In the JournalsPerspective

US heart disease death rates declining, but more slowly in South

Mortality rates from heart disease in the United States declined from 1973 to 2010, but the rate of decline was lowest in the South, according to data published in Circulation.

At the beginning of the study period, the counties with the highest death rates from heart disease were concentrated in the Northeast, but at the end, they were concentrated in the South, Michele Casper, PhD, and colleagues reported.

“This is the most comprehensive study to compare county-level patterns of geographic disparities in heart disease death rates over an extended timeframe,” Casper, epidemiologist at the CDC’s Division for Heart Disease and Stroke Prevention, said in a press release. “These findings provide local communities with important historical context regarding their current burden of heart disease, and emphasize the importance of local conditions in heart disease prevention and treatment efforts.”

Casper and colleagues calculated age-adjusted and spatially smoothed death rates from heart disease in adults aged 35 years or older by county for 2-year intervals from 1973-1974 to 2009-2010. They used a Bayesian spatiotemporal model to calculate precise rate estimates in all counties, even the smallest ones.

Geographic shift

In 1973-1974, the highest tier of age-adjusted heart disease mortality, 974.6 to 1,306 per 100,000 people, “formed an arc stretching from the Northeast through much of Appalachia and into the Midwest,” Casper and colleagues wrote. However, in 2009-2010, the highest tier had a rate of 450 to 769.1 per 100,000 people and “the strong concentration of high-rate counties in the Northeast had dissipated, and a large concentration of high-rate counties emerged in the South and southern Appalachia,” they wrote.

They noted that the counties with the lowest rates of death from heart disease were concentrated in the West in both periods.

The North had 48% of the counties in the highest quintile of heart disease mortality in 1973-1974 but just 4% in 2009-2010, and the Midwest had 17% in 1973-1974 but 6% in 2009-2010, whereas the South had 24% in 1973-1974 and 38% in 2009-2010, Casper and colleagues wrote.

The decline in heart disease mortality rates between 1973-1974 and 2009-2010 ranged by county from 9.2% to 83.4% (average, 61.6%). In the quintile with the slowest declines (9.2% to 49.6%) were primarily counties from Alabama, Mississippi, Louisiana, Arkansas, Oklahoma and parts of Texas, according to the researchers.

The magnitude of geographic inequality for heart disease mortality rates doubled between 1973-1974 and 2009-2010, with the coefficient of variation increasing 3.62% each year on average, they wrote.

The results “suggest that systematic changes may have occurred in a variety of biomedical, behavioral and socioenvironmental factors,” Casper and colleagues wrote.

Race , education could play role

In a related editorial, Donald A. Barr, MD, PhD, from the Program in Human Biology, Stanford Health Care, wrote that previous research showing that “the longitudinal shifts in rates of CHD and HF suggest that black Americans are increasingly bearing the burden of heart disease” could be a factor in the present findings.

Lower rates of smoking and cholesterol levels combined with higher rates of diabetes, obesity and high BP indicate that HF is making a large impact on heart disease mortality, and “this shift disproportionately impacts blacks and others with lower levels of education, population groups found disproportionately in southern states,” Barr wrote.

“As physicians, we need to be able to incorporate [rigorous biosocial training] into our own practice, while also assuring that future physicians will gain this understanding as part of their medical education,” he concluded. – by Erik Swain

Disclosure: The researchers report no relevant financial disclosures. Barr reports receiving royalties from Johns Hopkins University Press for writing three textbooks related to this issue.

Mortality rates from heart disease in the United States declined from 1973 to 2010, but the rate of decline was lowest in the South, according to data published in Circulation.

At the beginning of the study period, the counties with the highest death rates from heart disease were concentrated in the Northeast, but at the end, they were concentrated in the South, Michele Casper, PhD, and colleagues reported.

“This is the most comprehensive study to compare county-level patterns of geographic disparities in heart disease death rates over an extended timeframe,” Casper, epidemiologist at the CDC’s Division for Heart Disease and Stroke Prevention, said in a press release. “These findings provide local communities with important historical context regarding their current burden of heart disease, and emphasize the importance of local conditions in heart disease prevention and treatment efforts.”

Casper and colleagues calculated age-adjusted and spatially smoothed death rates from heart disease in adults aged 35 years or older by county for 2-year intervals from 1973-1974 to 2009-2010. They used a Bayesian spatiotemporal model to calculate precise rate estimates in all counties, even the smallest ones.

Geographic shift

In 1973-1974, the highest tier of age-adjusted heart disease mortality, 974.6 to 1,306 per 100,000 people, “formed an arc stretching from the Northeast through much of Appalachia and into the Midwest,” Casper and colleagues wrote. However, in 2009-2010, the highest tier had a rate of 450 to 769.1 per 100,000 people and “the strong concentration of high-rate counties in the Northeast had dissipated, and a large concentration of high-rate counties emerged in the South and southern Appalachia,” they wrote.

They noted that the counties with the lowest rates of death from heart disease were concentrated in the West in both periods.

The North had 48% of the counties in the highest quintile of heart disease mortality in 1973-1974 but just 4% in 2009-2010, and the Midwest had 17% in 1973-1974 but 6% in 2009-2010, whereas the South had 24% in 1973-1974 and 38% in 2009-2010, Casper and colleagues wrote.

The decline in heart disease mortality rates between 1973-1974 and 2009-2010 ranged by county from 9.2% to 83.4% (average, 61.6%). In the quintile with the slowest declines (9.2% to 49.6%) were primarily counties from Alabama, Mississippi, Louisiana, Arkansas, Oklahoma and parts of Texas, according to the researchers.

