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More than 40 years after the 1978 Bethesda Conference on the Declining Mortality from Coronary Heart Disease provided the scientific community with a blueprint for systematic analysis to understand declining rates of coronary heart disease, there are indications the decline has ended or even reversed despite advances in our knowledge about the condition and treatment. Recent data show a more complex situation, with mortality rates for overall cardiovascular disease, including coronary heart disease and stroke, decelerating, whereas those for heart failure are increasing. To mark the 40th anniversary of the Bethesda Conference, the National Heart, Lung, and Blood Institute and the American Heart Association cosponsored the “Bending the Curve in Cardiovascular Disease Mortality: Bethesda + 40” symposium. The objective was to examine the immediate and long-term outcomes of the 1978 conference and understand the current environment. Symposium themes included trends and future projections in cardiovascular disease (in the United States and internationally), the evolving obesity and diabetes epidemics, and harnessing emerging and innovative opportunities to preserve and promote cardiovascular health and prevent cardiovascular disease. In addition, participant-led discussion explored the challenges and barriers in promoting cardiovascular health across the lifespan and established a potential framework for observational research and interventions that would begin in early childhood (or ideally in utero). This report summarizes the relevant research, policy, and practice opportunities discussed at the symposium.

Introduction: Cardiovascular disease (CVD) death rates have plateaued. Hence, strategic targets to achieve reduction in CVD death rates set by the American Heart Association (20% by 2020) and others are at risk. Public health initiatives are urgently needed to refocus prevention of CVD in terms of cardiovascular health (CVH) and reduce disparities in CVH. Therefore, we sought to describe US CVH trends from 1999-2014 and forecast to 2050. Methods: We included a representative sample of 39,835 cardiovascular disease-free, non-institutionalized US adults aged ≥20 years. We calculated population prevalence of ideal, intermediate, and poor health behaviors (smoking, diet, physical activity, and body mass index) and health factors (glucose, cholesterol, and blood pressure) and individual-level composite CVH score including all 7 metrics (0-14 points) by sex, race/ethnicity, and education level as a proxy for socioeconomic status. We created forecasts to 2030 and 2050 assuming that observed trends might continue in a linear fashion. Results: Improvements from 1999-2014 in population levels of ideal blood pressure (29 to 38%) and cholesterol (43 to 50%) have been offset by declines in prevalence of ideal body weight (33 to 25%) and glucose (61 to 48%) in men with similar patterns in women and across race and education. Mean CVH score is projected to decline in all adults (men [7.5→6.9], women [7.5→6.8], blacks [7.1→6.0], whites [7.6→6.8], high school education or less [7.1→6.3], and some college education or more [7.9→6.8]) from 2013-2014 to 2050.The figure shows population prevalence by education level of poor, intermediate, and ideal levels of CVH metrics in 2013-2014 and projected prevalence for 2030 and 2050. Discussion: Encouraging progress in cholesterol and blood pressure in recent decades has been negated by persistent disparities and declines in composite CVH. The sobering predictions for 2030 and beyond highlight an urgent need for more effective prevention policies for equitable achievement of ideal CVH.

Background— Accurate forecasting of cardiovascular disease mortality is crucial to guide policy and programming efforts. Prior forecasts often have not incorporated past trends in rates of reduction in cardiovascular disease mortality. This creates uncertainties about future trends in cardiovascular disease mortality and disparities. Methods and Results— To forecast US cardiovascular disease mortality and disparities to 2030, we developed a hierarchical bayesian model to determine and incorporate prior age, period, and cohort effects from 1979 to 2012, stratified by age, sex, and race, which we combined with expected demographic shifts to 2030. Data sources included the National Vital Statistics System, Surveillance, Epidemiology, and End Results (SEER) single-year population estimates, and US Bureau of Statistics 2012 national population projections. We projected coronary disease and stroke deaths to 2030, first on the basis of constant age, period, and cohort effects at 2012 values, as is most commonly done (conventional), and then with the use of more rigorous projections incorporating expected trends in age, period, and cohort effects (trend based). We primarily evaluated absolute mortality. The conventional model projected total coronary and stroke deaths by 2030 to increase by ≈18% (67 000 additional coronary deaths per year) and 50% (64 000 additional stroke deaths per year). Conversely, the trend-based model projected that coronary mortality would decrease by 2030 by ≈27% (79 000 fewer deaths per year) and stroke mortality would remain unchanged (200 fewer deaths per year). Health disparities will be improved in stroke deaths but not coronary deaths. Conclusions— After prior mortality trends and expected demographic shifts are accounted for, total US coronary deaths are expected to decline, whereas stroke mortality will remain relatively constant. Health disparities in stroke but not coronary deaths will be improved but not eliminated. These age, period, and cohort approaches offer more plausible predictions than conventional estimates.

Introduction: In 2016, the US Food & Drug Administration (FDA) proposed voluntary industry reductions in sodium, a major modifiable risk factor for CVD, for processed foods. Yet, reformulation could cost the food industry up to $16bn over 10 years, perhaps partly explaining why in 2017 Congress blocked the FDA from implementing these long-term voluntary targets. Aim: To estimate the potential health gains and health-related cost savings for food industry employees from the FDA sodium targets. We defined the industry perspective as including all costs to the food industry and all health-related costs and health benefits to people working in the industry. Methods: Utilizing the validated US IMPACT Food Policy dynamic microsimulation model, we estimated QALYs gained, costs, and incremental cost effectiveness ratios (incremental cumulative cost per QALY gained, with costs and QALYs discounted at 3%) from 2017-2036 in individuals working in the wider food system (food services and drinking places; food and beverage stores; food manufacturing) and the subset of food manufacturing. Data sources included NHANES, matched to demographic data for workers from the American Community Survey, and meta-analyses of sodium effects on blood pressure and blood pressure on CVD. Costs included industry reformulation costs, government costs, and health-related costs (healthcare, productivity, informal care) for individuals working in the industry. We modelled the FDA sodium targets under 2 scenarios: a) Short-term, 100% compliance of 2-year reformulation targets with no further progress. b) Long-term, 100% compliance of 10-year reformulation targets We tested our assumptions with probabilistic sensitivity analysis. Results: Achieving the short-term, 2-year reformulation targets would generate net discounted industry costs of ~$7bn, health-related cost savings of ~$1.7bn (95% UI: $1.0bn, $2.9bn) and health gains of ~60,000 QALYs (50,000, 77,000) over 20 years, with an ICER of ~$85,000 ($12,000, $243,000) per QALY gained. Achieving the long-term sodium reduction targets could result in industry costs of ~$16bn, health-related cost savings of approximately $5.1bn ($3.4bn, $8.3bn), and industry health gain of ~180,000 (149,000, 209,000) QALYs, with an ICER of ~$60,000 ($2,000, $168,000). For the subset of food manufacturing, the long-term sodium reduction targets would lead to health-related savings of ~$1bn ($0.6bn, $1.6bn) and ~32,000 (27,000, 37,000) QALYs gained with an ICER of $489,000 ($160,000, $1,052,000). Conclusions: Sustained sodium reduction is estimated to benefit the overall food industry with a healthier workforce and partly offset the reformulation costs for the subset of the processed food industry.

