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Rural-Urban Differences in Mortality From Ischemic Heart Disease, Heart Failure, and Stroke in the United States

2021; Lippincott Williams & Wilkins; Volume: 14; Issue: 4 Linguagem: Inglês

10.1161/circoutcomes.120.007341

ISSN

1941-7705

Autores

Muhammad Shahzeb Khan, Pankaj Kumar, Jayakumar Sreenivasan, Safi U. Khan, Khurram Nasir, Mandeep R. Mehra, Christopher O’ Donnell, Haider J. Warraich,

Tópico(s)

Global Health Care Issues

Resumo

HomeCirculation: Cardiovascular Quality and OutcomesVol. 14, No. 4Rural-Urban Differences in Mortality From Ischemic Heart Disease, Heart Failure, and Stroke in the United States Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBRural-Urban Differences in Mortality From Ischemic Heart Disease, Heart Failure, and Stroke in the United States Muhammad Shahzeb Khan, MD, MSc, Pankaj Kumar, MBBS, Jayakumar Sreenivasan, MD, MSc, Safi U. Khan, MD, Khurram Nasir, MD, MPH, Mandeep R. Mehra, MD, MSc, Christopher O' Donnell, MD, MPH and Haider J. Warraich, MD Muhammad Shahzeb KhanMuhammad Shahzeb Khan Department of Medicine, University of Mississippi Medical Center, Jackson, MS (M.S.K.). , Pankaj KumarPankaj Kumar Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan (P.K.). , Jayakumar SreenivasanJayakumar Sreenivasan https://orcid.org/0000-0003-2065-4119 Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY (J.S.). , Safi U. KhanSafi U. Khan https://orcid.org/0000-0003-1559-6911 Department of Medicine, West Virginia University, Morgantown (S.U.K.). , Khurram NasirKhurram Nasir Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, TX (K.N.). , Mandeep R. MehraMandeep R. Mehra https://orcid.org/0000-0001-8683-7044 Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA (M.R.M., C.O., H.J.W.). Harvard Medical School, Boston, MA (M.R.M., C.O., H.J.W.). , Christopher O' DonnellChristopher O' Donnell https://orcid.org/0000-0002-2667-8624 Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA (M.R.M., C.O., H.J.W.). Harvard Medical School, Boston, MA (M.R.M., C.O., H.J.W.). Department of Medicine, Cardiology Section, VA Boston Healthcare System, West Roxbury, MA (C.O., H.J.W.). and Haider J. WarraichHaider J. Warraich Haider J. Warraich, MD, Department of Medicine, Cardiology Section, VA Boston Healthcare System, 4B-132, 1400 VFW Pkwy, Boston, MA 02132. Email E-mail Address: [email protected] https://orcid.org/0000-0001-9493-1372 Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA (M.R.M., C.O., H.J.W.). Harvard Medical School, Boston, MA (M.R.M., C.O., H.J.W.). Department of Medicine, Cardiology Section, VA Boston Healthcare System, West Roxbury, MA (C.O., H.J.W.). Originally published20 Apr 2021https://doi.org/10.1161/CIRCOUTCOMES.120.007341Circulation: Cardiovascular Quality and Outcomes. 