The magnitude of geographic inequality for heart disease mortality rates doubled between 1973-1974 and 2009-2010, with the coefficient of variation increasing 3.62% each year on average, they wrote.

The results “suggest that systematic changes may have occurred in a variety of biomedical, behavioral and socioenvironmental factors,” Casper and colleagues wrote.

Race , education could play role

In a related editorial, Donald A. Barr, MD, PhD, from the Program in Human Biology, Stanford Health Care, wrote that previous research showing that “the longitudinal shifts in rates of CHD and HF suggest that black Americans are increasingly bearing the burden of heart disease” could be a factor in the present findings.

Lower rates of smoking and cholesterol levels combined with higher rates of diabetes, obesity and high BP indicate that HF is making a large impact on heart disease mortality, and “this shift disproportionately impacts blacks and others with lower levels of education, population groups found disproportionately in southern states,” Barr wrote.

“As physicians, we need to be able to incorporate [rigorous biosocial training] into our own practice, while also assuring that future physicians will gain this understanding as part of their medical education,” he concluded. – by Erik Swain

Disclosure: The researchers report no relevant financial disclosures. Barr reports receiving royalties from Johns Hopkins University Press for writing three textbooks related to this issue.

    Perspective

    Herman A. Taylor

    • This is a very important study. I think it is a red flag waving for anyone concerned about the health, happiness and longevity of people who live in the South. It fairly dramatically points out that the South, particularly the Southeast, has emerged as the epicenter of the ongoing CV epidemic. I eagerly anticipate more in-depth research by this group and others who are focused on geographic disparities.

      We have to put that into context of the generally good news of the decline of heart disease as a cause of death among Americans. Not every part of the country has experienced the decline as dramatically as others. Some parts are truly benefiting from advances in modern research and therapeutics, while the South lags significantly behind. This is the region where the poorest Americans live as well, and the two facts are probably related. Additionally, around half of all African Americans call the South home; the fact that significant disparities along ethnic lines persist in our country are at least partly responsible for the patterns observed.

      Societally, we have further to go in the South in terms of ensuring adequate access to care for all our citizens of every economic and ethnic group. While these data likely don’t reflect the impact of the Affordable Care Act, the reluctance to embrace the current version of universal access to health insurance is counterproductive, even if you disagree with some specifics of current law. Being last to expand Medicaid will not help these statistics. Other policy initiatives could be embraced: Smoking bans in public places have been proven to reduce MI admissions to EDs in municipalities across the U.S. and internationally, but many Southern communities have been slow to adopt these life-saving measures. Similarly, policy decisions about green spaces, walking spaces, school exercise and school lunches can play a role; people with power in those realms should pay close attention to these data. Advancing obesity, diabetes and hypertension levels in our region are clearly contributory; we lead the country in all those categories of risk factors. With such high levels of CV risk factors, as well as social impediments to resources that support health care and healthful living, it stands to reason that you would see this manifest in excess deaths from heart disease.

      We need to use all available means to catch up with the rest of the country in terms of enjoying all the advances in research, advances in medical care and improved access to care. More research to increase the precision of our understanding of the micro-level details of these macro-trends that the maps reflect must continue. Precision medicine must be accompanied by an appreciation of the concept of “precision public health” — the study by Casper and colleagues is a good example of an important step in this direction — so we understand better what’s going on, so our solutions have maximal impact. Also, while we attack the known culprits, we also need to understand better how some people and places avoid disease. What is the source of the resilience of some people and communities despite the risks that social, personal and environmental factors might pose to individuals and the population? Indeed, there are Southerners who live long healthy lives, sometimes despite high-risk environments. Closer investigation of these hardy individuals and communities may reveal some surprises that might point to new ways to intervene and reduce disparities.

      When people have the latest options available to manage their health, and they can get to those options and lack of insurance is not an issue, that’s an important component of good overall outcomes. Making good, nutritious diets universally available, as well as doing all we can to improve healthy food selection options and the quality of the food supply are also very important. The “Southern diet” needs to be looked at carefully, and we need to inform the populace about the challenges posed to heart health by a diet with such a high calorie intake and high fat intake, and about healthy alternatives. We must offer opportunities for exercise, even in hot summer in the deep South. In some communities, the local schools offer the opportunity for people to use their facilities for exercise in relative comfort, and the population benefits. We should also emphasize systems of care, such as the ones developed by Kaiser Permanente and the Veterans Administration, to help reduce hypertension, which has such a dramatic impact on CHD and HF in the South. This is an important concept in the modern practice of cardiology.

      Cardiologists need to heed these data. First, the distribution of manpower should be impacted. Young cardiologists, especially, can seize the opportunity to locate where they can be a part of the solution to the heart disease epidemic where it is most profoundly impacting American life and productivity — in the Southern U.S., often away from the biggest population centers. The emphasis on hospital-based care and risk-factor intervention by cardiologists needs to be evidence-based, consistent and aggressive, and it absolutely must involve non-physician partners who are effective in counseling on diet, exercise and other health behaviors. We must stay attuned to developments in patient-centered, decentralized services, including of practices that help individuals improve self-care, such as home BP monitoring, telehealth links with remote areas, and the evolving mobile health solutions as they mature and become increasingly important. Finally, cardiologists must use their expert status to advocate for policies at the local, state and higher levels to make their communities as heart-friendly as possible. All Americans should have an equal shot at lives free of disability and early death tied to heart disease.

      • Herman A. Taylor, MD, MPH, FACC, FAHA
      • Director and endowed professor
        Cardiovascular Research Institute
        Morehouse School of Medicine, Atlanta
    • Disclosures: Taylor reports consulting for Alnylam Pharmaceuticals on a matter unrelated to the present study.