Geographic Variation in Trends and Disparities in Cardiovascular Mortality Related to Heart Failure in the United States, 2000-2017

Introduction Over the past several decades, significant advances in the management of heart failure (HF) have led to dramatic declines in cardiovascular (CV) mortality among patients with HF. However, it is unknown whether these improvements were consistent across geographic regions. Therefore we sought to describe recent trends in HF-related CV mortality at the regional and state level. Hypothesis Significant geographic variation exists in trends of HF-related CV mortality and have led to widening disparities. Methods HF-related CV mortality rates from 2000 to 2017 were determined using the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research when CVD (I00-I78) was listed as the underlying cause of death and HF (I50) was listed as a contributing cause of death. Mortality rates were age-adjusted using the 2000 US standard population, and age-adjusted mortality rates (AAMR) were examined by census region and by state. Within regions, AAMR were quantified for each race-sex group. We used JoinPoint Regression to identify the inflection point in AAMR trends and linear regression to quantify annual rate of change in AAMR. Results AAMR for HF-related CV mortality experienced an inflection point in 2011. AAMR declined consistently prior to 2011 and increased between 2011 and 2017 across all 4 regions. Annual increases in AAMR per 100,000 after 2011 were greatest in the Midwest (β=1.14 [95% CI 0.75, 1.53]), indicating an increase of 1.14 deaths per 100,000 per year. In the South annual AAMR increase was 0.96 per 100,000 per year (0.66, 1.26) followed by the West (0.72 [0.05, 1.39]) and Northeast (0.35 [0.03, 0.68]). In each region, HF-related CV AAMR were highest among black men. In addition, the steepest rate of annual change in AAMR occurred in black men (Midwest 2.45 [1.03,3.87], South 3.79 [2.61,4.96], West 3.65 [2.41,4.88], and Northeast 1.29 [0.69,1.90]) from 2011 to 2017. HF-related CV AAMR varied widely for all states (FIGURE) with the greatest burden focused in Mississippi, Utah, and Idaho in 2017. Conclusions Wide geographic variation exists in HF-related CV mortality rates with highest rates and greatest increases observed in the South and Midwest. Black men in each region have the highest HF-related CV mortality rates and saw the greatest increases between 2011 and 2017. Urgent action is needed to focus public health efforts on modifiable risk exposures in regions and subgroups with greatest burden of HF.