Improvements in therapy and prevention have led to declining cardiovascular mortality in the United States, but it is not clear whether these improvements have narrowed geographic disparities in cardiovascular outcomes. We sought to compare mortality due to cardiovascular disease, heart failure, stroke, and ischemic heart disease in the stroke belt cluster of 11 states versus the rest of the United States.
A retrospective cross-sectional analysis of the CDC WONDER database was done to evaluate the nationwide mortality trends derived from the death certificates of all American residents from 1999 to 2017. Mortality trends for death due to heart failure, stroke, ischemic heart disease or any cardiovascular cause, were identified in the stroke belt and non-stroke belt populations using ICD-10 codes. Piecewise linear regression was used to assess the change in mortality trends.
Among 16,111,775 deaths due to cardiovascular causes during the study period, the age-adjusted mortality rates (AAMR) were highest among non-Hispanic Black, males from non-metropolitan areas, living in the stroke belt. In the stroke belt, AAMR due to all cardiovascular causes [Average Annual Percentage Change (AAPC): -2.5 (95% CI:-2.9 to -2.0); p<0.001], stroke [AAPC: -2.9 (95% CI: -3.7 to -2.1); p<0.001] and ischemic heart disease [AAPC: -3.9 (95% CI: -4.3 to -3.5); p<0.001] declined from 1999 to 2017. Similarly, a decrease in cardiovascular [AAPC: -2.6 (95% CI:-3.1 to -2.1); p<0.001], stroke [AAPC:-2.9 (95% CI: -3.2 to -2.2); p<0.001] and ischemic heart disease [AAPC: -4.1 (95% CI: -4.5 to -3.6); p<0.001] mortality was seen in the non-stroke belt region from 1999 to 2017. There was no overall change in heart failure mortality in either regions (p for AAPC >0.05). The gap in age-adjusted mortality estimates for cardiovascular cause of death was 11.8% in 1999 and was 16% in 2017 across the two regions (
). The mortality gaps were persistent across sub-groups of age, sex, race, and level of urbanization.
Despite the overall decline in cardiovascular mortality, significant geographic disparities in cardiovascular mortality persist. Preventive efforts targeting risk factors and improved disease management may attenuate the longstanding geographical heterogeneity in cardiovascular mortality.