Background: Sodium consumption is a leading modifiable risk factor for CVD mortality and morbidity in the US. In 2016, the US Food and Drug Administration (FDA), following recent effective examples in several other countries, proposed voluntary sodium targets for industry to reduce sodium in processed foods. Aim: We aimed to estimate the potential CVD, equity and economic impacts of implementing this policy. Methods: We used the validated US IMPACT Food Policy microsimulation model to estimate the CVD cases averted, quality-adjusted life-years (QALYs) gained and cost-effectiveness from 2017-2036 of the FDA sodium reformulation policy in US adults (30+ years). Model inputs included national demographics and sodium intakes from NHANES, FDA short- and long-term sodium reformulation targets, sodium effects on blood pressure and of blood pressure on CVD from meta-analyses, government costs to administer and monitor the policy and industry reformulation costs, and validated healthcare and productivity costs. We modelled 3 scenarios: a) Optimal, 100% compliance of 10-year reformulation targets b) Modest, 50% compliance of 10-year reformulation targets c) Pessimistic, 100% compliance of 2-year reformulation targets with no further progress Costs were inflated to 2017 US dollars and outputs were discounted annually by 3%. We took a societal perspective for this analysis. Rigorous probabilistic sensitivity analyses were conducted. Results: The optimal scenario achieving the 10-year sodium reduction targets could prevent ~ 450,000 CVD cases (95% Uncertainty Interval: 240,000-740,000), gain 2.1 million QALYs (1.7m-2.4m), and produce $41billion ($14bn-$81bn) cost-savings from 2017-2036. The modest and pessimistic scenarios were also cost-saving, with both health gains and savings about one half and one quarter, respectively, of the optimal scenario. Relative disparities between non-Hispanic white and non-Hispanic black populations would be reduced in all scenarios. The pessimistic scenario yielded the largest reduction in absolute disparities (70,000 CVD cases (33,000-120,000) prevented in non-Hispanic blacks vs. 13,000 (0-54,000) in non-Hispanic whites). The optimal scenario would prevent approximately 4.6% (130,000 cases (65,0000-220,000)) of all CVD cases in non-Hispanic blacks compared to 1.5% (220,000 cases (120,000-360,000)) in non-Hispanic whites. Despite a smaller population, total net savings would be over 50% larger in non-Hispanic blacks than non-Hispanic whites ($19bn vs $12bn) in the optimal scenario. Conclusions: Implementing and even partly achieving the FDA sodium reduction targets could generate substantial health gains and net cost savings. Crucially, this policy could also reduce CVD disparities between non-Hispanic black and non-Hispanic white populations.

Each chapter listed in the Table of Contents (see next page) is a hyperlink to that chapter. The reader clicks the chapter name to access that chapter. Each chapter listed here is a hyperlink. Click on the chapter name to be taken to that chapter. Each year, the American Heart Association (AHA), in conjunction with the Centers for Disease Control and Prevention, the National Institutes of Health, and other government agencies, brings together in a single document the most up-to-date statistics related to heart disease, stroke, and the cardiovascular risk factors listed in the AHA’s My Life Check - Life’s Simple 7 (Figure1), which include core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure [BP], and glucose control) that contribute to cardiovascular health. The Statistical Update represents …

Introduction: Excess added sugars, particularly from sugar-sweetened beverages (SSBs), are linked to cardiometabolic risk including obesity, type 2 diabetes (T2D) and CVD. Despite recent declines in SSB intake in the US, added sugar intake from SSBs and foods remains high and exceeds dietary recommendations. In May 2016, the US Food and Drug Administration (FDA) announced major revisions to the Nutrition Facts panel, including mandatory labeling of added sugar content, as a strategy to target added sugars from packaged foods and beverages. Yet, potential health effects remain unclear; and the FDA recently announced delays in implementation. Aim: To estimate the cardiometabolic and economic effects of implementing FDA’s added sugar labeling policy over a 20-year horizon. Methods: A validated microsimulation model, the US IMPACT Food Policy Model, was used to estimate the T2D and CVD cases averted and quality-adjusted life-years (QALYs) gained from the FDA policy for US adults age 30+ years. Model inputs included: nationally representative demographics and added sugar intakes from NHANES; policy effects on consumer intake from labeling intervention studies; obesity-mediated effects and direct independent effects of added sugars from SSBs and other foods, considered separately, on T2D and CVD from meta-analyses; policy costs including government administrative costs and industry compliance costs from federal government reports; national health statistics from the CDC; and healthcare costs including medical, productivity, and indirect costs from the AHA and American Diabetes Association. All costs were inflated to constant 2017 US dollars, discounted annually at 3%. We took a societal perspective and assumed a willingness to pay of $100,000 per QALY. Probabilistic sensitivity analysis accounted for model parameter uncertainty and population heterogeneity. Results: Between 2018 and 2037, the FDA added sugar labeling policy could prevent approximately 580,000 (95% UI: 270,000–960,000) T2D cases and 210,000 (96,000–440,000) CVD cases, generating 600,000 (290,000–970,000) discounted QALYs. The policy would produce discounted net cost savings (health savings minus policy costs) of $47.3bn (21.7-78.6), including $25.6bn (11.9-43.1) from direct healthcare cost reductions. Most (>60%) savings were driven by costs related to T2D. Incorporating modelling and input uncertainty, the FDA added sugar label was estimated with >80% probability to be cost-effective by 2020 and cost-saving by 2022. Potential additional reductions from industry reformulations were not included and could further increase cost-savings. Conclusions: Implementing the FDA added sugar labeling mandate would generate substantial health gains and cost savings for the US population, highlighting the need for timely implementation, monitoring and evaluation.

