key: cord-0016818-v7k921oj
authors: Khan, Muhammad Shahzeb; Kumar, Pankaj; Sreenivasan, Jayakumar; Khan, Safi U.; Nasir, Khurram; Mehra, Mandeep R.; O’ Donnell, Christopher; Warraich, Haider J.
title: Rural-Urban Differences in Mortality From Ischemic Heart Disease, Heart Failure, and Stroke in the United States
date: 2021-04-21
journal: Circ Cardiovasc Qual Outcomes
DOI: 10.1161/circoutcomes.120.007341
sha: 82680479ae41df71c9f2026ec9b8b6f2568961bb
doc_id: 16818
cord_uid: v7k921oj

nan

Ischemic Heart Disease, Heart Failure, and Stroke in the United States RESEARCH LETTER −3.8%, 67.8-43.7) with a relatively higher reduction in large metropolitan areas compared with rural areas across all ages, race, and ethnic groups. However, from 2011 to 2017, stroke-related AAMR slightly increased in large metropolitan areas (APC +0.9%, 35.1-36. 3 ) while it showed a slow but consistent downtrend in rural (APC −1.2%, 43.7-40. 3 ) and a flattened nonsignificant decline in small metropolitan areas (APC 0.2%, 39. 3-38.5) areas. This increasing AAMR from stroke was specifically noted among older adults (APC +1.1%), Black people (APC +1.0%), and Hispanic people (APC +2.3%) in large metropolitan areas and younger adults in rural (APC +2.5%) and small metropolitan areas (+3.4%).

Rural areas experience higher mortality from IHD, HF, and stroke and have experienced fewer reductions in AAMR. Rural areas are home to a fifth of Americans and poor cardiovascular outcomes among rural areas could be because of poorer cardiovascular risk factor profile and access to health care. However, these trends could also be reflective of broader economic and demographic changes. Rural areas have seen significant economic decline and population loss. Rural hospital closures have been accelerating, hastened by the COVID-19 pandemic. For racial and ethnic minorities, structural inequities are magnified further in rural areas. Limitations of our analysis include data errors because of dependence on nonadjudicated death certificates to identify cause of death.

HF-related AAMR increase since 2011, across urban and rural areas, with notable spikes in racial minorities, consistent with previous reports. 4 While rural areas had both the highest HF-related AAMR and greatest absolute increase in AAMR, AAMR APC was largest in large metropolitan areas. These findings highlight a need to identify factors driving this disturbing trend, particularly amongst vulnerable groups.

Last, our study also found a small increase in strokerelated AAMR among older adults, Hispanic people, and Black people in large metropolitan areas and younger adults in nonurban areas. These findings in Hispanic individuals are at odds with otherwise lower risk of cardiovascular mortality in that group. 5 Studies on stroke-related mortality in Hispanic populations are limited, however, the higher AAMR could be from comparatively poor socioeconomic status and barriers to timely healthcare access. 5 It is, therefore, critical to focus on vulnerable rural communities to further reduce cardiovascular mortality in the United States. 

None.

Dr Mehra reports receiving travel support and consulting fees, paid to Brigham and Women's Hospital, from Abbott; fees for serving on a steering committee from Medtronic and Janssen (Johnson and Johnson), fees for serving on a data and safety monitoring board from Mesoblast, consulting fees from Portola, Bayer and Triple Gene, and fees for serving as a scientific board member from NuPulseCV, Leviticus, and FineHeart. The other authors report no conflicts. 

Rural-urban differences in cardiovascular mortality in the US

With Chartbook on Long-term Trends in Health

NCHS urban-rural classification scheme for counties. Vital Health Stat 2

National burden of heart failure events in the United States

American Heart Association Council on Cardiovascular and Stroke Nursing. Status of cardiovascular disease and stroke in Hispanics/Latinos in the United States: a science advisory from the

AAMR indicates age-adjusted mortality rate

APC, annual percentage change; HF, heart failure; IHD, ischemic heart disease; Metro, metropolitan; NA, not applicable; and PI, Pacific Islander. *APC