In the Journals

Differences in CVD mortality rates between US counties decline, but still significant

Ischemic heart disease and stroke mortality rates significantly differed in counties throughout the United States, according to a study in JAMA.

Less substantial variances were seen in atrial fibrillation, aortic and peripheral artery disease, rheumatic heart disease and diseases of the myocardium, researchers reported.

“The absolute different in county-level [CVD] mortality rates declined substantially over the past 35 years for both ischemic heart disease and cerebrovascular disease,” Gregory A. Roth, MD, MPH, assistant professor of cardiology at the University of Washington in Seattle, and colleagues wrote. “Despite this decline in absolute differences between counties, large differences remained in 2014. These findings suggest major efforts are still needed to reduce geographic variation in risk of death due to ischemic heart disease and cerebrovascular diseases.”

Death records review

Researchers reviewed death records from 1980 to 2014 to investigate geographic variations in CVD mortality rates. During the time range, 31,992,547 deaths from CVD were recorded. CVDs were the leading cause of death in the United States, even with a 50.2% decline (95% uncertainty interval [UI], 49.5-50.8) from 1980 (507.4 deaths per 100,000 persons) to 2014 (252.7 deaths per 100,000 persons). CVDs were the cause for 11.7 million years of life lost (95% UI, 11.6 million-11.9 million) and 846,000 deaths (95% UI, 827,000-865,000).

A 14.6% decrease in the variance in age-standardized CVD mortality rates among counties at the 10th and 90th percentile was seen from 1980 (172.1 deaths per 100,000 persons) to 2014 (147 deaths per 100,000 persons; posterior probability of decline > 99.9%). The decline in CVD mortality was due to a decrease in counties at the 10th and 90th percentile for cerebrovascular disease (1.7 deaths per 100,000 persons; 40.3 vs. 68.1) and ischemic heart disease (two deaths per 100,000 persons; 119.1 vs. 237.7) in 2014.

Significant increases in the gaps between the 1st and 99th percentile and the 10th and 90th percentile were seen for myocarditis, cardiomyopathy, PAD, AF, endocarditis and other circulatory and CVDs. Ratios between counties at the 90th and 10th percentiles fluctuated from 1.4 for aortic aneurysm (3.5 vs. 5.1 deaths per 100,000 persons) to 4.2 for hypertensive heart disease (4.3 vs. 17.9 deaths per 100,000 persons) for other CVD causes.

Higher mortality rates

Counties greater than the 90th percentile with a high concentration of CVD mortality rates were mainly seen along the Mississippi River Valley into central Oklahoma and eastern Kentucky. Some CVD conditions were concentrated outside of the southern part of the country, such as aortic aneurysm in the Midwest, AF in the Northwest and endocarditis in Alaska and the Mountain West.

Counties surrounding central Colorado, San Francisco, northern Nebraska, northeastern Virginia, central Minnesota and southern Florida had the lowest CV mortality rates.

“Further investigation is needed to better understand regional variation in the factors that lead to [CVD] deaths,” Roth and colleagues wrote. “These factors can best be understood in three major categories: (1) variation in the level of exposure to metabolic, behavioral and environmental risks for the residents of a county; (2) variation in the delivery of interventions that can modify risk due to these exposures over time; and (3) delivery of high-quality emergency services and acute medical care that improve health outcomes when [CV] events occur.”

In a related editorial, George A. Mensah, MD, FACC, a senior adviser in the immediate office of the director at the NHLBI, and colleagues wrote: “The findings of marked geographic disparities in CVD mortality described by Roth et al serve as a critical reminder to challenge clinicians, investigators and public health leaders to imagine a future in which an individual’s risk [for CV] death is no longer determined by ‘the place’ he or she was born or resides and no longer prevents pursuing a healthy and fulfilling life. The wide variance in county-level CVD mortality rates provides a useful target for developing innovative initiatives that enable communities to race to the top in achieving optimum [CV] health.” – by Darlene Dobkowski

Disclosure: The researchers and editorial authors report no relevant financial disclosures.

