Heterogeneity in national U.S. mortality trends within heart disease subgroups, 2000-2015

Causes of Death and Mortality Trends in Individuals with Thalassemia in the United States, 1999-2020

Purpose

Our study aims to describe the mortality trends and disparities among individuals with thalassemia in the United States (US).

Patients and Methods

We used CDC WONDER database to calculate the age-adjusted mortality rates (AAMRs) per 1,000,000 individuals and used the Joinpoint Regression Program to measure the average annual percent change (AAPC). Subgroup evaluations were performed by sex, age, race, census region, and urbanization level.

Results

From 1999 to 2020, there were 2797 deaths relatd to thalassemia in the US. The AAMR of thalassemia-related death showed a decreasing trend from 0.50 (95% CI, 0.41-0.58) in 1999 to 0.48 (95% CI, 0.41-0.55) in 2020 with the AAPC of -1.42 (95% CI, -2.42, -0.42). Asians have the highest AAMR (1.34 [95% CI, 1.20-1.47]), followed by non-Hispanic Blacks (0.65 [95% CI, 0.59-0.71]), non-Hispanic Whites (0.32 [95% CI, 0.30-0.33]), and Hispanics (0.11 [95% CI, 0.08-0.14]). Cardiovascular disease remains the leading cause of death among individuals with thalassemia. The urban population has a higher AAMR than the rural population (0.43 [95% CI, 0.41-0.45] vs 0.29 [95% CI, 0.26-0.32]).

Conclusion

Our study calls for targeted interventions to address the racial and geographic disparities existed among individuals of thalassemia in the US.

Trends in Mortality After Incident Hospitalization for Heart Failure Among Medicare Beneficiaries

Importance

Despite advances in treatment and care quality for patients hospitalized with heart failure (HF), minimal improvement in mortality has been observed after HF hospitalization since 2010.

Objective

To evaluate trends in mortality rates across specific intervals after hospitalization.

Design, Setting, and Participants

This cohort study evaluated a random sample of Medicare fee-for-service beneficiaries with incident HF hospitalization from January 1, 2008, to December 31, 2018. Data were analyzed from February 2023 to May 2024.

Main Outcomes and Measures

Unadjusted mortality rates were calculated by dividing the number of all-cause deaths by the number of patients with incident HF hospitalization for the following periods: in-hospital, 30 days (0-30 days after hospital discharge), short term (31 days to 1 year after discharge), intermediate term (1-2 years after discharge), and long term (2-3 years after discharge). Each period was considered separately (ie, patients who died during one period were not counted in subsequent periods). Annual unadjusted and risk-adjusted mortality ratios were calculated (using logistic regression to account for differences in patient characteristics), defined as observed mortality divided by expected mortality based on 2008 rates.

Results

A total of 1 256 041 patients (mean [SD] age, 83.0 [7.6] years; 56.0% female; 86.0% White) were hospitalized with incident HF. There was a substantial decrease in the mortality ratio for the in-hospital period (unadjusted ratio, 0.77; 95% CI, 0.67-0.77; risk-adjusted ratio, 0.74; 95% CI, 0.71-0.76). For subsequent periods, mortality ratios increased through 2013 and then decreased through 2018, resulting in no reductions in unadjusted postdischarge mortality during the full study period (30-day mortality ratio, 0.94; 95% CI, 0.82-1.06; short-term mortality ratio, 1.02; 95% CI, 0.87-1.17; intermediate-term mortality ratio, 0.99; 95% CI, 0.79-1.19; and long-term mortality ratio, 0.96; 95% CI, 0.76-1.16) and small reductions in risk-adjusted postdischarge mortality during the full study period (30-day mortality ratio, 0.88; 95% CI, 0.86-0.90; short-term mortality ratio, 0.94; 95% CI, 0.94-0.95; intermediate-term mortality ratio, 0.94; 95% CI, 0.92-0.95; and long-term mortality ratio, 0.95; 95% CI, 0.93-0.96).

Conclusions and Relevance

In this study of Medicare fee-for-service beneficiaries, there was a substantial decrease in in-hospital mortality for patients hospitalized with incident HF from 2008 to 2018, but little to no reduction in mortality for subsequent periods up to 3 years after hospitalization. These results suggest opportunities to improve longitudinal outpatient care for patients with HF after hospital discharge.

Reversals in the Decline of Heart Failure Mortality in the US, 1999 to 2021

This cohort study evaluates recent reversals in declines in cardiovascular mortality and whether they vary across sociodemographic categories.

Demographic trends of cardiorenal and heart failure deaths in the United States, 2011-2020

BACKGROUND

Heart failure (HF) and kidney disease frequently co-occur, increasing mortality risk. The cardiorenal syndrome results from damage to either the heart or kidney impacting the other organ. The epidemiology of cardiorenal syndrome among the general population is incompletely characterized and despite shared risk factors with HF, differences in mortality risk across key demographics have not been well described. Thus, the primary goal of this study was to analyze annual trends in cardiorenal-related mortality, evaluate if these trends differed by age, sex, and race or ethnicity, and describe these trends against a backdrop of HF mortality.

METHODS AND FINDINGS

The Centers for Disease Control and Prevention Wide-ranging ONline Data for Epidemiologic Research database was used to examine cardiorenal- and HF-related mortality in the US between 2011and 2020. International Classification of Diseases, 10 Revision codes were used to classify cardiorenal-related deaths (I13.x) and HF-related deaths (I11.0, I13.0, I13.2, and I50.x), among decedents aged 15 years or older. Decedents were further stratified by age group, sex, race, or ethnicity. Crude and age-adjusted mortality rates (AAMR) per 100,000 persons were calculated. A total of 97,135 cardiorenal-related deaths and 3,453,655 HF-related deaths occurred. Cardiorenal-related mortality (AAMR, 3.26; 95% CI: 3.23-3.28) was significantly lower than HF-related mortality (AAMR, 115.7; 95% CI: 115.6-115.8). The annual percent change (APC) was greater and increased over time for cardiorenal-related mortality (2011-2015: APC, 7.1%; 95% CI: 0.7-13.9%; 2015-2020: APC, 19.7%, 95% CI: 16.3-23.2%), whereas HF-related mortality also increased over that time period, but at a consistently lower rate (2011-2020: APC, 2.4%; 95% CI: 1.7-3.1%). Mortality was highest among older and male decedents for both causes. Cardiorenal-related deaths were more common in non-Hispanic or Latino Blacks compared to Whites, but similar rates were observed for HF-related mortality. A larger proportion of cardiorenal-related deaths, compared to HF-related deaths, listed cardiorenal syndrome as the underlying cause of death (67.0% vs. 1.2%).

CONCLUSIONS

HF-related deaths substantially outnumber cardiorenal-related deaths; however, cardiorenal-related deaths are increasing at an alarming rate with the highest burden among non-Hispanic or Latino Blacks. Continued surveillance of cardiorenal-related mortality trends is critical and future studies that contain detailed biomarker and social determinants of health information are needed to identify mechanisms underlying differences in mortality trends.

Association of serum albumin with heart failure mortality with NYHA class IV in Chinese patients: Insights from PhysioNet database (version 1.3)

BACKGROUND

Studies have proved that low albumin level is associated with increased mortality in most diseases, such as chronic kidney disease and hepatic cirrhosis. However, the relationship between albumin and all-cause death in heart failure patients in China is still unclear.

OBJECTIVES

We aimed to investigate the association between albumin level and 28-day mortality in Chinese hospitalized patients with NYHA IV heart failure.

METHODS

A total of 2008 Chinese patients were included. The correlation between serum albumin level and mortality was tested using a cox proportional hazards regression model. The smooth curve fitting was used to identify non-linear relationships between serum albumin and mortality. The Forest plot analysis was used to assess the association between albumin and 28-day mortality in different groups.

RESULTS

Compared with patients with NYHA II-III, patients with NYHA IV had lower albumin level and higher mortality within 28 days. The albumin on admission was independently and inversely associated with the endpoint risk, which remained significant (hazard ratio: 0.80; 95 % confidence interval: 0.66 to 0.96; p = 0.0196) after multivariable adjustment. The smooth curve fitting showed with the increase of albumin, the mortality within 28 days would decrease. A subgroup analysis found that the inverse association between the albumin level and risk of the mortality was consistent across the subgroup stratified by possible influence factors.

CONCLUSION

Serum albumin level is negatively associated with 28-day mortality in hospitalized heart failure patients within NYHA IV in China, which can be used as an independent predictor.