Background—Coronary heart disease (CHD) mortality rates have fallen dramatically over the past 4 decades in the Western world. However, recent data from the United States and elsewhere suggest a plateauing of CHD incidence and mortality among young women. We therefore examined recent trends in CHD mortality rates in the United States according to age and sex.Methods and Results—We analyzed mortality data between 1979 and 2011 for US adults ≥25 years of age. We calculated age-specific CHD mortality rates and compared estimated annual percentage changes during 3 approximate decades of data (1979–1989, 1990–1999, and 2000–2011). We then used Joinpoint regression modeling to assess changes in trends over time on the basis of inflection points of the mortality rates. Adults ≥65 years of age showed consistent mortality declines, which became even steeper after 2000 (women, −5.0%; men, −4.4%). In contrast, young men and women (Conclusions—The dramatic decline in CHD mortality since 1979 conceals major heterogeneities. CHD death rates in older groups are now falling steeply. However, young adults have experienced frustratingly small decreases in CHD mortality rates since 1990. The drivers of these major differences in CHD mortality trends by age and sex merit urgent study.

Background: Most industrialised countries have experienced remarkable reductions in mortality from cardiovascular disease (CVD) and other chronic diseases since the 1970s. Yet CVD and dementia together account for half of all disability in the elderly in the US, UK and beyond. However recent trends in CVD morbidity and disability prevalence in the US and UK offer some encouragement: concerns regarding a potential increase in the burden of these diseases do not appear to be materialising. Meanwhile, clinicians and service planners urgently need reliable forecasts of the burden of CVD and disability. Previous studies have not modelled the complex interactions of CVD, dementia and disability over time. In this study, we therefore set out to forecast trends in CVD related disability in England and Wales up to 2030. Methods: As part of the IMPACT-Better Ageing Model study, we developed and validated a probabilistic Markov model. This model tracked health transitions in the England and Wales population (60 million) through ten states characterised by the presence or absence of CVD, dementia, disability and death from 2015 to 2030. Disease occurrence and age/sex/year specific transition probabilities were derived from the English Longitudinal Study of Ageing (ELSA). We estimated future CVD and disability prevalence. As observed in ELSA, we assumed continuing parallel downward trends in CVD incidence and mortality and a 2.7% annual decline in dementia incidence. Uncertainty was estimated using Monte Carlo simulation. Findings: By 2030, approximately 2,100,000 individuals (2,000,000-2,200,000 95% Uncertainty Intervals) will live with CVD in England and Wales (a 35% decrease from 2015). Standardised CVD mortality rates will plummet by 75%. However, approximately 910,000 (882,000- 946,000 95% UI) of these CVD patients will live with disabilities (a 19% decrease from 2015). Approximately 185,000 (178,000- 192,000 UI) CVD patients will additionally be living with dementia. Despite the rapid decreases in CVD and disability burden, the standardised prevalence of disability among CVD individuals will therefore increase from 35.2% to 39.6%. Interpretation: Our model predicts a 35% reduction in the total burden of CVD in England and Wales by 2030. However, over one third of the individuals with CVD will also be living with poor functional levels. That will represent a substantial burden for our already hard-pressed health and social care services. Our results suggest that recent efforts on CVD prevention might not be enough, thus emphasizing the need for more effective prevention of all non-communicable diseases and dementia as the major causes of disability. Policies focussing on the shared NCD risk factors of poor diet, tobacco, alcohol and inactivity could substantially reduce the burden of these dread diseases and greatly benefit the future functional level of senior citizens in the UK, USA and elsewhere.

Background: The four major risk factors prioritised in WHO non-communicable disease prevention strategies are tobacco, alcohol, physical inactivity and, crucially, poor diet. Trans-fatty acid intake in most countries still exceeds the WHO target of 2g/day, mainly reflecting consumption of industrial trans-fats in junk food. Furthermore, the most effective policies for reducing trans-fats remain unclear. We therefore systematically reviewed the evidence on trans-fat policy interventions to inform future prevention strategies. We also explicitly compared “upstream” interventions covering whole populations with “downstream” interventions targeting individuals. Methods: A pre-piloted search strategy was used to systematically search six electronic databases (Cinahl, CRD, CDSR, Medline, SCI and SCOPUS) for papers evaluating the effectiveness of trans-fat interventions, with intake (g/day) as the main outcome measure. Two researchers independently screened, extracted and graded the papers for quality. Each study was then categorised on a continuum ranging from “downstream” interventions targeting individuals (dietary counselling, media campaigns or nutrition labelling) to more “upstream” structural interventions covering the entire population - reformulation, regulation, fiscal policies and comprehensive strategies involving multiple policies. A narrative synthesis was used to summarise and compare the effectiveness of different interventions. Results: After screening 996 candidate papers, a total of 22 papers were included in this systematic review: 12 empirical studies and 10 modelling studies. Quality was variable. The largest trans-fat reductions occurred in Denmark. Multiple interventions decreased intake from 4.5g/day in 1976 to 1.5g/day in 1995 and then virtually zero after a legislative ban in 2005. The US now intends to emulate this approach. No studies quantifying tax interventions were identified. Voluntary reformulation reduced trans-fat intake by 1.5g/day followed by worksite interventions (1.2g/day) and food labelling (0.8g/day). Dietary counselling targeting individuals achieved the smallest reductions (0.8g/day). Conclusions: Multi-component interventions including a legislative ban to eliminate trans-fats from foods appear the most effective strategy to minimise intake, as achieved in Denmark, and ongoing in the US. However this approach remains underused. Reformulation and other multi-component interventions can also achieve useful reductions. By contrast, more “downstream” interventions targeting settings or individuals consistently achieve much smaller reductions. This “effectiveness hierarchy”, previously observed in tobacco and alcohol control, might perhaps be considered more often when planning future prevention strategies; for instance to control other harmful nutrients such as salt or sugar.

