Trends and Patterns of Geographic Variation in Cardiovascular Mortality Among US Counties, 1980-2014

Abstract

IMPORTANCE In the United States, regional variation in cardiovascular mortality is well-known but county-level estimates for all major cardiovascular conditions have not been produced. OBJECTIVE To estimate age-standardized mortality rates from cardiovascular diseases by county. DESIGN AND SETTING Deidentified death records from the National Center for Health Statistics and population counts from the US Census Bureau, the National Center for Health Statistics, and the Human Mortality Database from 1980 through 2014 were used. Validated small area estimation models were used to estimate county-level mortality rates from all cardiovascular diseases, including ischemic heart disease, cerebrovascular disease, ischemic stroke, hemorrhagic stroke, hypertensive heart disease, cardiomyopathy, atrial fibrillation and flutter, rheumatic heart disease, aortic aneurysm, peripheral arterial disease, endocarditis, and all other cardiovascular diseases combined. EXPOSURES The 3110 counties of residence. MAIN OUTCOMES AND MEASURES Age-standardized cardiovascular disease mortality rates by county, year, sex, and cause. RESULTS From 1980 to 2014, cardiovascular diseases were the leading cause of death in the United States, although the mortality rate declined from 507.4 deaths per 100 000 persons in 1980 to 252.7 deaths per 100 000 persons in 2014, a relative decline of 50.2% (95% uncertainty interval [UI], 49.5%–50.8%). In 2014, cardiovascular diseases accounted for more than 846 000 deaths (95% UI, 827–865 thousand deaths) and 11.7 million years of life lost (95% UI, 11.6–11.9 million years of life lost). The gap in age-standardized cardiovascular disease mortality rates between counties at the 10th and 90th percentile declined 14.6% from 172.1 deaths per 100 000 persons in 1980 to 147.0 deaths per 100 000 persons in 2014 (posterior probability of decline >99.9%). In 2014, the ratio between counties at the 90th and 10th percentile was 2.0 for ischemic heart disease (119.1 vs 235.7 deaths per 100 000 persons) and 1.7 for cerebrovascular disease (40.3 vs 68.1 deaths per 100 000 persons). For other cardiovascular disease causes, the ratio ranged from 1.4 (aortic aneurysm: 3.5 vs 5.1 deaths per 100 000 persons) to 4.2 (hypertensive heart disease: 4.3 vs 17.9 deaths per 100 000 persons). The largest concentration of counties with high cardiovascular disease mortality extended from southeastern Oklahoma along the Mississippi River Valley to eastern Kentucky. Several cardiovascular disease conditions were clustered substantially outside the South, including atrial fibrillation (Northwest), aortic aneurysm (Midwest), and endocarditis (Mountain West and Alaska). The lowest cardiovascular mortality rates were found in the counties surrounding San Francisco, California, central Colorado, northern Nebraska, central Minnesota, northeastern Virginia, and southern Florida. CONCLUSIONS AND RELEVANCE Substantial differences exist between county ischemic heart disease and stroke mortality rates. Smaller differences exist for disease...

Defining Optimal Brain Health in Adults: A Presidential Advisory From the American Heart Association/American Stroke Association

“…128,176 Furthermore, cardiovascular mortality, including ischemic heart disease and stroke, may vary substantially on the basis of geographic variation. 177 Atherosclerosis, a manifestation of nonfavorable cardiovascular health, however, may not be inevitable. Recently, it has been shown that a forager-horticulturalist population, the South American Tsimane of Bolivia, who have few coronary artery disease risk factors, have the lowest reported levels of coronary artery disease of any population, 178 suggesting the value of primordial prevention.…”

Cardiovascular Medicine Amid Evolving Health Policy

“…Beyond ongoing national health policy initiatives, it is increasingly evident that factors outside of the hospital walls contribute significantly to the incidence, progression, and outcomes of cardiovascular disease (13,14). Major gains still need to be made to address the social determinants of cardiovascular disease.…”

Reducing Cardiovascular Disparities Through Community-Engaged Implementation Research

“…32,33 For example, Roth et al 33 showed a 4-fold difference in the mortality from hypertensive heart disease between counties at the 10th and 90th percentiles of the average national rate. Substantial Figure 1.…”