The Science of Precision Prevention: Research Opportunities and Clinical Applications to Reduce Cardiovascular Health Disparities

Precision prevention embraces personalized prevention but includes broader factors such as social determinants of health to improve cardiovascular health. The quality, quantity, precision, and diversity of data relatable to individuals and communities continue to expand. New analytical methods can be applied to these data to create tools to attribute risk, which may allow a better understanding of cardiovascular health disparities. Interventions using these analytic tools should be evaluated to establish feasibility and efficacy for addressing cardiovascular disease disparities in diverse individuals and communities. Training in these approaches is important to create the next generation of scientists and practitioners in precision prevention. This state-of-the-art review is based on a workshop convened to identify current gaps in knowledge and methods used in precision prevention intervention research, discuss opportunities to expand trials of implementation science to close the health equity gaps, and expand the education and training of a diverse precision prevention workforce.

Exploring Heart Failure Mortality Trends and Disparities in Women: A Retrospective Cohort Analysis

Heart failure (HF) remains a significant cause of morbidity and mortality in women. Population-level analyses shed light on existing disparities and promote targeted interventions. We evaluated HF-related mortality data in women in the United States to identify disparities based on race/ethnicity, urbanization level, and geographic region. We conducted a retrospective cohort analysis utilizing the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research database to identify HF-related mortality in the death files from 1999 to 2020. Age-adjusted HF mortality rates were standardized to the 2000 US population. We fit log-linear regression models to analyze mortality trends. Age-adjusted HF mortality rates in women have decreased significantly over time, from 97.95 in 1999 to 89.19 in 2020. Mortality mainly downtrended from 1999 to 2012, followed by a significant increase from 2012 to 2020. Our findings revealed disparities in mortality rates based on race and ethnicity, with the most affected population being non-Hispanic Black (age-adjusted mortality rates [AAMR] 90.36), followed by non-Hispanic White (AAMR 83.25), American Indian/Alaska Native (AAMR 64.27), and Asian/Pacific Islander populations (AAMR 37.46). We also observed that nonmetropolitan (AAMR 103.36) and Midwestern (AAMR 90.45) regions had higher age-adjusted mortality rates compared with metropolitan (AAMR 78.43) regions and other US census regions. In conclusion, significant differences in HF mortality rates were observed based on race/ethnicity, urbanization level, and geographic region. Disparities in HF outcomes persist and efforts to reduce HF-related mortality rates should focus on targeted interventions that address social determinants of health, including access to care and socioeconomic status.

Achieving Health Equity in the Care of Patients with Heart Failure

PURPOSE OF REVIEW

To discuss the prevailing racial and ethnic disparities in heart failure (HF) care by identifying barriers to equitable care and proposing solutions for achieving equitable outcomes.

RECENT FINDINGS

Throughout the entire spectrum of HF care, from prevention to implementation of guideline-directed medical therapy and advanced interventions, racial and ethnic disparities exist. Factors such as differential distribution of risk factors, poor access to care, inadequate representation in clinical trials, and discrimination from healthcare clinicians, among others, contribute to these disparities. Recent data suggests that despite improvements, disparities prevail in several aspects of HF care, hindering our progress towards equity in HF care. This review highlights the urgent need to address racial and ethnic disparities in HF care, emphasizing the importance of a multifaceted approach involving policy changes, quality improvement strategies, targeted interventions, and intentional community engagement. Our proposed framework was derived from existing research and emphasizes integrating equity into routine quality improvement efforts, tailoring interventions to specific populations, and advocating for policy transformation. By acknowledging these disparities, implementing evidence-based strategies, and fostering collaborative efforts, the HF community can strive to reduce disparities and achieve equity in HF care.

What was the impact of tobacco taxes on smoking prevalence and coronary heart disease mortality in the United States -2005-2016, and did it vary by race and gender?

Tobacco taxes have reduced smoking and coronary heart disease (CHD) mortality, yet few studies have examined heterogeneity of these associations by race and gender. We constructed a yearly panel (2005-2016) that included age-adjusted cigarette smoking prevalence and CHD mortality rates across all 50 U.S. States and the District of Columbia using the Behavioral Risk Factor Surveillance System and Wide-ranging Online Data for Epidemiological Research. We examined associations between changes in total cigarette excise taxes (i.e., federal and state) and changes in smoking prevalence and CHD mortality, using linear regression models with state and year fixed effects. Each dollar of tobacco tax was associated with a reduction in age-adjusted smoking prevalence 1 year later of -0.4 [95% CIs: -0.6, -0.2] percentage points; and a relative reduction in the rate of CHD mortality 2 years later of -2.0% [95% CIs: -3.7%, -0.3%], or -5 deaths/100,000 in absolute terms. Associations between tobacco taxes and smoking prevalence were statistically significantly different by race and gender and were strongest among Black non-Hispanic women (-1.2 [95% CIs: -1.6, -0.8] percentage points). Associations between tobacco taxes and CHD mortality were not statistically significantly different by race and gender, but point estimates for percent changes were highest among Black non-Hispanic men (-2.9%) and Black non-Hispanic women (-3.5%) compared to White non-Hispanic men (-1.8%) and White non-Hispanic women (-1.5%). These findings suggest that tobacco taxation is an effective intervention for reducing smoking prevalence and CHD mortality among White and Black non-Hispanic populations in the United States.

Impact of Social Vulnerability and Demographics on Ischemic Heart Disease Mortality in the United States

Background

Cardiovascular disease is a leading cause of morbidity and mortality, largely dominated by ischemic heart diseases (IHDs). Social determinants of health, including geographic, psychosocial, and socioeconomic factors, influence the development of IHD.

Objectives

This study aimed to evaluate yearly trends and disparities in IHD mortality and to assess the impact of social vulnerability.

Methods

We performed cross-sectional analyses using United States county-level mortality data and social vulnerability index (SVI) obtained from the Centers for Disease Control and Prevention databases. Age-adjusted mortality rates (AAMRs) per 100,000 population were compared between aggregated U.S. county groups, stratified by demographic information and SVI quartiles. Log-linear regression models were used to identify mortality trends from 1999 to 2020, with inflection points determined through the Monte-Carlo permutation test.

Results

We identified a total of 9,108,644 deaths related to IHD between 1999 and 2020. Overall AAMR decreased from 194.6 in 1999 to 91.8 in 2020. Males (AAMR: 161.51) and Black (AAMR: 141.49) populations exhibited higher AAMR compared to females (AAMR: 93.16) and White (AAMR: 123.34) populations, respectively. Disproportionate AAMRs were observed among nonmetropolitan (AAMR: 136.17) and Northeastern (AAMR: 132.96) regions. Counties with a higher SVI experienced a greater AAMR, with a cumulative excess of 20.91 deaths per 100,000 person-years associated with increased social vulnerability.

Conclusions

Despite a decline in IHD mortality from 1999 to 2020, disparities persisted among racial, gender, and geographic subgroups. A higher SVI was linked to increased IHD mortality. Policy interventions should prioritize integrating the SVI into health care delivery systems to effectively address these disparities.

Adverse Childhood Experiences, Social Isolation, Job Strain, and Cardiovascular Disease Mortality in U.S. Older Employees

Stress is a key driver of cardiovascular disease (CVD), yet the contribution of psychosocial stressors to the development of CVD has not been systematically examined in United States (U.S.) populations. The objective of this study was to assess prospective associations of adverse childhood experiences (ACEs), social isolation, and job strain with CVD mortality. Data were from the large, nationally representative, population-based Health and Retirement Study (HRS). ACEs, social isolation and job strain were assessed using validated survey instruments at baseline between 2006-2008, and death information was followed up through 2018. Cox proportional hazards regression models were used to examine prospective associations of ACEs, social isolation, and job strain with CVD mortality among 4046 older employees free from CVD at baseline. During 42,149 person-years of follow-up time, 59 death cases of CVD were reported. After adjustment for covariates, ACEs and job strain were significantly associated with increased risk of CVD mortality (aHR and 95% CI = 3.67 [1.59, 8.48] and 2.24 [1.21, 4.11], respectively), whereas social isolation demonstrated an inflated but nonsignificant association (aHR and 95% CI = 1.62 [0.72, 3.66]). These findings highlight the role of psychosocial exposures as novel and clinically relevant risk factors for CVD.

Health of the Food Environment Is Associated With Heart Failure Mortality in the United States

BACKGROUND

Food environment factors contribute to cardiovascular disease, but their effect on population-level heart failure (HF) mortality is unclear.

METHODS

We utilized the National Vital Statistics System and USDA Food Environment Atlas to collect HF mortality rates (MR) and 2 county food environment indices: (1) food insecurity percentage (FI%) and (2) food environment index (FEI), a scaled index (0-10, 10 best) incorporating FI% and access to healthy food. We used linear regression to estimate the association between food environment and HF MR Results: Mean county FI% and FEI were 13% and 7.8 in 2956 included counties. Counties with FI% above the national median had significantly higher HF MR (30.7 versus 26.7 per 100 000; P<0.001) compared with FI% below the national median. Counties with HF MR above the national median had higher FI%, lower FEI, lower density of grocery stores, poorer access to stores among older adults, and lower Supplemental Nutrition Assistance Program participation rate (P<0.001 for all). Lower county FI% (β=-1.3% per 1% decrease) and higher county FEI (β=-3.6% per 1-unit increase in FEI) were significantly associated with lower HF MR after adjustment for county demographic, socioeconomic, and health factors. This association was stronger for HF MR compared with non-HF cardiovascular disease MR and all-cause MR The relationship between food environment and HF MR was stronger in counties with the highest income inequity and poverty rate.