Introduction: Coronary heart disease (CHD) is the leading cause of death worldwide. CHD mortality rates have decreased in most high-income countries, but increased in some Latin-American countries. CHD mortality rates have plateaued among young adults ( Objective: To describe and compare standardized, age-specific and garbage-code corrected mortality trends for coronary heart disease (CHD) from 1985 to 2012 in three contrasting Latin American countries. Methods: CHD deaths (1985-2012) in Argentina, Colombia and Mexico were grouped by calendar year, sex and 10-year age bands to calculate the overall age-adjusted and age and sex specific mortality rates for adults aged ≥25 years. We corrected for garbage-codes for the three countries (1997-2012) using the Global Burden of Disease (GBD) methodology. We then fitted Joinpoint regression models, using the original and garbage code corrected rates, to estimate the annual percent change (APC) and detect points in time when significant changes in the trends occurred. Results: In 2012, age-standardised mortality rates per 100,000 were 65.3 in Argentina, 132.4 in Colombia and 130.3 in Mexico. Compared to 1985, by 2012 mortality fell by 17.5% in Colombia and 52.5% in Argentina. The largest annual decreases in mortality rates were observed in Argentina from 1988-1994 (APC=-5.7 p-value60 years). Application of the garbage code corrections produced dramatic increases in mortality rates, more in women than men, and particularly in Argentina: approximately 80 additional deaths per 100,000 (compared with just 14 additional deaths per 10 5 in Colombia and 13 per 10 5 in Mexico). Conclusions: Different Latin American countries demonstrate dramatically different CHD epidemiology. Mortality rates increased after correcting for garbage code misclassification. Although CHD mortality is falling in Argentina, the modest falls in Colombia and substantial rises in Mexico highlight the region’s urgent need for effective, population-wide prevention policies.

Quantifying reductions in US cardiovascular deaths and disparities by different diet policies Background: Large disparities exist in US dietary habits and cardiovascular disease (CVD) mortality. While economic incentives have demonstrated success in improving dietary choices, the quantitative impact of different dietary policies on CVD disparities is not well-established Methods: Using a US IMPACT Food Policy Model and probabilistic sensitivity analyses, we estimated and compared the reductions in CVD mortality and disparities in the US population potentially achievable from 2015 to 2030 with specific dietary policy scenarios a) a national mass media campaign (Media campaign) aimed to increase consumption of fruits and vegetables (F&V) or reduce sugar sweetened beverages (SSBs), b) national fiscal policies to tax SSB and increase price by 10% and subsidize F&V to reduce prices by 10%; and c) a targeted policy, to subsidize F&V to reduce prices by 30% among Supplemental Nutrition Assistance Programme (SNAP) participants only. We also evaluated a combined multi-component approach, combining each of the above policies. Results: Among individual policy options, a national 10% F&V subsidy was estimated to be most effective, resulting in approximately 150,500 (95% CI, 142,700-157,900) CVD deaths potentially prevented or postponed (DPPs) by 2030. This far exceed the approximately 35,100 (32,000-37,900) DPPs from a 30% F&V subsidy targeting SNAP participants, or some 23,000 (21,700-24,600) DPPs from a 1-year Media campaign or approximately 21,400 (19,500-23,600) DPPs from a 10% SSB tax. Neither the Media campaign nor individual national economic policies would significantly reduce CVD disparities. However, the SNAP-targeted intervention would significantly reduce CVD disparities between SNAP participants and SNAP-ineligible individuals, by approximately 7% (10 DPPs per 100,000 population). The combined policy approach would save more lives than any single policy studied (approximately 215,500 DPPs by 2030) while also significantly reducing disparities by approximately 5% (7 DPPs per 100,000 population). Conclusions: Fiscal strategies targeting diet could reduce CVD burdens. A national 10% F&V subsidy would save by far the most lives, while a SNAP-targeted 30% F&V subsidy would most reduce disparities. A combined policy would have the greatest overall impact on both mortality and disparities.

We thank Drs Gupta and Rajagopalan for bringing up the important issue of changing patterns of smoking behavior in the United States as a potential explanation for the recent stagnation in coronary heart disease (CHD) mortality decline in young women we reported.1 Tobacco smoking is a powerful risk factor for CHD in young people,2 and smoking confers a higher risk of CHD in women than in …

Introduction: Cardiovascular disease (CVD) mortality burdens remain large and unequal in the US, and much is attributable to poor diets. However, few data exist regarding the potential population level impact of policies aimed at improving dietary intake, such as the Supplemental Nutrition Assistance Programme (SNAP), and potential effects on disparities. Aim: To estimate reductions in CVD mortality and disparities achievable in the US population up to 2030 through food price changes and mass media campaign interventions targeting fruits and vegetables (F&V) and sugar sweetened beverages (SSBs). Methods: We developed a US IMPACT Food Policy Model to compare four contrasting food policy scenarios targeting dietary intake: A) - national F&V mass media campaign, B) F&V price reductions of 10% universally and C) 30% to SNAP participants, D) - SSB price increase of 10% universally. Data sources included the National Vital Statistics System, SEER single year population estimates, the US Bureau 2012 National Population projections, and NHANES. We stratified the US population into SNAP participants, SNAP eligible but not participating, and SNAP ineligible. We modelled cumulative deaths prevented or postponed (DPP) and life years gained (LYG) using best-evidence effect sizes for each policy, existing mortality rates and trends, and F&V and SSB mortality effects. We stratified by age, sex, and CVD subtype from 2015 to 2030. Sensitivity analyses were conducted with Monte Carlo simulation. Results: Scenario B (universal 10% price reduction) would yield the greatest national benefits, generating approximately 88,000 DPPs (95% CI: 81,000-94,000) and 1,369,000 LYGs (1,268,000-1,460-000) by 2030. This compares with between 28,000 (26,000-30,000) and 84,000 (79,000-89,000) DPPs in Scenario A, depending on duration of media campaigns; and approximately 27,000 (24,000-30,000) and 29,000 (25,000-33,000) DPPs in scenarios C and D respectively. Scenario C (30% price reduction to SNAP participants) might reduce CVD disparities by about 18% comparing SNAP participants with the ineligible population. Scenarios A, B and D would have negligible effects on mortality disparities. Conclusions: All four dietary policies would be effective in reducing mortality. Reducing fruit and vegetable (F&V) price by 10% to the entire US would save most lives. Reducing F&V price by 30% to SNAP participants would reduce disparities the most, particularly if SNAP program coverage and penetration were improved. These results support population fiscal strategies targeting diet to reduce cardiovascular mortality and disparities in the US.