2021;14:e007341Rural areas experience higher age-adjusted mortality rates (AAMR) from cardiovascular disease than urban areas.1 However, trends for major cardiovascular disease subgroups remain unknown. Therefore, we analyzed trends in AAMR by urban-rural status for major cardiovascular disease subtypes: ischemic heart disease (IHD), heart failure (HF), and stroke.We queried the publicly available, nationally representative deidentified CDC Wide-ranging Online Data for Epidemiological Research database for deaths secondary to IHD, HF, and stroke from 1999 to 2017. The analysis was considered exempt from Institutional Review Board approval. Annual AAMR estimates of deaths per 100 000 population from IHD, HF, and stroke were obtained using International Classification of Diseases codes2 for large metropolitan (≥1 million), small-medium metropolitan (50 000–999 999), and nonmetropolitan rural (<50 000) areas.3 We used the Poisson regression with log link and robust standard errors to estimate annual percentage change (APC) in AAMR across 1999 to 2011 and 2011 to 2017 as the year 2011 has been previously used as an inflection point to assess recent changes in cardiovascular disease AAMR.1 The coefficients for the year obtained from the regression model were used to calculate the APC estimates [APC=100×(exp[coefficient]−1)]. Post hoc Bonferroni correction was used to ensure consistency of our results. The Pearson χ2 test was performed for categorical variables. A 2-tailed P value of <0.05 was considered statistically significant.A total of 12 364 036 deaths (50% in large metropolitan, 30.3% in small-medium metropolitan, and 19.7% in rural areas) occurred from 1999 to 2017. The combined AAMR was largest in the rural areas followed by small metropolitan areas and large metropolitan areas.IHD AAMR showed a sharp decline from 1999 to 2011 (large metropolitan APC −5.2%, 201.3–107.4; small metropolitan APC −4.7%, 182.1–105.5; and rural APC −4.2%, 198.2–122.1) followed by a slower but consistent decline from 2011 to 2017 (large metropolitan APC −3%, 107.4–88.8; small metropolitan APC −2.4%, 105.5–91.7; and rural APC −1.8%, 122.1–109.4) with a relatively large reduction in large metropolitan areas followed by small metropolitan and rural areas uniformly across all ages, race, and ethnic groups (Table).Table. Trends in AAMR Across Decedents Characteristics for Ischemic Heart Disease, Heart Failure, and Stroke (1999–2017)CharacteristicsIschemic heart diseaseHeart failureHeart failureStrokeAAMR per 100 000 population rate (95% CI)1999–20112011–2017AAMR per 100 000 population rate (95% CI)AAMR per 100 000 population rate (95% CI)1999–20112011–2017AAMR per 100 000 population rate (95% CI)1999–20112011–2017 Large metro201.3 (200.6–202.1)107.4 (106.9–107.9)88.8 (88.3–89.2)−5.2*−3*27.6 (27.3–27.9)22.1 (21.8–22.3)24.6 (24.4–24.8)−2.1*+2.6*58 (57.6–58.4)35.1 (34.8–35.3)36.3 (36.0–36.5)−4.6*+0.9* Medium/small metro182.1 (181.2–183.0)105.5 (104.9–106.1)91.7 (91.1–92.2)−4.7*−2.4*31 (30.7–31.4)24.2 (23.9–24.5)26.3 (26.0–26.6)−2.2*+1.9*63.6 (63.0–64.1)39.3 (38.9–39.7)38.5 (38.2–38.9)−4.5*+0.2 Rural198.2 (196.9–199.4)122.1 (121.2–123.0)109.4 (108.6–110.2)−4.2*−1.8*35.8 (35.3–36.3)28 (27.5–28.4)30.2 (29.8–30.6)−2.2*+1.7*67.8 (67.1–68.5)43.7 (43.1–44.2)40.3 (39.8–40.8)−3.8*−1.2*Age 64 y Large metro1365.3 (1359.8–1370.8)709 (705.4–712.6)576.4 (573.4–579.3)−5.5*−3.4*184.8 (182.8–186.9)150.3 (148.7–152.0)169.2 (167.6–170.8)−2*+2.5*406.6 (403.6–409.6)238.5 (236.4–240.6)248.7 (246.7–250.6)−4.9*+1.1* Medium/small metro1204.5 (1197.9–1211.2)670.3 (665.9–674.7)570.2 (566.4–574.0)−5.1*−2.8*212.3 (209.5–215.1)163.9 (161.7–166.1)177.6 (175.5–179.7)−2.3*+1.8*448.2 (444.2–452.3)267.3 (264.6–270.1)259.9 (257.3–262.5)−4.8*−0.2 Rural1292.6 (1283.9–1301.2)752.2 (746.0–758.4)657.5 (652.1–663.0)−4.6*−2.2*246.1 (242.4–249.9)189.8 (186.7–192.9)202.5 (199.5–205.6)−2.2*+1.5*477.4 (472.2–482.6)296.4 (292.5–300.3)265.9 (262.4–269.4)−4.1*−1.6*Female Large metro161.4 (160.5–162.2)81.2 (80.7–81.8)64.1 (63.7–64.6)−5.6*−3.8*23.6 (23.3–23.9)18.6 (18.3–18.9)20.7 (20.4–21.0)−2.1*+2.6*56 (55.5–56.5)34.3 (33.9–34.6)35.1 (34.8–35.5)−4.5*+1.1* Medium/small metro140.4 (139.3–141.4)76.8 (76.1–77.4)63.9 (63.3–64.5)−5.2*−3.2*27.5 (27.0–27.9)20.9 (20.6–21.3)22.5 (22.1–22.8)−2.5*+2*62 (61.3–62.7)38.8 (38.4–39.3)37.8 (37.4–38.3)−4.3*−0.2 Rural151.6 (150.2–152.9)88.9 (87.9–89.9)76.7 (75.8–77.7)−4.6*−2.3*32 (31.4–32.6)24.5 (24.0–25.1)26.3 (25.8–26.8)−2.2*+1.5*66 (65.1–66.9)43.2 (42.5–43.9)39.5 (38.9–40.2)−3.6*+1.1*Male Large metro256.3 (254.9–257.7)142.1 (141.2–143.0)120.6 (119.9–121.4)−5*−2.7*33 (32.5–33.5)26.8 (26.4–27.2)29.8 (29.4–30.2)−1.8*+2.1*59.9 (59.3–60.6)35.4 (34.9–35.8)36.9 (36.5–37.3)−4.8*+1* Medium/small metro238.4 (236.6–240.1)142.4 (141.2–143.5)126.3 (125.3–127.3−4.5*−2*35.6 (34.9–36.3)28.4 (27.9–28.9)31.1 (30.6–31.6)−2.1*+1.7*64.7 (63.8–65.7)39.1 (38.5–39.7)38.6 (38.1–39.2)−4.6*0.1 Rural259.9 (257.6–262.1)162.8 (161.2–164.4)148.3 (146.9–149.8)−4*−1.6*40.5 (39.6–41.4)32.1 (31.4–32.8)34.8 (34.1–35.6)−2*+1.7*69.2 (68.0–70.4)43.1 (42.3–44.0)40.2 (39.4–40.9)−4.2*−1*Native American Large metro106.2 (95.1–117.4)47.5 (42.6–52.4)41.8 (37.9–45.7)−5.7*−2.6*17.7 (13.4–22.8)8.3 (6.3–10.6)13.1 (10.9–15.4)−5.3*+6.8*28.9 (23.1–34.7)15.3 (12.4–18.2)17.1 (14.5–19.7)−5.9*+0.1 Medium/small metro124 (111.6–136.4)79.7 (72.5–86.9)70.2 (64.6–75.8)−3.9*−2.2*21.4 (16.5–27.4)14.6 (11.5–17.7)15.5 (12.8–18.2)−1.8*1.349.1(40.9–57.2)29.3 (24.8–33.7)27.5 (23.9–31.1)−5.9*−0.1 Rural190.4 (177.2–203.7)123.3 (115.0–131.7)97.3 (91.0–103.6)−3.5*−3.3*36.4 (30.4–42.4)26.8 (22.7–30.8)25.3 (22.0–28.6)−1.8*−0.963.6 (55.7–71.6)39 (34.3–43.8)36.1 (32.2–40.0)−3.4*−1.6Asian/PI Large metro118.1 (114.6–121.6)63.9 (62.3–65.6)54.3 (53.1–55.5)−4.9*−3.2*12.3 (11.2–13.5)8.7 (8.1–9.3)9.5 (9.0–10.1)−2.2*+1.149.2 (46.9–51.4)30.5 (29.3–31.6)28.4 (27.5–29.3)−4.5*−1 Medium/small metro111.2 (105.6–116.9)58.1 (55.2–61.0)53.1 (50.7–55.5)−4.9*−1.9*20.6 (18.2–23.1)12.9 (11.5–14.2)14.3 (13.0–15.5)−3.5*+1.360.1 (55.9–64.3)35.7 (33.4–38.0)35.7 (33.7–37.7)−4.8*+0.2 Rural157.8 (139.8–175.7)72.8 (64.4–81.2)53.6 (47.6–59.7)−5.6*−4.4*39.1 (30.6–49.4)17 (13.1–21.6)16.7 (13.4–20.0)−40.287.2 (73.6–100.8)32 (26.4–37.5)37.2 (32.1–42.3)−6.1*+1.1Hispanic Large metro166.7 (163.8–169.5)85.7 (84.2–87.2)70.1 (69.0–71.2)−5.4*−3.4*17.1 (16.2–18.0)15 (14.4–15.6)15.5 (15.0–16.0)−1.4*1.2*43.4 (42.0–44.9)29.1 (28.3–30.0)31.8 (31.0–32.5)−3.6*+2.3* Medium/small metro146.4 (141.9–150.9)79.4 (77.1–81.7)70.4 (68.6–72.3)−4.9*−2*19.7 (18.0–21.4)15 (14.0–16.0)15.9 (15.0–16.8)−2.2*0.951.6 (48.9–54.3)34.5 (32.9–36.0)32.2 (30.9–33.4)−3.6*−1* Rural171.6 (162.7–180.4)86.4 (81.8–91.0)77.9 (74.2–81.6)−5.7*−1.9*28.8 (25.0–32.5)17.8 (15.6–19.9)18.3 (16.5–20.1)−3*1.460.2 (54.9–65.5)32.8 (30.0–35.7)31.1 (28.7–33.5)−4.3*−1.4*Non-Hispanic Black Large metro236.4 (233.9–239.0)130 (128.3–131.6)106.7 (105.4–108.0)−5*−3.3*37.8 (36.8–38.8)27.8 (27.0–28.5)31.5 (30.8–32.2)−2.4*+2.6*76.3 (74.8–77.7)48.5 (47.5–49.5)50.5 (49.6–51.4)−4.1*+0.9 Medium/small metro207.2 (203.3–211.0)122.1 (119.5–124.7)105.6 (103.4–107.8)−4.9*−2.3*45 (43.2–46.8)34.2 (32.8–35.5)37.8 (36.5–39.1)−2.4*+2.4*92 (89.4–94.6)57.3 (55.5–59.1)55.9 (54.3–57.5)−4.2*0 Rural220.4 (215.0–225.7)130 (126.2–133.9)115.7 (112.2–119.1)−4.5*−1.7*51.3 (48.7–53.8)40.4 (38.2–42.6)43.9 (41.7–46.0)−2*+1.6*98 (94.4–101.5)63.8 (61.1–66.5)59.6 (57.1–62.1)−3.7*−0.7Non-Hispanic White Large metro201.1 (200.3–202.0)109.2 (108.6–109.7)91.3 (90.8–91.8)−5.1*−3.9*27.2 (26.9–27.5)22.6 (22.3–22.9)25.9 (25.6–26.1)−1.7*+3*56.2 (55.7–56.6)33.5 (33.2–33.8)34.7 (34.4–35.0)−4.7*+0.7 Medium/small metro182.7 (181.7–183.7)107.1 (106.4–107.8)93.2 (92.6–93.8)−4.7*−2.4*30.4 (30.0–30.8)24.1 (23.7–24.4)26.3 (26.0–26.6)−2.1*+1.6*61.6 (61.0–62.1)37.9 (37.5–38.3)37.2 (36.8–37.6)−4.5*−0.2 Rural196.8 (195.6–198.1)122.7 (121.8–123.7)110.5 (109.6–111.3)−4.1*−1.7*34.7 (34.1–35.2)27.4 (26.9–27.8)29.6 (29.2–30.1)−2.2*+1.7*65.7 (64.9–66.4)42.5 (42.0–43.1)39.1 (38.6–39.6)−3.9*−1.3*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 P<0.05.HF AAMR showed significant downtrend from 1999 to 2011 (large metropolitan APC −2.1%, 27.6–22.1; small metropolitan APC −2.2%, 31–24.2; and rural APC −2.2%, 35.8–28) across all subgroups. However, from 2011 to 2017, across all areas, HF AAMR increased (large metropolitan APC +2.6%, 22.1–24.6; small metropolitan APC +1.9%, 24.2–26.3; and rural APC +1.7%, 28–30.2) predominantly more in large metropolitan areas compared with rural and small metropolitan areas.Stroke-related AAMR declined consistently from 1999 to 2011 (large metropolitan APC −4.6%, 58–35.1; small metropolitan APC −4.5%, 63.6–39.3; and rural APC −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 stroke-related 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.Sources of FundingNone.Disclosures 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.FootnotesHaider J. Warraich, MD, Department of Medicine, Cardiology Section, VA Boston Healthcare System, 4B-132, 1400 VFW Pkwy, Boston, MA 02132. Email [email protected]orgReferences1. Cross SH, Mehra MR, Bhatt DL, Nasir K, O'Donnell CJ, Califf RM, Warraich HJ. Rural-urban differences in cardiovascular mortality in the US, 1999-2017.JAMA. 2020; 323:1852–1854. doi: 10.1001/jama.2020.2047CrossrefMedlineGoogle Scholar2. National Center for Health Statistics (US). Health, United States, 2016: With Chartbook on Long-term Trends in Health. National Center for Health Statistics (US); 2017.Google Scholar3. Ingram DD, Franco SJ. 2013 NCHS urban-rural classification scheme for counties.Vital Health Stat 2. 