CONCLUSIONS

Healthier food environment is significantly associated with lower HF mortality at the county level. This reinforces the role of food security on cardiovascular outcomes.

Implementing the National Heart, Lung, and Blood Institute's Strategic Vision in the Division of Cardiovascular Sciences-2022 Update

Spurred by the 2016 release of the National Heart, Lung, and Blood Institute's Strategic Vision, the Division of Cardiovascular Sciences developed its Strategic Vision Implementation Plan-a blueprint for reigniting the decline in cardiovascular disease (CVD) mortality rates, improving health equity, and accelerating translation of scientific discoveries into better cardiovascular health (CVH). The 6 scientific focus areas of the Strategic Vision Implementation Plan reflect the multifactorial nature of CVD and include (1) addressing social determinants of CVH and health inequities, (2) enhancing resilience, (3) promoting CVH and preventing CVD across the lifespan, (4) eliminating hypertension-related CVD, (5) reducing the burden of heart failure, and (6) preventing vascular dementia. This article presents an update of strategic vision implementation activities within Division of Cardiovascular Sciences. Overarching and cross-cutting themes include training the scientific workforce and engaging the extramural scientific community to stimulate transformative research in cardiovascular sciences. In partnership with other NIH Institutes, Federal agencies, industry, and the extramural research community, Division of Cardiovascular Sciences strategic vision implementation has stimulated development of numerous workshops and research funding opportunities. Strategic Vision Implementation Plan activities highlight innovative intervention modalities, interdisciplinary systems approaches to CVD reduction, a life course framework for CVH promotion and CVD prevention, and multi-pronged research strategies for combatting COVID-19. As new knowledge, technologies, and areas of scientific research emerge, Division of Cardiovascular Sciences will continue its thoughtful approach to strategic vision implementation, remaining poised to seize emerging opportunities and catalyze breakthroughs in cardiovascular sciences.

Reviewing the Modern Therapeutical Options and the Outcomes of Sacubitril/Valsartan in Heart Failure

Sacubitril/valsartan (S/V) is a pharmaceutical strategy that increases natriuretic peptide levels by inhibiting neprilysin and regulating the renin-angiotensin-aldosterone pathway, blocking AT1 receptors. The data for this innovative medication are mainly based on the PARADIGM-HF study, which included heart failure with reduced ejection fraction (HFrEF)-diagnosed patients and indicated a major improvement in morbidity and mortality when S/V is administrated compared to enalapril. A large part of the observed favorable results is related to significant reverse cardiac remodeling confirmed in two prospective trials, PROVE-HF and EVALUATE-HF. Furthermore, according to a subgroup analysis from the PARAGON-HF research, S/V shows benefits in HFrEF and in many subjects having preserved ejection fraction (HFpEF), which indicated a decrease in HF hospitalizations among those with a left ventricular ejection fraction (LVEF) < 57%. This review examines the proven benefits of S/V and highlights continuing research in treating individuals with varied HF characteristics. The article analyses published data regarding both the safeness and efficacy of S/V in patients with HF, including decreases in mortality and hospitalization, increased quality of life, and reversible heart remodeling. These benefits led to the HF guidelines recommendations updating and inclusion of S/V combinations a key component of HFrEF treatment.

Long-term survival and life expectancy following an acute heart failure hospitalization in Australia and New Zealand

AIMS

Contemporary long-term survival following a heart failure (HF) hospitalization is uncertain. We evaluated survival up to 10 years after a HF hospitalization using national data from Australia and New Zealand, identified predictors of survival, and estimated the attributable loss in life expectancy.

METHODS AND RESULTS

Patients hospitalized with a primary diagnosis of HF from 2008-2017 were identified and all-cause mortality assessed by linking with Death Registries. Flexible parametric survival models were used to estimate survival, predictors of survival and loss in life expectancy. A total of 283 048 patients with HF were included (mean age 78.2 ± 12.3 years, 50.8% male). Of these, 48.3% (48.1-48.5) were surviving by 3 years, 34.1% (33.9-34.3) by 5 years and 17.1% (16.8-17.4) by 10 years (median survival 2.8 years). Survival declined with age with 53.4% of patients aged 18-54 years and 6.2% aged ≥85 years alive by 10 years (adjusted hazard ratio [aHR] for mortality 4.84, 95% confidence interval [CI] 4.65-5.04 for ≥85 years vs. 18-54 years) and was worse in male patients (aHR 1.14, 95% CI 1.13-1.15). Prior HF (aHR 1.20, 95% CI 1.18-1.22), valvular and rheumatic heart disease (aHR 1.11, 95% CI 1.10-1.13) and vascular disease (aHR 1.07, 95% CI 1.04-1.09) were cardiovascular comorbidities most strongly associated with long-term death. Non-cardiovascular comorbidities and geriatric syndromes were common and associated with higher mortality. Compared with the general population, HF was associated with a loss of 7.3 years in life expectancy (or 56.6% of the expected life expectancy) and reached 20.5 years for those aged 18-54 years.

CONCLUSION

Less than one in five patients hospitalized for HF were surviving by 10 years with patients experiencing almost 60% loss in life expectancy compared with the general population, highlighting the considerable persisting societal burden of HF. Concerted multidisciplinary efforts are needed to improve post-hospitalization outcomes of HF.

Lymphocyte activation gene-3-associated protein networks are associated with HDL-cholesterol and mortality in the Trans-omics for Precision Medicine program

Deficiency of the immune checkpoint lymphocyte activation gene-3 (LAG3) protein is significantly associated with both elevated HDL-cholesterol (HDL-C) and myocardial infarction risk. We determined the association of genetic variants within ±500 kb of LAG3 with plasma LAG3 and defined LAG3-associated plasma proteins with HDL-C and clinical outcomes. Whole genome sequencing and plasma proteomics were obtained from the Multi-Ethnic Study of Atherosclerosis (MESA) and the Framingham Heart Study (FHS) cohorts as part of the Trans-Omics for Precision Medicine program. In situ Hi-C chromatin capture was performed in EBV-transformed cell lines isolated from four MESA participants. Genetic association analyses were performed in MESA using multivariate regression models, with validation in FHS. A LAG3-associated protein network was tested for association with HDL-C, coronary heart disease, and all-cause mortality. We identify an association between the LAG3 rs3782735 variant and plasma LAG3 protein. Proteomics analysis reveals 183 proteins significantly associated with LAG3 with four proteins associated with HDL-C. Four proteins discovered for association with all-cause mortality in FHS shows nominal associations in MESA. Chromatin capture analysis reveals significant cis interactions between LAG3 and C1S, LRIG3, TNFRSF1A, and trans interactions between LAG3 and B2M. A LAG3-associated protein network has significant associations with HDL-C and mortality.

Rodriguez et al. use whole genome sequencing and plasma proteomics from the Multi-Ethnic Study of Atherosclerosis (MESA) and the Framingham Heart Study (FHS) cohorts of the Trans-Omics for Precision Medicine program and perform in situ Hi-C chromatin capture in cell lines isolated from four MESA participants. They demonstrate that lymphocyte activation gene-3 protein networks are associated with HDL-cholesterol and mortality, which could guide the development of precision medicine.

County-Level Trends in Hypertension-Related Cardiovascular Disease Mortality-United States, 2000 to 2019

Background

Amid stagnating declines in national cardiovascular disease (CVD) mortality, documenting trends in county‐level hypertension‐related CVD death rates can help activate local efforts prioritizing hypertension prevention, detection, and control.

Methods and Results

Using death certificate data from the National Vital Statistics System, Bayesian spatiotemporal models were used to estimate county‐level hypertension‐related CVD death rates and corresponding trends during 2000 to 2010 and 2010 to 2019 for adults aged ≥35 years overall and by age group, race or ethnicity, and sex. Among adults aged 35 to 64 years, county‐level hypertension‐related CVD death rates increased from a median of 23.2 per 100 000 in 2000 to 43.4 per 100 000 in 2019. Among adults aged ≥65 years, county‐level hypertension‐related CVD death rates increased from a median of 362.1 per 100 000 in 2000 to 430.1 per 100 000 in 2019. Increases were larger and more prevalent among adults aged 35 to 64 years than those aged ≥65 years. More than 75% of counties experienced increasing hypertension‐related CVD death rates among patients aged 35 to 64 years during 2000 to 2010 and 2010 to 2019 (76.2% [95% credible interval, 74.7–78.4] and 86.2% [95% credible interval, 84.6–87.6], respectively), compared with 48.2% (95% credible interval, 47.0–49.7) during 2000 to 2010 and 66.1% (95% credible interval, 64.9–67.1) for patients aged ≥65 years. The highest rates for both age groups were among men and Black populations. All racial and ethnic categories in both age groups experienced widespread county‐level increases.