Background: Non-communicable disease (NCD) prevention strategies now prioritise four major risk factors: food, tobacco, alcohol and physical activity. Dietary salt intake is on average 5g/day higher than the recommended intake leading to high blood pressure, cardiovascular disease and gastric cancer. Substantial reductions in salt intake are therefore urgently needed. However, debate continues about the most effective approaches. We therefore systematically reviewed the evidence on possible interventions to inform future prevention programmes. We hypothesised an effectiveness hierarchy whereby “upstream structural” interventions targeting populations are more powerful than “downstream, agentic” interventions targeting individuals. Methods: We searched six electronic databases using a pre-piloted search strategy focussing on the effectiveness of population interventions to reduce salt intake. Retrieved papers were screened, appraised and graded for quality independently by two researchers. Extracted data were categorised using nine stages along the agentic/structural continuum, from “downstream”: dietary counselling (individuals, worksite and communities), through media campaigns, nutrition labelling, voluntary and mandatory reformulation, to the most “upstream” regulatory and fiscal interventions. We also considered comprehensive strategies involving multiple components. Results: After screening 2464 candidate papers, 65 were included in this systematic review (46 empirical and 19 modelling studies). Quality was variable. Multi-component strategies combining downstream with upstream interventions generally achieved the biggest reductions in salt consumption across an entire population, -3g/day in Finland, -4g/day in Japan and -1.5g/day recently in the UK. Tax interventions were considered in a few modelling studies; effects were mixed and modest. Mandatory reformulation achieved reductions of at least -1.45g/day, more than food labelling or worksite interventions (each typically -1.2g/day, but with a wide range). Smaller population benefits came from interventions in schools (-0.2g/day to -0.7g/day), and even smaller ones from health education media campaigns (-0.2g/day or less). Dietary advice achieved -2g/day reductions in compliant individuals in trials (representing an estimated population reduction of approximately -1g/day). Conclusions: Comprehensive strategies involving multiple components and “upstream” population-wide policies such as mandatory reformulation, and food labelling or worksite interventions appear to be most effective in achieving population-wide reductions in salt consumption. In conclusion, this ‘effectiveness hierarchy’ might deserve greater emphasis in future NCD prevention strategies, with correspondingly less emphasis on weaker ”downstream” individually-based interventions.

Background: Food taxes and subsidies are promising strategies for improving diets and reducing cardiometabolic diseases (CMD). Both dietary habits and CMD burdens are unequally distributed in the US, with major disparities by socioeconomic status (SES). Information on impacts of national food price policies on disparities is lacking. Aim: To estimate the impact on CMD deaths and health disparities in US adults of price interventions (taxes, subsidies) targeting 7 key dietary factors. Methods: Using nationally representative data, we conducted comparative risk assessment analysis to estimate the impact of a 10% price subsidy on fruits, vegetables, whole grains, and nuts and a 10% tax on processed meat, unprocessed red meat, and sugar-sweetened beverages, on CMD deaths and disparities in SES subgroups. We evaluated 18% (based on global price elasticity data) and 50% (based on recent experience from soda taxes in Mexico) greater price responsiveness in lowest vs. highest SES groups. Results: Each separate price intervention would reduce CMD deaths (Figure). Jointly subsidizing and taxing these 7 dietary factors (10% price change each) and assuming 18% greater price-responsiveness in lowest vs. highest SES, this intervention would prevent 5.27% of CMD deaths in those with Conclusions: Introducing modest price changes on key dietary factors could reduce CMD burdens and improve disparities in the US. Policy-based strategies targeting disparities will require considering both baseline dietary habits as well as price responsiveness in specific population subgroups.

Background: Cardiovascular disease (CVD) and dementia have profound impacts on the morbidity and disability burden in older people. Uncertainty remains regarding the future incidence of these conditions. We forecast future levels of morbidity and disability in England and Wales up to 2040 under two scenarios regarding CVD and dementia future trends. Methods: We developed a probabilistic Markov model (IMPACT-BAM) which follows the transitions of the England and Wales population into health states characterised by the presence or absence of CVD, dementia and disability to 2040. Data sources include national health registers (ONS) and cohort studies (HSE, Whitehall II and ELSA). Modelled CVD and Non-CVD mortality and prevalence trends for disability and morbidity were used to estimate trends in life expectancy (LE), morbidity-free life expectancy (MFLE) and disability-free life expectancy (DFLE). We assumed that CVD incidence and mortality will continue their current trends and modelled two scenarios: Scenario A assumes constant dementia incidence, a common assumption when projecting future burden of dementia; Scenario B assumes 2% annual decline in dementia incidence, as suggested in UK population-based cohorts. Results: In 2011, LE at age 65 was 18.4 years for men and 21.0 years for women. In Scenario A, LE at 65 in 2040 will increase to 26.7 and 24.8 years in men and women. DFLE at 65 will increase (by 5.5 years in men and 2.8 years in women, to 21.7 and 20.7 years respectively). MFLE at 65 will increase slightly (by 1.5 years in men and 1.4 in women, to 10.7 and 13.2 years respectively). Disability prevalence would increase by 3.1% to 14.4% ( 1,081,483 of 7,510,299) in men and decrease slightly (by 0.6% to 14% (1,214,754 of 8,676,813)) in women. In Scenario B, LE at 65 in 2040 will increase to a similar degree as in Scenario A, but DFLE and MFLE will increase faster (DFLE: by 7.5 years in men and 4.6 in women, to 23.7 and 22.5 years respectively; MFLE: by 4.5 years for both genders to 13.8 years in men and 16.3 in women). Disability prevalence will slightly increase (by 0.8% to 12.1% (908,746 of 7,510,299)) in men and decrease by 3.0% to 11.4% (989,157 of 8,676,813) in women. Conclusions: The future disability burden crucially depends on assumptions about future dementia incidence trends. If the dementia incidence continues unchanged, the duration of morbidity and disability will be prolonged. However, if dementia incidence decreases (as suggested in the UK and mirroring CVD declines) we could live more years in good health, with morbidity compressed into a shorter period before death.

Introduction: Cardiovascular disease (CVD) accounts for over 800,000 US deaths annually, with substantial disparities by race. Poor diet is a leading CVD risk factor, including low intake of fruit and vegetable (F&V). Few data exist regarding the potential population level impact and effect on race disparities of policies aimed at increasing F&V intake. Aim: To estimate CVD mortality reductions, including by race, potentially achievable by price reduction and mass media campaign interventions in the US population up to 2030. Methods: We developed a US IMPACT Food Policy Model to compare three contrasting policies targeting F&V intake: A - a national mass media campaign (MMC); B and C - a universal F&V price reduction of 10 and 30% respectively. The MMC assumed unequal coverage by age, gender and race, and duration of either 1 or 15 years. Data sources included the National Vital Statistics System, SEER single year population estimates, the US Bureau 2012 National Population projections and NHANES. We used US population and CVD projections to 2030, F&V mortality effect sizes and best evidence effect sizes for each policy. We modelled cumulative deaths prevented or postponed and life years gained (LYG) by age, gender, race and CVD subtype from 2015 to 2030. Results were tested in a probabilistic sensitivity analysis using Monte Carlo simulation. Results: Scenario A (MMC) could result in 27,000 (95% CI: 21,000-33,000) to 85,000 (83,000-89,000) fewer deaths dependent upon media campaign duration (from 1 to 15 years), gaining up to 1,280,000 LYGs (1,250,000-1,320,000) by 2030. Approximately 62% of deaths prevented would be CHD; and 53% would be in men, with 20% being saved in year 1. Scenario B (10% price decrease) could prevent approximately 90,000 deaths (71,000-114,000) and gain 1,450,000 LYGs (1,180,000-1,740,000) by 2030. Scenario C (30% price decrease) could prevent some 270,000 deaths (215,000-338,000) by 2030, representing a 3.9% reduction in expected CVD mortality. Price reduction policies would have equitable effects in non-hispanic whites vs. blacks. In comparison, a MMC would be ~ 35% less effective in preventing CVD deaths in non-Hispanic blacks. Conclusions: Price reduction policies (10 or 30%) and a nationwide MMC would each effectively reduce US CVD mortality. A 30% price reduction policy would save most lives and do so most equitably. Deaths prevented via a MMC might reduce substantially after year 1 and also increase disparities. These results inform potential fiscal and population level strategies to reduce CVD mortality in the US.

