A steep drop in the death rate from heart disease and heart attacks is a success story of medicine and technology, with more episodes to come.

Heart disease soon may drop behind cancer as the nation's leading killer. Heart specialists credit drugs to lower cholesterol and blood pressure, the decline in smoking and a continual stream of new heart procedures and gadgets. Emergency care has improved on ambulances and in hospitals.

But many specialists say the story would be even brighter if Americans exercised more, ate more wisely and wrestled the nation's obesity and diabetes problems under control.

"That's been our biggest problem," said Dr. Thomas Porter, a University of Nebraska Medical Center cardiologist. "Not getting people to row the boat with us."

The numbers still attest to remarkable improvements. The age-adjusted death rate for heart disease has dropped 35 percent over approximately the past 15 years and more than 70 percent since 1950. Deaths by heart attack alone declined from about 300,000 in 1980 to about 114,000 in 2014.

"It's an absolutely major success story," said Dr Phillip Horwitz, executive director of the University of Iowa Heart and Vascular Center.

Stenting procedures to hold open once-clogged heart arteries, heart-monitoring and heart-jolting gadgets, heart rehabilitation programs and other innovations have played roles.

Nevertheless, there's no easy way to predict who will suffer with heart disease.

Tony Sambol's father had major heart surgery when in his 50s. The son took a cholesterol-lowering drug, or statin; was a runner into his 40s; still walked and climbed stairs for exercise; didn't smoke; and enjoyed eating fruits and vegetables. He was lean and seemed fit.

"He's a picture of health," his wife, Jeanne, said last week.

"Was a picture of health," he said.

When Sambol, 59, was evaluated for hip-replacement surgery late last year, doctors found that his heart wasn't functioning well. He had two severely blocked heart arteries and underwent coronary bypass surgery in January.

Now he's in Methodist Hospital's cardiac rehabilitation program, where he exercises and attends sessions on diet, stress management, stretching and other elements.

"I do what they tell me," Sambol said in a break between exercises last week.

"Tony, it's time to stretch," said Karen Staskiewicz, a nurse who helps guide the program.

While five patients worked out Wednesday afternoon, Staskiewicz noted that Sambol didn't have a lot of the characteristics that go with heart disease. But his father's heart disease indicates it's in the Sambol bloodline.

"Sometimes, if they have family history (of heart disease), that's enough to get them here," Staskiewicz said.

Sambol, assistant director of the Nebraska Public Health Lab at UNMC, has cut back on the red meat that he eats. He chooses chicken and fish more frequently. He's also on two additional heart-disease medications and a higher dose of his cholesterol-lowering drug. Jeanne Sambol said her husband's heart specialist has predicted Sambol has "a lot of years" ahead of him.

Cardiologists call this an encouraging time to practice their profession, because new therapies and strategies are rolling in. This has been true for years now.

The age-adjusted death rate for heart disease hit its high in 1950 and began a slow, then steeper, descent. Age-adjusted means statistics are tweaked to reflect the general age of the population so that one period can be fairly compared with another.

"I think a lot of it, honestly, is drugs," said Dr. Jeffrey Carstens, a cardiologist with CHI Health in Omaha, referring to medications that fight heart disease.

Drugs to combat high blood pressure began to come out in the 1950s and early 1960s. Statins to lower cholesterol emerged in the 1980s.

At the same time that blood pressure medicines started to have an effect, cigarette smoking began a slow descent.

Gallup reports that adult smoking peaked at 45 percent in the mid-1950s, dropped somewhat in the 1960s and 1970s, and declined more rapidly after that. The federal Centers for Disease Control and Prevention estimated that 16.8 percent of American adults smoked cigarettes in 2014.

The drop in smoking rate is "huge — a huge contributor" to the decline in heart-disease death rates, said Dr. Charles Olson, a cardiologist with Methodist Physicians Clinic.

Innovations in various areas suggest the death rate from heart disease may continue its decline. Injectable statin drugs are emerging, which means that patients who don't tolerate oral medications or don't have desired results will have an alternative that goes directly into the bloodstream.