Conclusions

Large, widespread county‐level increases in hypertension‐related CVD mortality sound an alarm for intensified clinical and public health actions to improve hypertension prevention, detection, and control and prevent subsequent CVD deaths in counties across the nation.

Development and Validation of a Long-Term Incident Heart Failure Risk Model

BACKGROUND

Average lifetime risk for heart failure (HF) is high but differs significantly across and within sex-race groups. No models for estimating long-term risk for HF exist, which would allow for earlier identification and interventions in high-risk subsets. The authors aim to derive 30-year HF risk equations.

METHODS

Adults between the ages of 20 to 59 years and free of cardiovascular disease at baseline from 5 population-based cohorts were included. Among 24 838 participants (55% women, 25% Black based on self-report), follow-up consisted of 599 551 person-years. Sex- and race-specific 30-year HF risk equations were derived and validated accounting for competing risk of non-HF death. HF was based on a clinical diagnosis. Model discrimination and calibration were assessed using 10-fold cross-validation. Finally, the model was applied to varying risk factor patterns for systematic examination.

RESULTS

The rate of incident HF was 4.0 per 1000 person-years. Harrell C statistics were 0.82 (0.80-0.83) and 0.84 (0.82-0.85) in White and Black men and 0.84 (0.82-0.85) and 0.85 (0.83-0.87) in White and Black women, respectively. Hosmer-Lemeshow calibration was acceptable, with χ2 <30 in all subgroups. Risk estimation varied across sex-race groups: for example, in an average 40-year-old nonsmoker with an untreated systolic blood pressure of 140 mm Hg and body mass index of 30 kg/m2, risk was estimated to be 22.8% in a Black man, 13.7% in a White man, 13.0% in a Black woman, and 12.1% in a White woman.

CONCLUSIONS

Sex- and race-specific equations for prediction of long-term risk of HF demonstrated high discrimination and adequate calibration.

Is the pace of decline in cardiovascular mortality decelerating in Spain?

INTRODUCTION AND OBJECTIVES

To update the information on mortality from cardiovascular diseases and assess recent trends in Spain.

METHODS

Deaths from cardiovascular diseases (codes I20-I25, I50, I05-I09, I00-I02, I26-I49, I51, I52, I60-I69, I10-I15, and I70-I79 of the 10th revision of the International Classification of Diseases and Causes of Death) were obtained from the National Statistics Institute. Trends were analyzed using Joinpoint regression models. The results revealed the years (periods) composing each trend, as well as the annual percent change for each of them. The direction and magnitude of recent trends (last available 5-year period) were assessed by using the average annual percent change.

RESULTS

The decline in mortality rates from cardiovascular diseases slowed from -3.7% and -4.0% in 1999-2013 to -1.7% and -2.2% since 2013 in men and women, respectively. During the study period (1999-2018) all the analyzed causes decreased significantly. Nevertheless, recent trends differed according to age, sex, and the cause analyzed. Truncated rates (35-64 years) slowed (cardiovascular disease and stroke in men and ischemic heart disease in both sexes), stabilized (cardiovascular disease, stroke, and other heart diseases in women, and blood vessel disease in men), or increased (other diseases of the heart in men and diseases of the blood vessels in women).

CONCLUSIONS

In Spain, as in other countries, the reduction in mortality rates from cardiovascular diseases slowed (overall rates for both sexes and truncated in men) or stabilized (truncated rates in women) from 2014 to 2018.

Recent trends in cardiovascular disease deaths: a state specific perspective

BACKGROUND

The rate of decline in cardiovascular disease (CVD) mortality has lessened nationally. How these findings apply to specific states or causes of CVD deaths is not known. Examining these trends at the state level is important to plan local interventions.

METHODS

We analyzed CVD mortality trends in Minnesota (MN) using the U.S. Centers for Disease Control and Prevention (CDC) Wide-ranging ONline Data for Epidemiologic Research (WONDER). Trends were analyzed by age, sex, type of CVD and location of death.

RESULTS

CVD mortality rates in MN declined in 2000-2009 and then leveled off in 2010-2018, paralleling national rates. Age- and sex-adjusted CVD mortality decreased by 3.7% per year in 2000-2009 (average annual percent changes [AAPC]: -3.7; 95% CI: - 4.8, - 2.6) with no change observed in 2010-2018. Those aged 65-84 years had the most rapid early decline in CVD mortality (AAPC: -5.9, 95% CI: - 6.2, - 5.7) and had less improvement in 2010-2018 (AAPC: -1.8, 95% CI: - 2.2, - 1.5), and the younger age group (25-64 years) now experiences the most adverse trends (AAPC: 1.2, 95% CI: 0.7-1.8). Coronary heart disease (CHD) and cerebrovascular disease had the largest relative decreases in mortality in 2000-2009 (CHD AAPC: -5.2; 95% CI: - 6.5,-3.9; cerebrovascular disease AAPC: -4.4, 95% CI: - 5.2, - 3.6) with no change 2010-2018. Heart failure (HF)/cardiomyopathy followed similar trends with a 2.5% decrease (AAPC 95% CI: - 3.5, - 1.5) per year in 2000-2009 and no change in 2010-2018. Deaths from other CVD also decreased in the early time period (AAPC: -1.6, 95% CI: - 2.7, - 0.5) but increased in 2010-2018 (AAPC: 1.9, 95% CI: 0.5, 3.3). In- and out-of-hospital death rates improved in 2000-2009 with a slowing in improvement for in-hospital death and no further improvement for out-of-hospital death in 2010-2018.

CONCLUSION

Concerning CVD mortality trends occurred in MN. In the most recent decade (2010-2018) mortality from all CVD subtypes plateaued or even increased. CVD mortality among the younger age groups increased as well. These data are congruent with adverse national trends supporting their generalizability. These adverse trends underscore the urgent need for CVD prevention and treatment, as well as continued surveillance to assess progress at the state and national level.

Temporal trends in heart failure mortality in an integrated healthcare delivery system, California, and the US, 2001-2017

BACKGROUND

In recent years, decreases in mortality rates attributable to cardiovascular diseases have slowed but mortality attributable to heart failure (HF) has increased.

METHODS

Between 2001-2017, trends in age-adjusted mortality with HF as an underlying cause for Kaiser Permanente Southern California (KPSC) members were derived through linkage with state death files and compared with trends among California residents and the US. Average annual percent change (AAPC) and 95% confidence intervals (CI) were calculated using Joinpoint regression. Analyses were repeated examining HF as a contributing cause of death.

RESULTS

In KPSC, the age-adjusted HF mortality rates were comparable to California but lower than the US, increasing from 23.9 per 100,000 person-years (PY) in 2001 to 44.7 per 100,000 PY in 2017, representing an AAPC of 1.3% (95% CI 0.0%, 2.6%). HF mortality also increased in California from 33.9 to 46.5 per 100,000 PY (AAPC 1.5%, 95% CI 0.3%, 2.7%), while remaining unchanged in the US at 57.9 per 100,000 PY in 2001 and 2017 (AAPC 0.0%, 95% CI - 0.5%, 0.5%). Trends among KPSC members ≥ 65 years old were similar to the overall population, while trends among members 45-64 years old were flat between 2001-2017. Small changes in mortality with HF as a contributing cause were observed in KPSC members between 2001 and 2017, which differed from California and the US.

CONCLUSION

Lower rates of HF mortality were observed in KPSC compared to the US. Given the aging of the US population and increasing prevalence of HF, it will be important to examine individual and care-related factors driving susceptibility to HF mortality.

Epidemiology of Heart Failure: A Contemporary Perspective

Designated as an emerging epidemic in 1997, heart failure (HF) remains a major clinical and public health problem. This review focuses on the most recent studies identified by searching the Medline database for publications with the subject headings HF, epidemiology, prevalence, incidence, trends between 2010 and present. Publications relevant to epidemiology and population sciences were retained for discussion in this review after reviewing abstracts for relevance to these topics. Studies of the epidemiology of HF over the past decade have improved our understanding of the HF syndrome and of its complexity. Data suggest that the incidence of HF is mostly flat or declining but that the burden of mortality and hospitalization remains mostly unabated despite significant ongoing efforts to treat and manage HF. The evolution of the case mix of HF continues to be characterized by an increasing proportion of cases with preserved ejection fraction, for which established effective treatments are mostly lacking. Major disparities in the occurrence, presentation, and outcome of HF persist particularly among younger Black men and women. These disturbing trends reflect the complexity of the HF syndrome, the insufficient mechanistic understanding of its various manifestations and presentations and the challenges of its management as a chronic disease, often integrated within a context of aging and multimorbidity. Emerging risk factors including omics science offer the promise of discovering new mechanistic pathways that lead to HF. Holistic management approaches must recognize HF as a syndemic and foster the implementation of multidisciplinary approaches to address major contributors to the persisting burden of HF including multimorbidity, aging, and social determinants of health.