Background: Industrial trans fatty acids (TFAs) are commonly added to processed foods as a cheap way to increase shelf-life and enhance palatability. Natural TFA are found in small quantities in meat and dairy products. TFA substantially increase the risk of Coronary Heart Disease (CHD). The UK burden of CHD remains large, and unequal across socio-economic groups. TFA intake is also unequal, with largest intake in the most deprived groups. Methods: We modelled three policy options for reducing TFA in the English diet; a) increased labelling requirements resulting in partial voluntary reformulation; b) a ban on TFA in all restaurant & take-away food, and c) a total TFA ban in all processed foods. We quantified health benefits for the period 2015-2020 for each policy (deaths prevented and life-years-gained -LYG). Analyses were stratified by age, gender, and socioeconomic quintiles (IMDQ). Mortality gains were linked to economic cost and benefits: direct healthcare costs, productivity loss averted, and informal care; government costs comprising legislative and monitoring; and costs to industry. Results were tested in a probabilistic sensitivity analysis. Results: The most effective UK policy in reducing CHD mortality from 2015-2020, would be a total TFA ban resulting in approximately 8,600 fewer CHD deaths [95% confidence interval 3,400 - 14,700] with a substantial inequality reduction of some 3,300 deaths [1,300 - 6,000]. Labelling with partial voluntary reformulation might result in approximately 2,500 fewer CHD deaths [1,100 - 4,600]; and an inequality reduction of some 800 deaths [300 - 1,400]. Whilst a TFA ban in restaurant and take-away food could yield approximately 2,200 fewer CHD deaths [900 - 3,800]; and an inequality reduction of some 700 [300 - 1,200]). All policies would be cost-saving for the government due to big reductions in health care costs. A total ban could achieve annual societal savings of approximately £96 million The labelling and restaurant and take-away bans might gain £12 - £14 million savings for, representing £8,600 to £3,700-£4,800 per QALY. Industry costs might reach some £210 million if extensive reformulations were required, but could be negligible if reformulations were absorbed into natural product reformulation cycles. Conclusions: Policies to reduce TFA consumption in the English population are a priority public health measure. As both TFA consumption and CHD burden are higher deprived groups, any TFA reduction will reduce inequalities in CHD mortality. A total ban on TFA in ALL processed foods would have the greatest coverage across social groups. It would also represent a good investment from a societal perspective. Policies with less comprehensive coverage would be correspondingly less effective at reducing mortality, inequalities and cost effective, but would still yield substantial health, and economic gains.

Background: Cardiovascular mortality rates have fallen dramatically over the past four decades. However, recent unfavorable trends in coronary heart disease (CHD) risk factors among young adults (obesity, diabetes, and tobacco use) raise concerns about their subsequent impact on CHD mortality. Furthermore, recent data from the US and other countries suggest a worsening of CHD incidence and mortality among young women. We therefore examined recent trends in CHD mortality rates in the US according to age and sex. Methods: We used mortality data between 1980 and 2011 from US adults ≥ 25 years. We calculated age-specific CHD mortality rates and estimated annual percentage change (EAPC) for US adults, and compared three decades of data (1980-1989, 1990-1999, and 2000-2011). We also used Joinpoint regression modeling to assess changes in trends over time, based on inflection points of the mortality distribution. Results: Young men and women (aged Conclusions: The dramatic declines in cardiovascular mortality since 1980 conceals major heterogeneities. CHD death rates in older groups are now falling steeply. However, young men and women have enjoyed small decreases in CHD mortality rates since 1990. The drivers of these major differences in CHD mortality trends by age and sex needs urgent study.

Background: Countries across Europe have introduced a wide variety of policies to improve nutrition. However, the sheer diversity of interventions is potentially bewildering. We therefore aimed to map existing public health nutrition policies and identify their perceived effectiveness, in order to inform future evidence-based diet strategies. Methods: Mapping exercise: We created a public health nutrition policy database for 30 European countries (EU 27 plus Iceland, Norway and Switzerland), by summarising policy documents, grey literature, web searches and advice from topic experts. National nutrition policies were then classified using the marketing “4Ps” approach: Product (reformulation, elimination, new healthier products); Price (taxes, subsidies); Promotion (advertising, food labelling and health education) and Place (schools, workplaces, etc.) Policy interviews: We interviewed 71 senior policy-makers, public health nutrition policy experts and academics from 14 of the 30 countries, eliciting their views on diverse current and possible nutrition strategies. Results Product: Voluntary reformulation of foods, (especially salt, sugar and total fat) is widespread but with questionable impact. Denmark, Austria, Iceland and Switzerland have trans fats bans. Twelve countries regulate maximum salt content in specific foods. Price: EU School Fruit Scheme subsidies are almost universal, with variable implementation. Taxes are uncommon. However, Finland, France, Hungary and Latvia have implemented ‘sugar taxes’ on sugary foods and sugar-sweetened beverages. Finland, Hungary and Portugal also tax salty products. Promotion: Dialogue, recommendations, nutrition guidelines, information and education campaigns are widespread (all 30 countries). Labelling information is widespread, but variable. Restrictions on marketing to children are widespread but mostly voluntary. Place: Interventions reducing the availability of unhealthy foods were most commonly found in schools and workplace canteens (e.g. vending machines). Comparative effectiveness: Interviewees generally considered mandatory reformulation more effective than voluntary, and regulation and fiscal interventions much more effective than information strategies, but politically much more challenging. Implications: Public health nutrition policies in Europe appear diverse, dynamic, complex and bewildering. However, the “4Ps” framework potentially offers a structured and comprehensive categorisation. Most European countries are active in nutrition policy. However, exemplars are few, including Finland, Norway, Iceland, Denmark, Hungary, Portugal and the UK. Do these offer any useful lessons for US states addressing similar challenges? In conclusion, fiscal and regulatory nutrition policies appear potentially powerful and should be considered across Europe, and perhaps across the US?