Stenting blocked heart arteries started in large numbers roughly 20 years ago. But in about 30 percent of cases the artery narrowed again because of scar tissue and growth around and through the stent. Now many stents contain drugs that prevent that cell growth from occurring, and renarrowing has declined substantially, Olson said.

Stenting and medicines have reduced the need for the extensive coronary artery bypass graft surgery, an open-heart surgery in which the breastbone is cracked open. Those surgeries dropped from 395,100 in 2001 to 213,700 in 2011, according to the Healthcare Cost and Utilization Project.

"I think this is an exciting time" in heart care, said Dr. Chad Travers, a cardiologist with the Nebraska Heart Institute in Lincoln.

Dr. Eric Ernest, a UNMC faculty member and the state's EMS medical director, said emergency medical crews now generally use electrocardiogram technology to assess a patient for heart attack, administer aspirin to the patient and strive to get the patient to a hospital with a cardiac catheterization lab.

Those are prevalent in metro areas, he said, but air transport may be necessary in rural areas to rapidly get a patient to a hospital with cardiac catheterization, where the artery can promptly be opened and stented. The sooner blood and oxygen flow freely through the heart again, the less damage is done to the organ.

For all of the improvements, negative trends in diet, diabetes, obesity and other elements tamp down the strides being made. Obesity and diabetes are key players in heart disease.

"The uphill battle is the obesity and the lack of exercise. ... We still see, sadly, 40-year-olds having heart attacks," Carstens said. "Most of them are overweight. A lot of them smoke."

Obesity increased among American adults from 30.5 percent in 1999-2000 to 37.7 percent in 2013-14, the National Center for Health Statistics reported. The percentage of Americans diagnosed with diabetes increased from 4.4 percent in 2000 to 7.2 percent in 2013, the CDC said.

Dr. Mary Norine Walsh, vice president of the American College of Cardiology, said it's vital that everyone see a primary care physician to be assessed for high blood pressure, diabetes, high cholesterol, exercise regimens and other factors.

"We still see lots of patients who could benefit from change and avoid getting disease in the first place," said Walsh, who is medical director of the heart failure and transplant surgery program at St. Vincent in Indianapolis.

"We've got a long way to go," the Nebraska Heart Institute's Travers said. "And that begins with each individual, you know?"

Hospital cardiac rehab programs have formed over the past few decades to give workout programs to heart-disease patients and instruct them in healthy practices. Creighton University Medical Center's program has been around since 1980. Methodist Hospital's celebrated its 30th anniversary in 2015.

Denise Baccus had an irregular heart rhythm for many years, but it didn't affect her life or work as an information technology manager in Omaha. Last summer, though, she routinely became out of breath, gasping when she walked or went up stairs. She ignored it.

"I was in denial," said Baccus, 63. A colleague said she looked sickly. She went to the doctor early last fall and things happened fast. She was diagnosed with congestive heart failure and had a heart artery stented.

She had to face the severity of her disease. "It didn't look like I was ever going to go back to work," she said.

She entered Methodist's cardiac rehab program, where she increased her ability to exercise and had her love of fast food drummed out of her.

One of her nurses there, Brian Choquette, said there is no question that cardiac rehab is effective for many patients. "It's life-changing," he said. "I find it very exciting. People feel better, they get better, they feel more optimistic."

Baccus has stopped eating pizza and burgers for lunch and makes her own meal with low-sodium lunch meat sandwiches, plus apples, oranges, celery sticks and baby carrots. She takes seven meds for her heart disease and walks 40 minutes a day on her treadmill.

Her last heart test confirmed what the evidence indicated. Her heart is performing much better. And she's back at work.

Contact the writer: 402-444-1123, rick.ruggles@owh.com twitter.com/rickruggles

"It's an absolutely major success story." — Dr Phillip Horwitz, executive director, University of Iowa Heart and Vascular Center

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