Cardiac MRI for Patients with Increased Cardiometabolic Risk

Cardiac MRI (CMR) has rich potential for future cardiovascular screening even though not approved clinically for routine screening for cardiovascular disease among patients with increased cardiometabolic risk. Patients with increased cardiometabolic risk include those with abnormal blood pressure, body mass, cholesterol level, or fasting glucose level, which may be related to dietary and exercise habits. However, CMR does accurately evaluate cardiac structure and function. CMR allows for effective tissue characterization with a variety of sequences that provide unique insights as to fibrosis, infiltration, inflammation, edema, presence of fat, strain, and other potential pathologic features that influence future cardiovascular risk. Ongoing epidemiologic and clinical research may demonstrate clinical benefit leading to increased future use. © RSNA, 2021.

Trends in heart failure-related cardiovascular mortality in rural versus urban United States counties, 2011-2018: A cross-sectional study

BACKGROUND

Adults in rural counties in the United States (US) experience higher rates broadly of cardiovascular disease (CVD) compared with adults in urban counties. Mortality rates specifically due to heart failure (HF) have increased since 2011, but estimates of heterogeneity at the county-level in HF-related mortality have not been produced. The objectives of this study were 1) to quantify nationwide trends by rural-urban designation and 2) examine county-level factors associated with rural-urban differences in HF-related mortality rates.

METHODS AND FINDINGS

We queried CDC WONDER to identify HF deaths between 2011-2018 defined as CVD (I00-78) as the underlying cause of death and HF (I50) as a contributing cause of death. First, we calculated national age-adjusted mortality rates (AAMR) and examined trends stratified by rural-urban status (defined using 2013 NCHS Urban-Rural Classification Scheme), age (35-64 and 65-84 years), and race-sex subgroups per year. Second, we combined all deaths from 2011-2018 and estimated incidence rate ratios (IRR) in HF-related mortality for rural versus urban counties using multivariable negative binomial regression models with adjustment for demographic and socioeconomic characteristics, risk factor prevalence, and physician density. Between 2011-2018, 162,314 and 580,305 HF-related deaths occurred in rural and urban counties, respectively. AAMRs were consistently higher for residents in rural compared with urban counties (73.2 [95% CI: 72.2-74.2] vs. 57.2 [56.8-57.6] in 2018, respectively). The highest AAMR was observed in rural Black men (131.1 [123.3-138.9] in 2018) with greatest increases in HF-related mortality in those 35-64 years (+6.1%/year). The rural-urban IRR persisted among both younger (1.10 [1.04-1.16]) and older adults (1.04 [1.02-1.07]) after adjustment for county-level factors. Main limitations included lack of individual-level data and county dropout due to low event rates (<20).

CONCLUSIONS

Differences in county-level factors may account for a significant amount of the observed variation in HF-related mortality between rural and urban counties. Efforts to reduce the rural-urban disparity in HF-related mortality rates will likely require diverse public health and clinical interventions targeting the underlying causes of this disparity.

Bending the Curve in Cardiovascular Disease Mortality: Bethesda + 40 and Beyond

More than 40 years after the 1978 Bethesda Conference on the Declining Mortality from Coronary Heart Disease provided the scientific community with a blueprint for systematic analysis to understand declining rates of coronary heart disease, there are indications the decline has ended or even reversed despite advances in our knowledge about the condition and treatment. Recent data show a more complex situation, with mortality rates for overall cardiovascular disease, including coronary heart disease and stroke, decelerating, whereas those for heart failure are increasing. To mark the 40th anniversary of the Bethesda Conference, the National Heart, Lung, and Blood Institute and the American Heart Association cosponsored the "Bending the Curve in Cardiovascular Disease Mortality: Bethesda + 40" symposium. The objective was to examine the immediate and long-term outcomes of the 1978 conference and understand the current environment. Symposium themes included trends and future projections in cardiovascular disease (in the United States and internationally), the evolving obesity and diabetes epidemics, and harnessing emerging and innovative opportunities to preserve and promote cardiovascular health and prevent cardiovascular disease. In addition, participant-led discussion explored the challenges and barriers in promoting cardiovascular health across the lifespan and established a potential framework for observational research and interventions that would begin in early childhood (or ideally in utero). This report summarizes the relevant research, policy, and practice opportunities discussed at the symposium.

Changing Spatiotemporal Trends in County-Level Heart Failure Death Rates in the United States, 1999 to 2018

Background

Amid recently rising heart failure (HF) death rates in the United States, we describe county‐level trends in HF mortality from 1999 to 2018 by racial/ethnic group and sex for ages 35 to 64 years and 65 years and older.

Methods and Results

Applying a hierarchical Bayesian model to National Vital Statistics data representing all US deaths, ages 35 years and older, we estimated annual age‐standardized county‐level HF death rates and percent change by age group, racial/ethnic group, and sex from 1999 through 2018. During 1999 to 2011, ~30% of counties experienced increasing HF death rates among adults ages 35 to 64 years. However, during 2011 to 2018, 86.9% (95% CI, 85.2–88.2) of counties experienced increasing mortality. Likewise, for ages 65 years and older, during 1999 to 2005 and 2005 to 2011, 27.8% (95% CI, 25.8–29.8) and 12.6% (95% CI, 11.2–13.9) of counties, respectively, experienced increasing mortality. However, during 2011 to 2018, most counties (67.4% [95% CI, 65.4–69.5]) experienced increasing mortality. These temporal patterns by age group held across racial/ethnic group and sex.

Conclusions

These results provide local context to previously documented recent national increases in HF death rates. Although county‐level declines were most common before 2011, some counties and demographic groups experienced increasing HF death rates during this period of national declines. However, recent county‐level increases were pervasive, occurring across counties, racial/ethnic group, and sex, particularly among ages 35 to 64 years. These spatiotemporal patterns highlight the need to identify and address underlying clinical risk factors and social determinants of health contributing to these increasing trends.

Progress Toward Achieving National Targets for Reducing Coronary Heart Disease and Stroke Mortality: A County-Level Perspective

Background

The American Heart Association and Healthy People 2020 established objectives to reduce coronary heart disease (CHD) and stroke death rates by 20% by the year 2020, with 2007 as the baseline year. We examined county‐level achievement of the targeted reduction in CHD and stroke death rates from 2007 to 2017.

Methods and Results

Applying a hierarchical Bayesian model to National Vital Statistics data, we estimated annual age‐standardized county‐level death rates and the corresponding percentage change during 2007 to 2017 for those aged 35 to 64 and ≥65 years and by urban‐rural classification. For those aged ≥35 years, 56.1% (95% credible interval [CI], 54.1%–57.7%) and 39.8% (95% CI, 36.9%–42.7%) of counties achieved a 20% reduction in CHD and stroke death rates, respectively. For both CHD and stroke, the proportions of counties achieving a 20% reduction were lower for those aged 35 to 64 years than for those aged ≥65 years (CHD: 32.2% [95% CI, 29.4%–35.6%] and 64.1% [95% CI, 62.3%–65.7%]), respectively; stroke: 17.9% [95% CI, 13.9%–22.2%] and 45.6% [95% CI, 42.8%–48.3%]). Counties achieving a 20% reduction in death rates were more commonly urban counties (except stroke death rates for those aged ≥65 years).

Conclusions

Our analysis found substantial, but uneven, achievement of the targeted 20% reduction in CHD and stroke death rates, defined by the American Heart Association and Healthy People. The large proportion of counties not achieving the targeted reduction suggests a renewed focus on CHD and stroke prevention and treatment, especially among younger adults living outside of urban centers. These county‐level patterns provide a foundation for robust responses by clinicians, public health professionals, and communities.

Trends in Ischaemic Heart Disease in Australia, 2001-2015: A Comparison of Urban and Rural Populations

OBJECTIVE

Ischaemic heart disease (IHD) is a major source of disease burden worldwide. Recent trends show incidence is declining but it is unclear whether the trends are similar in urban and rural populations. This study examines the trends of IHD events (i.e. hospitalisations and deaths) in New South Wales, Australia by rurality.

METHODS

This was a retrospective analysis of linked administrative data for hospitalisation and death records across NSW between 2001 and 2015. Participants were NSW residents aged 15-105 years who died or were hospitalised with a principal diagnosis of IHD. The main outcome measures were annual age-standardised mortality and hospitalisations for IHD by calendar year and rurality.