Introduction: Coronary Heart Disease (CHD) disease remains a leading cause of UK mortality, generating a large and unequal burden of disease. Dietary trans-fats represent a powerful CHD risk factor. However, UK efforts to reduce the dietary intake of trans-fats (currently 1% of daily energy) have been limited in comparison with some other nations. Furthermore, quantifying the potential outcomes of such measures, and the effects on health inequalities has rarely been researched. We therefore modelled the effect of specific reductions in trans fatty acid (TFA) intake on CHD mortality, CHD related admissions and its effect on socioeconomic inequalities up to 2030. Methods: We extended the previously validated IMPACT model, to estimate the potential effects of reductions in TFA intake by 1% and 0.5% of daily energy upon the England and Wales population aged 25 years and above. We stratified these estimates by age, sex and Socioeconomic circumstances(SEC). We estimated a reduction in expected CHD deaths in 2030 attributable to a modest reduction in TF intake (-0.5% energy) and a complete ban (-1% energy). Main output measures were deaths prevented or postponed (DPP), life years gained (LYGs) and hospital admissions. Results: Reducing trans-fat consumption in the English and Welsh population by 1% of daily energy intake would result in approximately 3,900 fewer deaths per year; 10,000 fewer hospital admissions; and 37,000 additional life years. Smaller TFA reductions of 0.5% would yield approximately 1,900 fewer deaths, 5,000 fewer hospital admissions, and gain approximately 18,000 life years. Further, reducing trans-fats consumption to 0.5% across all SECs would reduce health inequalities. Three times as many DPPs and LYGs would be observed in the most deprived compared with the most affluent groups. Conclusions: Reducing dietary trans-fat intakes could substantially decrease CHD mortality and hospital admissions, gaining thousands of life years. Crucially, this policy could also reduce health inequalities. Strategies should therefore aim to achieve the lowest possible trans-fats intakes, as successfully achieved in many other European countries. However, such policies currently remain underused in the UK, generating an avoidable and unequal burden on the health services and on society.

Introduction: Hypertension is an important risk factor for coronary heart disease (CHD) in the UK and US. Although CHD death rates are falling, a large proportion of hypertensive patients are poorly controlled and population salt intake, a major determinant of hypertension, remains well above the recommended daily maximum of 6g/day. G. Rose identified two strategies to reduce CHD mortality. The first proposes that small, but population-wide, reductions in systolic blood pressure (SBP), achieved by public health measures to reduce salt intake, will deliver large reductions in mortality. The second seeks to reduce mortality by treating hypertensive patients and keeping them below a given risk-threshold. Here we explore the potential to reduce CHD deaths through a combination of these strategies in England and Wales up to 2030. Methods: We used the Stock of Health (SoH) model assuming each individual is born with a SoH, and on an annual basis this stock depreciates due to demographic factors, and fixed and variable risk factors. When the individual’s SoH reaches a critical point, a death from CHD occurs. The model parameters were calibrated using data from the US Cardiovascular Lifetime Risk Pooling Project. Births, deaths and risk factors distributions were estimated using data from England and Wales (ONS). We modelled a baseline scenario, three population-level strategies and two high-risk strategies. The population level strategies to reduce SBP were: (1) a reduction of 0.1 mmHg achievable by health promotion or labelling strategies, (2) a reduction of 1.3 mmHg achievable by mandatory reformulation and (3) matching England and Wales SBP levels to the observed values in the US population (average reduction:7 mmHg). In the high-risk strategies, 30% and 50% of the currently uncontrolled hypertensive patients respectively are treated to keep their SBP under 140 mmHg. Results: In the baseline scenario, the total number of CHD deaths from 2013 to 2030 will be approximately 465,000 (95% CI 460,308 to 469,334). We predict 1,244 (95% CI -3,320 to 5,807) fewer deaths by health promotion; approximately 16,203 (11,691 to 20,718) fewer deaths by mandatory reformulation of foods and some 78,051 (74,016 to 82,087) fewer deaths by reducing SBP levels to the observed levels in US. Conversely, by controlling the SBP of 30% and 50% of uncontrolled hypertensive patients, we predict 4,594 (6 to 9,191) and 7,172 (6,473 to 11,767) fewer deaths respectively. Conclusion: Both risk-targeted treatment strategies and population shifts attributable to salt reduction appear to provide potential substantial contributions to reducing CHD mortality in England and Wales. There remains, however, considerable potential to achieve much greater reductions in mortality by reducing SBP levels to those seen in the US.

Background: Poland has experienced one of the most dramatic declines in coronary heart disease (CHD) mortality rates in recent decades. This decline reflects the use of evidence based treatments and, crucially, population wide changes in diet. Our aim is to explore the potential for further gains in Poland by achieving population wide reductions in smoking, dietary salt and saturated fat intake and physical inactivity levels. Methods: A validated and updated policy model was used to forecast potential decreases in CHD deaths by 2020 as consequence of lifestyle and dietary changes in the population. Data from the most recent Polish risk factor survey was used for the baseline (2011). We modeled two different policy scenarios regarding possible future changes in risk factors: A) conservative scenario: reduction of smoking prevalence and physically inactivity rates by 5% between 2011 and 2020, and reduction of dietary consumption of energy from saturated fats by 1% and of salt by 10%. B) ideal scenario: reduction of smoking and physically inactivity prevalence by 15%, and dietary reduction of energy from saturated fats by 3% and of salt by 30%. We also conducted extensive sensitivity analysis using different counterfactual scenarios of future mortality trends. Results: Baseline scenarios. By assuming continuing declines in mortality and no future improvements in risk factors the predicted number of CHD deaths in 2020 would be approximately 13,600 (9,838-18,184) while if mortality rates remain stable, the predicted number of deaths would approximate 22,200 (17,792-26,688). Conservative scenario. Assuming continuing declines in mortality, small changes in risk factors could result in approximately 1,500 (688-2,940) fewer deaths. This corresponds to a 11% mortality reduction. Under the ideal scenario, our model predicted some 4,600 (2,048-8,701) fewer deaths (a 34% mortality reduction). Reduction in smoking prevalence by 5% (conservative scenario) or 15% (ideal scenario) could result in mortality reductions of 4.5% and 13.8% respectively. Decreases in salt intake by 10% or 30% might reduce CHD deaths by 3.0% and 8.6% respectively. Replacing 1% or 3% of dietary saturated fats by poly-unsaturates could reduce CHD deaths by 2.6% or 7.7% Lowering the prevalence of physically inactive people by 5%-15% could decrease CHD deaths by 1.2%-3.7%. Conclusion: Small and eminently feasible population reductions in lifestyle related risk factors could substantially decrease future number of CHD deaths in Poland, thus consolidating the earlier gains.

