Despite sustained declines in overall cardiovascular disease mortality in the U.S., disparities based on race, ethnicity and place still persist, with mortality varying far more across counties than states, according to a county-by-cause-by-population analysis published in JACC, the flagship journal of the American College of Cardiology (ACC).
Cardiovascular disease is the leading cause of death around the world. In the United States, it is a major contributor to mortality and health disparities, with mortality rates varying widely across racial and/or ethnic groups. Public health efforts to educate the public on prevention and treatment have helped to reduce death rates, but the decline has slowed over the last 15 years.
The new analysis explores county-level cardiovascular disease mortality considering race and/or ethnicity and cardiovascular disease cause of death. Researchers estimated age-standardized mortality rates (ASMRs) for five racial and/or ethnic groups across 3,110 counties and 21 causes of cardiovascular disease death from 2000 to 2019 using death certificate data from the U.S. National Vital Statistics System. They leveraged methods previously developed for estimating cause specific mortality by county and race and/or ethnicity for a comprehensive set of causes of death from the Global Burden of Diseases cause list.
Detailed knowledge of county-level variation is important for all racial and/or ethnic populations. It can inform appropriate local-level clinical and public health practices, policies and strategies needed to have a sustained effect on reducing or eliminating racial, ethnic and place-based cardiovascular disease disparities."
George A. Mensah, MD, FACC, lead author of the study and Director of the Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute
In 2019, the ASMR for total cardiovascular disease was 237.8 deaths per 100,000 individuals. Over the course of the study period, mortality declined for total cardiovascular disease as well as 12 of 17 detailed causes of death. Meanwhile, mortality rates increased for three detailed causes of death.
The 17 detailed causes are: rheumatic heart disease, ischemic heart disease, ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, hypertensive heart disease, nonrheumatic calcific aortic valve disease, non-rheumatic degenerative mitral valve disease, myocarditis, alcoholic cardiomyopathy, other cardiomyopathy, pulmonary arterial hypertension, atrial fibrillation and flutter, aortic aneurysm, lower extremity peripheral arterial disease, endocarditis and the remaining cardiovascular and circulatory diseases (as other). The three subtotals are stroke, non-rheumatic valvular heart disease and cardiomyopathy and myocarditis.
Despite the decline in total cardiovascular disease, the pace of improvement slowed after 2011. This deceleration was seen in several detailed causes of death and was accompanied by adverse trends in specific conditions: hypertensive heart disease and atrial fibrillation and flutter increased overall, and ischemic stroke showed a post-2011 increase despite longer-term declines.
The Black population suffered the highest mortality rate for total cardiovascular disease and 12 of 17 detailed causes, while the Asian population suffered the lowest for total cardiovascular disease and 13 of 17 detailed causes. Mortality varied much more by county than by state, both within and among racial and/or ethnic populations, and spatial mortality patterns also varied significantly by cardiovascular disease cause.
"For clinical practice, these findings point to the value of integrating local epidemiology into risk assessment, outreach and care delivery," Mensah said. "Health systems and clinicians need to align prevention strategies with the dominant local causes and the populations experiencing the greatest burden."
In a related editorial comment, ACC President Roxana Mehran, MD, FACC, said the findings are a reminder that heart disease statistics on a national scale can hide the realities patients are facing on a local level. She highlights how ACC is leading a coordinated approach to reducing disparities and improving cardiovascular health for all through partnerships, education, advocacy and workforce initiatives.
"Dr. Mensah et al. provided an essential pre-pandemic map of cardiovascular disparities across time, place, race and ethnicity," Mehran said. "The next challenge is to turn this map into a roadmap for action. Our commitment to cardiovascular health equity should be measured not by how precisely we describe inequities, but by how effectively we close them."
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