RESULTS

Between 2001 and 2015, age-standardised annual IHD hospitalisations declined in urban areas from 587 to 260 and in rural areas from 766 to 395 per 100,000 people. The annual decline in hospitalisations was greater in urban than rural areas, with Annual Percentage Change (APC) of -5.6% (95% CI, -6.1%, -5.0%) and -4.5% (95% CI, -5.0%, -4.0%), respectively (p=0.012). Ischaemic heart disease mortality declined at a similar rate in urban and rural regions (APC -7.6% and -6.7% per annum, p=0.28). Absolute inequalities in IHD deaths persisted until 2015 when there were 49 (urban) and 70 (rural) IHD deaths per 100,000 people.

CONCLUSIONS

Ischaemic heart disease hospitalisations and mortality have declined considerably between 2001 and 2015 in both rural and urban areas, yet inequalities persist, suggesting more intensive preventive efforts are required to further reduce the burden of IHD in rural populations.

Trends in Incidence and Case Fatality Rates of Heart Disease and Its Subtypes in Korea, 2006-2015

Heart disease (HD) is the second leading cause of death in Korea. Several studies in Korea have analyzed the trends of incidence and mortality of myocardial infarction (MI) and ischemic heart disease (IHD), but few have investigated incidence and mortality trends of HD and its subtypes. The aim of this study was to assess the national trends in incidence and case fatality rates of overall HD and its subtypes (including IHD, heart failure (HF), arrhythmia, hypertensive HD (HHD), valvular HD, pulmonary HD, and others) in Korea between 2006 and 2015. Using records from the National Health Insurance Service (NHIS) claims database (2003–2015) and by obtaining the causes of death (Korean Statistical Information Service, 2006–2017), we analyzed the crude and age-standardized incidence rates from 2006 to 2015 and the case fatality rates from 2006 to 2017 of HD and its subtypes. Between 2006 and 2015, the incidence of overall HD changed minimally, but the age-standardized incidence of HD decreased from 210.0 persons per 100,000 populations in 2006 to 161.3 persons in 2015. However, incidence rates have increased in arrhythmia, HD other, pulmonary HD, and the case fatality rates have increased in HF, valvular HD, and HD other. Therefore, it is essential to continuously monitor the incidence and case fatality rates of HD and its subtypes and expand the focus onto prevention and treatment strategies from MI or IHD to various HD subtypes. Active prevention and management are needed to alleviate the burden of HD due to an aging population in Korea.

Systematic examination of a heart failure risk prediction tool: The pooled cohort equations to prevent heart failure

Identification of individuals at risk for heart failure is needed to deliver targeted preventive strategies and maximize net benefit of interventions. To examine the clinical utility of the recently published heart failure-specific risk prediction model, the Pooled Cohort Equations to Prevent Heart Failure, we sought to demonstrate the range of risk values associated with diverse risk factor combinations in White and Black men and women. We varied individual risk factors while holding the other risk factors constant at age-adjusted national mean values for risk factors in each race-sex and age group. We also examined multiple combinations of risk factor levels and examined the range of predicted 10-year heart failure risk using the Pooled Cohort Equations to Prevent Heart Failure risk tool. Ten-year predicted heart failure risk varied widely for each race-sex group across a range of ages and risk factor scenarios. For example, predicted 10-year heart failure risk in a hypothetical 40 year old varied from 0.1% to 9.7% in a White man, 0.5% to 12.3% in a Black man, <0.1% to 9.3% in a White woman, and 0.2% to 28.0% in a Black woman. Higher risk factor burden (e.g. diabetes and hypertension requiring treatment) consistently drove higher risk estimates in all race-sex groups and across all ages. Our analysis highlights the importance of a race and sex-specific multivariable risk prediction model for heart failure to personalize the clinician-patient discussion, inform future practice guidelines, and provide a framework for future risk-based prevention trials for heart failure.

Cardiometabolic-Based Chronic Disease, Adiposity and Dysglycemia Drivers: JACC State-of-the-Art Review

A new cardiometabolic-based chronic disease (CMBCD) model is presented that provides a basis for early and sustainable, evidence-based therapeutic targeting to promote cardiometabolic health and mitigate the development and ravages of cardiovascular disease. In the first part of this JACC State-of-the-Art Review, a framework is presented for CMBCD, focusing on 3 primary drivers (genetics, environment, and behavior) and 2 metabolic drivers (adiposity and dysglycemia) with applications to 3 cardiovascular endpoints (coronary heart disease, heart failure, and atrial fibrillation). Specific mechanistic pathways are presented configuring early primary drivers with subsequent adiposity, insulin resistance, β-cell dysfunction, and metabolic syndrome, leading to cardiovascular disease. The context for building this CMBCD model is to expose actionable targets for prevention to achieve optimal cardiovascular outcomes. The tactical implementation of this CMBCD model is the subject of second part of this JACC State-of-the-Art Review.

Cardiometabolic-Based Chronic Disease, Adiposity and Dysglycemia Drivers: JACC State-of-the-Art Review

A new cardiometabolic-based chronic disease (CMBCD) model is presented that provides a basis for early and sustainable, evidence-based therapeutic targeting to promote cardiometabolic health and mitigate the development and ravages of cardiovascular disease. In the first part of this JACC State-of-the-Art Review, a framework is presented for CMBCD, focusing on 3 primary drivers (genetics, environment, and behavior) and 2 metabolic drivers (adiposity and dysglycemia) with applications to 3 cardiovascular endpoints (coronary heart disease, heart failure, and atrial fibrillation). Specific mechanistic pathways are presented configuring early primary drivers with subsequent adiposity, insulin resistance, β-cell dysfunction, and metabolic syndrome, leading to cardiovascular disease. The context for building this CMBCD model is to expose actionable targets for prevention to achieve optimal cardiovascular outcomes. The tactical implementation of this CMBCD model is the subject of second part of this JACC State-of-the-Art Review.

Heterogeneous trends in burden of heart disease mortality by subtypes in the United States, 1999-2018: observational analysis of vital statistics

OBJECTIVE

To describe trends in the burden of mortality due to subtypes of heart disease from 1999 to 2018 to inform targeted prevention strategies and reduce disparities.

DESIGN

Serial cross sectional analysis of cause specific heart disease mortality rates using national death certificate data in the overall population as well as stratified by race-sex, age, and geography.

SETTING

United States, 1999-2018.

PARTICIPANTS

12.9 million decedents from total heart disease (49% women, 12% black, and 19% <65 years old).

MAIN OUTCOME MEASURES

Age adjusted mortality rates (AAMR) and years of potential life lost (YPLL) for each heart disease subtype, and respective mean annual percentage change.

RESULTS

Deaths from total heart disease fell from 752 192 to 596 577 between 1999 and 2011, and then increased to 655 381 in 2018. From 1999 to 2018, the proportion of total deaths from heart disease attributed to ischemic heart disease decreased from 73% to 56%, while the proportion attributed to heart failure increased from 8% to 13% and the proportion attributed to hypertensive heart disease increased from 4% to 9%. Among heart disease subtypes, AAMR was consistently highest for ischemic heart disease in all subgroups (race-sex, age, and region). After 2011, AAMR for heart failure and hypertensive heart disease increased at a faster rate than for other subtypes. The fastest increases in heart failure mortality were in black men (mean annual percentage change 4.9%, 95% confidence interval 4.0% to 5.8%), whereas the fastest increases in hypertensive heart disease occurred in white men (6.3%, 4.9% to 9.4%). The burden of years of potential life lost was greatest from ischemic heart disease, but black-white disparities were driven by heart failure and hypertensive heart disease. Deaths from heart disease in 2018 resulted in approximately 3.8 million potential years of life lost.

CONCLUSIONS

Trends in AAMR and years of potential life lost for ischemic heart disease have decelerated since 2011. For almost all other subtypes of heart disease, AAMR and years of potential life lost became stagnant or increased. Heart failure and hypertensive heart disease account for the greatest increases in premature deaths and the largest black-white disparities and have offset declines in ischemic heart disease. Early and targeted primary and secondary prevention and control of risk factors for heart disease, with a focus on groups at high risk, are needed to avoid these suboptimal trends beginning earlier in life.