Ischemic heart disease and stroke mortality rates significantly differed in counties throughout the United States, according to a study in JAMA.

Less substantial variances were seen in atrial fibrillation, aortic and peripheral artery disease, rheumatic heart disease and diseases of the myocardium, researchers reported.

“The absolute different in county-level [CVD] mortality rates declined substantially over the past 35 years for both ischemic heart disease and cerebrovascular disease,” Gregory A. Roth, MD, MPH, assistant professor of cardiology at the University of Washington in Seattle, and colleagues wrote. “Despite this decline in absolute differences between counties, large differences remained in 2014. These findings suggest major efforts are still needed to reduce geographic variation in risk of death due to ischemic heart disease and cerebrovascular diseases.”

Death records review

Researchers reviewed death records from 1980 to 2014 to investigate geographic variations in CVD mortality rates. During the time range, 31,992,547 deaths from CVD were recorded. CVDs were the leading cause of death in the United States, even with a 50.2% decline (95% uncertainty interval [UI], 49.5-50.8) from 1980 (507.4 deaths per 100,000 persons) to 2014 (252.7 deaths per 100,000 persons). CVDs were the cause for 11.7 million years of life lost (95% UI, 11.6 million-11.9 million) and 846,000 deaths (95% UI, 827,000-865,000).

A 14.6% decrease in the variance in age-standardized CVD mortality rates among counties at the 10th and 90th percentile was seen from 1980 (172.1 deaths per 100,000 persons) to 2014 (147 deaths per 100,000 persons; posterior probability of decline > 99.9%). The decline in CVD mortality was due to a decrease in counties at the 10th and 90th percentile for cerebrovascular disease (1.7 deaths per 100,000 persons; 40.3 vs. 68.1) and ischemic heart disease (two deaths per 100,000 persons; 119.1 vs. 237.7) in 2014.

Significant increases in the gaps between the 1st and 99th percentile and the 10th and 90th percentile were seen for myocarditis, cardiomyopathy, PAD, AF, endocarditis and other circulatory and CVDs. Ratios between counties at the 90th and 10th percentiles fluctuated from 1.4 for aortic aneurysm (3.5 vs. 5.1 deaths per 100,000 persons) to 4.2 for hypertensive heart disease (4.3 vs. 17.9 deaths per 100,000 persons) for other CVD causes.

Higher mortality rates

Counties greater than the 90th percentile with a high concentration of CVD mortality rates were mainly seen along the Mississippi River Valley into central Oklahoma and eastern Kentucky. Some CVD conditions were concentrated outside of the southern part of the country, such as aortic aneurysm in the Midwest, AF in the Northwest and endocarditis in Alaska and the Mountain West.

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Counties surrounding central Colorado, San Francisco, northern Nebraska, northeastern Virginia, central Minnesota and southern Florida had the lowest CV mortality rates.

“Further investigation is needed to better understand regional variation in the factors that lead to [CVD] deaths,” Roth and colleagues wrote. “These factors can best be understood in three major categories: (1) variation in the level of exposure to metabolic, behavioral and environmental risks for the residents of a county; (2) variation in the delivery of interventions that can modify risk due to these exposures over time; and (3) delivery of high-quality emergency services and acute medical care that improve health outcomes when [CV] events occur.”

In a related editorial, George A. Mensah, MD, FACC, a senior adviser in the immediate office of the director at the NHLBI, and colleagues wrote: “The findings of marked geographic disparities in CVD mortality described by Roth et al serve as a critical reminder to challenge clinicians, investigators and public health leaders to imagine a future in which an individual’s risk [for CV] death is no longer determined by ‘the place’ he or she was born or resides and no longer prevents pursuing a healthy and fulfilling life. The wide variance in county-level CVD mortality rates provides a useful target for developing innovative initiatives that enable communities to race to the top in achieving optimum [CV] health.” – by Darlene Dobkowski

Disclosure: The researchers and editorial authors report no relevant financial disclosures.