Background: Between 2000 and 2007, coronary heart disease (CHD) mortality rates in England plummeted by one third. An important part of this substantial CHD mortality decline was achieved through reductions in major cardiovascular risk factors (primary prevention). However, the relative contributions from medications and from population-wide changes remains unclear, particularly the effects on health inequalities. Methods: Using a previously validated policy model, the fall in CHD mortality in England was analysed. The contributions from risk factor declines in asymptomatic individuals through medications and through population-wide changes were quantified. Data were stratified using the Index of Multiple Deprivation (IMD). Model outputs were quantified as deaths prevented or postponed (DPPs). Results: Between 2000 and 2007, approximately 21,900 fewer CHD deaths were attributable to risk factor declines in systolic blood pressure and cholesterol in the English population. Some 7,100 of these 21,900 fewer deaths (DPPs) were attributed to medications (32%) and approximately 14,800 DPPs were attributed to secular changes in asymptomatic individuals (68%). Substantial declines in systolic blood pressure were responsible for approximately 14,300 fewer deaths. This comprised approximately 12,500 DPPs attributable to population-wide changes and some 1,800 DPPs attributable to hypertension medications. The hypertension medications resulted in approximately 350 fewer deaths in the most affluent quintile compared with 270 DPP in the most deprived. In contrast, the population-wide (secular) falls in blood pressure resulted in approximately 2400 fewer deaths in the most deprived quintile compared with only 1900 DPPs in the most affluent. Cholesterol falls resulted in approximately 7,700 fewer deaths. This comprised some 5,300 fewer deaths attributable to statin medications and approximately 2,400 fewer deaths attributable to population-wide changes (mostly diet). Statin medications prevented more deaths in the most affluent quintile (1050 DPPs) compared with the most deprived (770 DPPs). Population-wide changes in cholesterol prevented substantially more deaths in the most deprived quintile (820 DPPs) compared with the most affluent (260 DPPs). Conclusions: Population-based declines in blood pressure and cholesterol resulted in much greater reductions in CHD deaths than did primary prevention medications. Mortality falls were greatest in the most deprived quintiles, mainly reflecting their bigger initial burden of disease. Future CHD prevention policies should prioritise healthier diets ahead of medications.

Background: Although the rate of death (mortality) from Coronary Heart Disease (CHD) has halved since the 1970s, CHD remains a major cause of all-cause mortality in the UK. Furthermore, population ageing plus recent increases in obesity and diabetes may soon increase total CHD deaths. Predictions of future CHD mortality are thus potentially problematic. Here we explore future projections of CHD mortality in England & Wales under two conventional but dramatically contrasting assumptions. Materials and Methods: In SCENARIO A, we used a conventional counterfactual, assuming that the last-observed CHD mortality rates (ONS) from 2011 would persist unchanged to 2030.The future number of deaths was then calculated by applying those rates onto 2012-2030 population estimates. In SCENARIO B, we assumed that the recent trend in CHD mortality rates would continue. We used a well-established hierarchical Bayesian Age Period Cohort (BAPC) model, which works under the assumption that variability in CHD mortality can be explained by a combination of age, period and cohort effects. We fitted this model to the observed CHD mortality from 1979 to 2011 and then continued the linear trends in age, period and cohort effects up to 2030. We then used the BAPC model to predict mortality rates in 2012-2030, and then applied these rates to population projections to compute future deaths. Results: In scenario A, by assuming that 2011 mortality rates would continue at that level, the number of CHD deaths would increase 61.5% (39,597 of 64,323) by 2030. In scenario B, by assuming recent trends continued, the number of deaths would decrease 56.7% (-36,500 of 64,323) by 2030. This substantial decrease would occur despite a predicted slowing of mortality decline in middle aged groups. Conclusion: The decline in CHD mortality has been reasonably continuous since 1979, and there is little reason to believe it will soon halt. The underlying assumption of a commonly used mortality counterfactual thus appears slightly dubious. By contrast, the BAPC model offers a far more plausible prediction of future trends by simultaneously considering age, period and cohort effects and projecting each into the future. Thus, despite population ageing, we estimated that the number of CHD deaths would halve again between 2011 and 2030. Even so, shifts in population risk factors might still cause CHD mortality to move away from a trajectory of decline. There is no room for complacency and the promotion of cardiovascular health remains a top policy priority.

Background— Socioeconomic deprivation is associated with increased heart failure (HF) incidence, hospitalization rates, and mortality. However, whether the delivery of survival-enhancing medical therapy is equitable remains uncertain. We examined secular trends in the uptake of key medical therapies (angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, β-blockers, spironolactone) stratified by socioeconomic circumstances in patients with HF. Secondary analyses examined trends in HF incidence, prevalence, and survival. Methods and Results— This study was a cross-sectional observational analysis of nationally representative primary care data from England. Treatments for patients with HF in 1999 and 2007 (n=13 330) were extracted from the General Practice Research Database. Socioeconomic circumstances were defined with the Index of Multiple Deprivation 2007, a weighted composite of 7 area-level deprivation domains. Treatment uptake estimates were age standardized. The incidence and prevalence of HF decreased year to year. Although clear socioeconomic gradients in both the incidence and prevalence of HF were apparent, the absolute difference between most and least deprived reduced over time. Uptake of therapies improved over time in both men and women. Angiotensin-converting enzyme inhibitor/angiotensin receptor blocker uptake increased from 46% to 64%, β-blocker uptake from 12% to 41%, and spironolactone uptake from 3% to 20%. Modest age and sex inequalities were apparent. However, no consistent socioeconomic gradients were observed in either treatment or case fatality. Conclusions— Socioeconomic gradients in the incidence and prevalence of HF are reducing. Treatment is generally equitable and independent of socioeconomic circumstances. Most important, no significant inequality in outcomes was apparent. Future strategies should continue to address inequalities in the underlying causes of HF and to increase overall treatment levels further.