Divergent Temporal Trends in Morbidity and Mortality Related to Heart Failure and Atrial Fibrillation: Age, Sex, Race, and Geographic Differences in the United States, 1991-2015

Background Heart failure ( HF ) and atrial fibrillation ( AF ) are rising in prevalence and pose a substantial public health burden. Methods and Results We evaluated temporal trends specific to age, sex, race, and geographic region in rates of HF - and AF -related morbidity, mortality, and years of potential life lost at age 75 years between 1991 and 2015 in the United States. For trends in hospitalization with a primary diagnosis of HF versus AF , we used data for patients aged ≥30 years from 1993 to 2014 from the Nationwide Inpatient Sample. For trends in death due to HF versus AF , we used data from 1991 to 2015 from the National Center for Health Statistics. Over the past 25 years, the age-adjusted rates of hospitalization declined for HF (-1.72% per year) but increased for AF (+1.61% per year). HF mortality rates remained unchanged, whereas those for AF increased (+11.2% per year). Years of potential life lost increased for both HF (+0.4% per year) and AF (+9.8% per year). Trends in HF and AF morbidity rates varied moderately by age group, whereas mortality rates varied by age and race. HF and AF hospitalization and mortality rates rose for individuals aged <50 years. HF hospitalization rates declined in all 4 US census regions, whereas AF rates increased. Conclusions We observed divergent trends of decreasing hospitalization and mortality rates for HF versus increasing rates for AF . Variations in disease burden by race and geography warrant specific targeting of "at risk" groups in selected US regions. Additional studies are warranted to evaluate the rising burden of both conditions in younger adults.

Association Between Aging of the US Population and Heart Disease Mortality From 2011 to 2017

Importance

A deceleration in the rate of decrease of heart disease (HD) mortality between 2011 and 2014 has been reported. In the context of the rapid increase in the population of adults aged 65 years and older, extending the examination of HD mortality through 2017 has potentially important implications for public health and medical care.

Objective

To examine changes in the age-adjusted mortality rate and the number of deaths within subcategories of HD from 2011 to 2017 in conjunction with the change in the size of the US population during the same period.

Design, Setting, and Participants

In this quality improvement study, the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) data set was used to identify national changes in the US population aged 65 years and older and in the age-adjusted mortality rates and number of deaths that were listed with an underlying cause of HD, coronary heart disease (CHD), heart failure, and other HDs from January 1, 2011, to December 31, 2017.

Main Outcomes and Measures

Changes from 2011 to 2017 in the US population and in age-adjusted mortality rates and number of deaths that were listed with an underlying cause of HD, CHD, heart failure (both as an underlying and a contributing cause), and other HDs overall, by sex and race/ethnicity.

Results

The total size of this population of US adults aged 65 years and older increased 22.9% from 41.4 million to 50.9 million between January 1, 2011, and December 31, 2017, while the population of adults younger than 65 years increased by only 1.7%. During this period, the age-adjusted mortality rate decreased 5.0% for HD and 14.9% for CHD while increasing 20.7% for heart failure and 8.4% for other HDs. The number of deaths increased 8.5% for HD, 38.0% for heart failure, and 23.4% for other HDs while decreasing 2.5% for CHD. A total of 80% of HD deaths occurred in the group of adults aged 65 years and older.

Conclusions and Relevance

The substantial increase in the growth rate of the group of adults aged 65 years and older who have the highest risk of HD was associated with an increase in the number of HD deaths in this group despite a slowly declining HD mortality rate in the general population. With the number of adults aged 65 years and older projected to increase an additional 44% from 2017 to 2030, innovative and effective approaches to prevent and treat HD, particularly the substantially increasing rates of heart failure, are needed.

Historic and recent trends in county-level coronary heart disease death rates by race, gender, and age group, United States, 1979-2017

Given recent slowing of declines in national all-cause, heart disease, and stroke mortality, examining spatiotemporal distributions of coronary heart disease (CHD) death rates and trends can provide data critical to improving the cardiovascular health of populations. This paper documents county-level CHD death rates and trends by age group, race, and gender from 1979 through 2017. Using data from the National Vital Statistics System and a Bayesian multivariate space-time conditional autoregressive model, we estimated county-level age-standardized annual CHD death rates for 1979 through 2017 by age group (35–64 years, 65 years and older), race (white, black, other), and gender (men, women). We then estimated county-level total percent change in CHD death rates during four intervals (1979–1990, 1990–2000, 2000–2010, 2010–2017) using log-linear regression models. For all intervals, national CHD death rates declined for all groups. Prior to 2010, although most counties across age, race, and gender experienced declines, pockets of increasing CHD death rates were observed in the Mississippi Delta, Oklahoma, East Texas, and New Mexico across age groups and gender, and were more prominent among non-white populations than whites. Since 2010, across age, race, and gender, county-level declines in CHD death rates have slowed, with a marked increase in the percent of counties with increasing CHD death rates (e.g. 4.4% and 19.9% for ages 35 and older during 1979–1990 and 2010–2017, respectively). Recent increases were especially prevalent and geographically widespread among ages 35–64 years, with 40.5% of counties (95% CI: 38.4, 43.1) experiencing increases. Spatiotemporal differences in these long term, county-level results can inform responses by the public health community, medical providers, researchers, and communities to address troubling recent trends.

Coronary Disease Surveillance in the Community: Angiography and Revascularization

Background Temporal declines in cardiac stress tests results, coronary revascularization, and cardiovascular mortality have suggested a decline in the population burden of coronary disease until the 2000s. However, recent data indicate these favorable trends could be ending. We aimed to assess the evolution of the population burden of coronary disease in the community by examining trends in angiography and revascularization. Methods and Results We analyzed age- and sex-adjusted trends from all coronary angiographic diagnostic procedures and revascularizations performed in Olmsted County, MN from 2000 to 2018. A total of 12 981 invasive angiograms were performed among 9049 individuals (64% men; 55% aged ≥65 years). Adjusted angiography rates decreased by 30% (95% CI, 25%-34%) between 2000 and 2009 and leveled off thereafter. Including computed tomography, angiography uncovered an increase in angiography use in recent years (risk ratio=1.15 [95% CI, 1.07-1.23] for 2018 versus 2014) and a decline in the prevalence of anatomic CAD from 2000 to 2018. CAD severity declined substantially from 2000 to 2009, followed by a plateau. Among 6570 revascularizations (72% men; 57% aged ≥65 years), 77% were percutaneous coronary interventions and 23% coronary artery bypass graft surgeries. The adjusted revascularization rates declined by 34% (95% CI, 27%-39%) from 2000 to 2009, followed by a plateau (risk ratio=1.10 [95% CI, 1.00-1.22]). Conclusions Between 2000 and 2018 in the community, coronary angiography use declined initially, leveled off, and then increased. Trends in CAD severity and revascularization use decreased then plateaued. The most recent trends are concerning as they suggest the burden of coronary disease is no longer declining. This warrants reinvigorated primary prevention and population surveillance.

Cardiometabolic-Based Chronic Disease, Adiposity and Dysglycemia Drivers: JACC State-of-the-Art Review

A new cardiometabolic-based chronic disease (CMBCD) model is presented that provides a basis for early and sustainable, evidence-based therapeutic targeting to promote cardiometabolic health and mitigate the development and ravages of cardiovascular disease. In the first part of this JACC State-of-the-Art Review, a framework is presented for CMBCD, focusing on 3 primary drivers (genetics, environment, and behavior) and 2 metabolic drivers (adiposity and dysglycemia) with applications to 3 cardiovascular endpoints (coronary heart disease, heart failure, and atrial fibrillation). Specific mechanistic pathways are presented configuring early primary drivers with subsequent adiposity, insulin resistance, β-cell dysfunction, and metabolic syndrome, leading to cardiovascular disease. The context for building this CMBCD model is to expose actionable targets for prevention to achieve optimal cardiovascular outcomes. The tactical implementation of this CMBCD model is the subject of second part of this JACC State-of-the-Art Review.

Cardiometabolic-Based Chronic Disease, Adiposity and Dysglycemia Drivers: JACC State-of-the-Art Review

A new cardiometabolic-based chronic disease (CMBCD) model is presented that provides a basis for early and sustainable, evidence-based therapeutic targeting to promote cardiometabolic health and mitigate the development and ravages of cardiovascular disease. In the first part of this JACC State-of-the-Art Review, a framework is presented for CMBCD, focusing on 3 primary drivers (genetics, environment, and behavior) and 2 metabolic drivers (adiposity and dysglycemia) with applications to 3 cardiovascular endpoints (coronary heart disease, heart failure, and atrial fibrillation). Specific mechanistic pathways are presented configuring early primary drivers with subsequent adiposity, insulin resistance, β-cell dysfunction, and metabolic syndrome, leading to cardiovascular disease. The context for building this CMBCD model is to expose actionable targets for prevention to achieve optimal cardiovascular outcomes. The tactical implementation of this CMBCD model is the subject of second part of this JACC State-of-the-Art Review.

Epidemiology of heart failure and trends in diagnostic work-up: a retrospective, population-based cohort study in Sweden

Purpose

The purpose of this study was to examine the trends in heart failure (HF) epidemiology and diagnostic work-up in Sweden.

