persuasive if they connect the long-term societal changes in urban infrastructure proposed to how they will affect an individual’s risk of developing cardiovascular disease – a short-term impact many people may be unaware of but may be open to considering through the avenues of reducing air pollution, switching to sustainable plant-oriented diets and having more green spaces for exercise.

“If you tell people that one good way of promoting cardiovascular health is developing the next generation of smart cities, people will likely say, ‘Well, you know, I never thought of that, but I think it’s a good idea.’ What we need are solutions for global health, but also for our neck of the woods that are sustainable, that are healthy for the heart. We can do all of this.”

For more information on Dr. Rajagopalan’s review article in the EHJ, please email Sanjay.Rajagopalan@UHhospitals.org.

Contributing Expert:

Sanjay Rajagopalan, MD
Chief of Cardiovascular Medicine
UH Harrington Heart & Vascular Institute
Herman K. Hellerstein, MD, Chair in Cardiovascular Research
Professor
Case Western Reserve University School of Medicine
Director of the Cardiovascular Research Institute