2014; 177:1–73.Google Scholar4. Jackson SL, Tong X, King RJ, Loustalot F, Hong Y, Ritchey MD. National burden of heart failure events in the United States, 2006 to 2014.Circ Heart Fail. 2018; 11:e004873. doi: 10.1161/CIRCHEARTFAILURE.117.004873LinkGoogle Scholar5. Rodriguez CJ, Allison M, Daviglus ML, Isasi CR, Keller C, Leira EC, Palaniappan L, Piña IL, Ramirez SM, Rodriguez B, et al; American Heart Association Council on Epidemiology and Prevention; American Heart Association Council on Clinical Cardiology; 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 American Heart Association.Circulation. 2014; 130:593–625. doi: 10.1161/CIR.0000000000000071LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited ByAriss R, Minhas A, Lang J, Ramanathan P, Khan S, Kassi M, Warraich H, Kolte D, Alkhouli M and Nazir S (2022) Demographic and Regional Trends in Stroke‐Related Mortality in Young Adults in the United States, 1999 to 2019, Journal of the American Heart Association, 11:18, Online publication date: 20-Sep-2022.Minhas A, Wyand R, Ariss R, Nazir S, Shahzeb Khan M, Jia X, Greene S, Fudim M, Wang A, Warraich H, Kalra A, Alam M and Virani S (2022) Demographic and Regional Trends of Hypertrophic Cardiomyopathy-Related Mortality in the United States, 1999 to 2019, Circulation: Heart Failure, 15:9, (e009292), Online publication date: 1-Sep-2022. Minhas A, Sheikh A, Ijaz S, Mostafa A, Nazir S, Khera R, Loccoh E and Warraich H (2022) Rural-Urban Disparities in Heart Failure and Acute Myocardial Infarction Hospitalizations, The American Journal of Cardiology, 10.1016/j.amjcard.2022.04.014, 175, (164-169), Online publication date: 1-Jul-2022. Cato S, Ramer S, Hajjar I and Kulshreshtha A Alzheimer's Disease Mortality as a Function of Urbanization Level: 1999–2019, Journal of Alzheimer's Disease, 10.3233/JAD-215586, 87:4, (1461-1466) Nazir S, Ariss R, Minhas A, Issa R, Michos E, Birnbaum Y, Moukarbel G, Ramanathan P and Jneid H (2022) Demographic and Regional Trends of Mortality in Patients With Aortic Dissection in the United States, 1999 to 2019, Journal of the American Heart Association, 11:7, Online publication date: 5-Apr-2022. Ariss R, Minhas A, Issa R, Ahuja K, Patel M, Eltahawy E, Michos E, Fudim M and Nazir S (2022) Demographic and Regional Trends of Mortality in Patients With Acute Myocardial Infarction in the United States, 1999 to 2019, The American Journal of Cardiology, 10.1016/j.amjcard.2021.10.023, 164, (7-13), Online publication date: 1-Feb-2022. Fanaroff A, Evans P and Nathan A (2022) Rural-Urban Disparities in Cardiovascular Outcomes, Journal of the American College of Cardiology, 10.1016/j.jacc.2021.11.016, 79:3, (280-282), Online publication date: 1-Jan-2022. April 2021Vol 14, Issue 4 Advertisement Article InformationMetrics © 2021 American Heart Association, Inc.https://doi.org/10.1161/CIRCOUTCOMES.120.007341PMID: 33877879 Originally publishedApril 20, 2021 Keywordscardiovascular diseasestrokemortalityheart failureheart diseasesPDF download Advertisement SubjectsHealth ServicesMortality/SurvivalQuality and Outcomes

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