Methods

Adults with incident HF (≥2 ICD-10 diagnostic codes) were identified from linked national health registers (cohort 1, 2005-2013) and electronic medical records (cohort 2, 2010-2015; primary/secondary care patients from Uppsala and Västerbotten). Trends in annual HF incidence rate and prevalence, risk of all-cause and cardiovascular disease (CVD)-related 1-year mortality and use of diagnostic tests 6 months before and after first HF diagnosis (cohort 2) were assessed.

Results

Baseline demographic and clinical characteristics were similar for cohort 1 (N=174,537) and 2 (N=8,702), with mean ages of 77.4 and 76.6 years, respectively; almost 30% of patients were aged ≥85 years. From 2010 to 2014, age-adjusted annual incidence rate of HF/1,000 inhabitants decreased (from 3.20 to 2.91, cohort 1; from 4.34 to 3.33, cohort 2), while age-adjusted prevalence increased (from 1.61% to 1.72% and from 2.15% to 2.18%, respectively). Age-adjusted 1-year all-cause and CVD-related mortality was higher in men than in women among patients in cohort 1 (all-cause mortality hazard ratio [HR] men vs women 1.07 [95% CI 1.06-1.09] and CVD-related mortality subdistribution HR for men vs women 1.04 [95% CI 1.02-1.07], respectively). While 83.5% of patients underwent N-terminal pro-B-type natriuretic peptide testing, only 36.4% of patients had an echocardiogram at the time of diagnosis, although this increased overtime. In the national prevalent HF population (patients with a diagnosis in 1997-2004 who survived into the analysis period; N=273,999), death from ischemic heart disease and myocardial infarction declined between 2005 and 2013, while death from HF and atrial fibrillation/flutter increased (P<0.0001 for trends over time).

Conclusion

The annual incidence rate of HF declined over time, while prevalence of HF has increased, suggesting that patients with HF were surviving longer over time. Our study confirms that previously reported epidemiological trends persist and remain to ensure proper diagnostic evaluation and management of patients with HF.

Implementing the National Heart, Lung, and Blood Institute's Strategic Vision in the Division of Cardiovascular Sciences

As we commemorate the 70th Anniversary of the National Heart, Lung, and Blood Institute (NHLBI) and celebrate important milestones that have been achieved by the Division of Cardiovascular Sciences (DCVS), it is imperative that DCVS and the Extramural Research community at-large continue to address critical public health challenges that persist within the area of Cardiovascular Diseases (CVD). The NHLBI's Strategic Vision, developed with extensive input from the extramural research community and published in 2016, included overarching goals and strategic objectives that serve to provide a general blueprint for sustaining the legacy of the Institute by leveraging opportunities in emerging scientific areas (e.g., regenerative medicine, omics technology, data science, precision medicine, and mobile health), finding new ways to address enduring challenges (e.g., social determinants of health, health inequities, prevention, and health promotion), and training the next generation of heart, lung, blood, and sleep researchers. DCVS has developed a strategic vision implementation plan to provide a cardiovascular framing for the pursuit of the Institute's overarching goals and strategic objectives garnered from the input of the broader NHLBI community. This plan highlights six scientific focus areas that demonstrate a cross-cutting and multifaceted approach to addressing cardiovascular sciences, including 1) addressing social determinants of cardiovascular health (CVH) and health inequities, 2) enhancing resilience, 3) promoting CVH and preventing CVD Across the lifespan, 4) eliminating hypertension-related CVD, 5) reducing the burden of heart failure, and 6) preventing vascular dementia. These priorities will guide our efforts in Institute-driven activities in the coming years but will not exclude development of other novel ideas or the support of investigator-initiated grant awards. The DCVS Strategic Vision implementation plan is a living document that will evolve with iterative dialogue with the NHLBI community and adapt as the dynamic scientific landscape changes to seize emerging opportunities.

Genetic variation in the SIM1 locus is associated with erectile dysfunction

Erectile dysfunction is a common condition of men in middle and older ages. Twin studies suggest that about one-third of the risk is due to genetic factors, independent of other known erectile dysfunction risk factors. However, studies that have searched for specific genetic contributors have been limited due to small sample sizes, candidate gene approaches, and weak phenotyping. As a result, there are no confirmed genetic risk factors for erectile dysfunction. This study finds a specific genetic cause for erectile dysfunction.

Erectile dysfunction affects millions of men worldwide. Twin studies support the role of genetic risk factors underlying erectile dysfunction, but no specific genetic variants have been identified. We conducted a large-scale genome-wide association study of erectile dysfunction in 36,649 men in the multiethnic Kaiser Permanente Northern California Genetic Epidemiology Research in Adult Health and Aging cohort. We also undertook replication analyses in 222,358 men from the UK Biobank. In the discovery cohort, we identified a single locus (rs17185536-T) on chromosome 6 near the single-minded family basic helix-loop-helix transcription factor 1 (SIM1) gene that was significantly associated with the risk of erectile dysfunction (odds ratio = 1.26, P = 3.4 × 10⁻²⁵). The association replicated in the UK Biobank sample (odds ratio = 1.25, P = 6.8 × 10⁻¹⁴), and the effect is independent of known erectile dysfunction risk factors, including body mass index (BMI). The risk locus resides on the same topologically associating domain as SIM1 and interacts with the SIM1 promoter, and the rs17185536-T risk allele showed differential enhancer activity. SIM1 is part of the leptin–melanocortin system, which has an established role in body weight homeostasis and sexual function. Because the variants associated with erectile dysfunction are not associated with differences in BMI, our findings suggest a mechanism that is specific to sexual function.

Comparative Trends in Heart Disease, Stroke, and All-Cause Mortality in the United States and a Large Integrated Healthcare Delivery System

OBJECTIVES

Heart disease and stroke remain among the leading causes of death nationally. We examined whether differences in recent trends in heart disease, stroke, and total mortality exist in the United States and Kaiser Permanente Northern California (KPNC), a large integrated healthcare delivery system.

METHODS

The main outcome measures were comparisons of US and KPNC total, age-specific, and sex-specific changes from 2000 to 2015 in mortality rates from heart disease, coronary heart disease, stroke, and all causes. The Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research data system was used to determine US mortality rates. Mortality rates for KPNC were determined from health system, Social Security vital status, and state death certificate databases.

RESULTS

Declines in age-adjusted mortality rates were noted in KPNC and the United States for heart disease (36.3% in KPNC vs 34.6% in the United States), coronary heart disease (51.0% vs 47.9%), stroke (45.5% vs 38.2%), and all-cause mortality (16.8% vs 15.6%). However, steeper declines were noted in KPNC than the United States among those aged 45 to 65 years for heart disease (48.3% KPNC vs 23.6% United States), coronary heart disease (55.6% vs 35.9%), stroke (55.8% vs 26.0%), and all-cause mortality (31.5% vs 9.1%). Sex-specific changes were generally similar.

CONCLUSIONS

Despite significant declines in heart disease and stroke mortality, there remains an improvement gap nationally among those aged less than 65 years when compared with a large integrated healthcare delivery system. Interventions to improve cardiovascular mortality in the vulnerable middle-aged population may play a key role in closing this gap.

Vascular robustness: The missing parameter in cardiovascular risk prediction

Undetected high risk for premature death of cardiovascular disease (CVD) among individuals with low-to-moderate risk factor scores is an acknowledged obstacle to CVD prevention. The vasculature's functional robustness against risk factor derailment may serve as a novel discriminator of mortality risk under similar risk factor loads. To test this assumption, we hypothesized that the expected inverse robustness-mortality association is verifiable as a significant trend along the age spectrum of risk factor-challenged cohorts.

This is a retrospective cohort study of 372 adults (mean age 56.1 years, range 21–92; 45% female) with a variety of CV risk factors.

An arterial model (VascAssist 2, iSYMED GmbH, Germany) was used to derive global parameters of arterial function from non-invasively acquired pulse pressure waves. Participants were stratified by health status: apparently healthy (AH; n = 221); with hypertension and/or hypercholesterolemia (CC; n = 61); with history of CV event(s) (CVE; n = 90). Multivariate linear regression was used to derive a robustness score which was calibrated against the CVD mortality hazard rate of a sub-cohort of the LURIC study (n = 1369; mean age 59.1 years, range 20–75; 37% female).

Robustness correlated linearly with calendar age in CC (F(1, 59) = 10.42; p < 0.01) and CVE (F(1, 88) = 40.34; p < 0.0001) but not in the AH strata, supporting the hypothesis of preferential elimination of less robust individuals along the aging trajectory under risk factor challenges.

Vascular robustness may serve as a biomarker of vulnerability to CVD risk factor challenges, prognosticating otherwise undetectable elevated risk for premature CVD mortality.

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Vascular robustness is proposed as parameter to improve CV risk prediction.

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Vascular robustness may be expressed as a correction factor to calendar age.

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A vascular robustness score identifies hidden risk in young adults.

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Validation studies are warranted to assess the discriminatory power of robustness.