Research Highlights:
- An analysis of death certificate data for more than 11 million U.S. adults from 2010 to 2022 found that cardiovascular disease death rates increased by about 21% for adults ages 25-64 living in rural areas, however, the rates declined by about 9% for adults ages 65 or older living in urban areas.
- After the onset of the COVID-19 pandemic in 2020, cardiovascular death rates increased significantly more in rural compared to urban areas, a consistent finding across all ages.
- Therefore, rural-urban disparities in cardiovascular mortality widened between 2010-2022, especially among younger adults (ages 25-64), and these differences became more pronounced after the onset of the COVID-19 pandemic.
- Note: The study featured in this news release will be presented at the American Heart Association's Scientific Sessions 2024. The peer-reviewed manuscript is simultaneously published today in the Journal of the American College of Cardiology.
DALLAS, Nov. 11, 2024 — Cardiovascular disease deaths increased by about 21% for adults ages 25-64 living in rural areas between 2010 and 2022, however, the rate declined by 9% for adults ages 65 or older living in urban areas, according to a study to be presented at the American Heart Association's Scientific Sessions 2024, and simultaneously published in the Journal of the American College of Cardiology. The meeting, Nov. 16-18, 2024 in Chicago, is a premier global exchange of the latest scientific advancements, research and evidence-based clinical practice updates in cardiovascular science.
Using data from the U.S. Centers for Disease Control and Prevention's WONDER database, researchers analyzed national death data for more than 11 million adults from 2010-2022. The study investigated the cardiovascular death rates for people living in rural vs. urban (large metropolitan) areas of the U.S. According to the National Center for Health Statistics, large metropolitan areas are defined as those with a population of more than 1 million people; small/medium metro areas as those with 250,000 – 999,999 people; and rural areas as those that are near cities with less than 50,000 people or not near any major metropolitan area.
"Previous research has demonstrated disparities in cardiovascular mortality between rural and urban Americans, with, historically, more people in rural areas dying from heart disease compared to people living in cities," said lead study author Lucas X. Marinacci, M.D., a cardiology fellow at Beth Israel Deaconess Medical Center and a post-doctoral research fellow under the mentorship of Dr. Rishi Wadhera, the corresponding study author, at the Richard A. and Susan F. Smith Center for Outcomes Research, also at Beth Israel Deaconess Medical Center in Boston. "Rural communities bear a disproportionate burden of cardiovascular risk factors, as well as economic hardship and health care system challenges, such as hospital closures, physician shortages and lack of public health infrastructure, all of which were exacerbated by the COVID-19 pandemic."
The analysis found that between 2010 and 2022, cardiovascular mortality rates increased in rural areas and decreased in urban areas of the U.S., resulting in a widening rural-urban disparity. There was a concerning rise in cardiovascular mortality among younger adults that was concentrated in rural areas. There was a sharp increase in cardiovascular mortality rates following the onset of the COVID-19 pandemic, a change that was more pronounced in rural populations. Specifically:
- The age-adjusted cardiovascular mortality rate, or number of deaths from cardiovascular disease per 100,000 people, increased by 0.8% in rural areas between 2010 and 2022, but decreased by 6.4% in urban areas.
- Younger, rural adults ages 25-64 experienced a 21% relative increase in their cardiovascular death rate in 2022 compared to 2010, whereas death rates among younger adults in urban areas increased by only 3%.
- Conversely, cardiovascular mortality rates declined significantly among adults older than age 65 between 2010 and 2022, with a 4.4% decrease for older adults in rural areas and an 8.5% decrease among those living in urban areas.
- After the onset of the COVID-19 pandemic in 2020, cardiovascular death rates increased nationwide, yet the relative increase was significantly larger in rural (8.3%) versus urban (3.6%) areas.
"Leading up to the pandemic, the cardiometabolic health of rural communities was already in decline, particularly among younger adults. This may have made them more vulnerable to both the direct and indirect cardiovascular effects of COVID-19," Marinacci said. "Cardiovascular risk factor control worsened during the pandemic, and those in rural areas experienced greater interruptions in health care coverage, access and affordability. The unprecedented surge in economic and psychosocial distress that occurred during the wake of the pandemic also disproportionately impacted rural populations.
"Therefore, a growing burden of cardiometabolic disease combined with other risk-enhancing factors — all of which were likely exacerbated by the pandemic — may have caused rural-urban disparities in death rates to widen even further during the 12-year study period," he added.
According to Marinacci, there is an urgent need to implement public health initiatives that are specifically focused on reducing cardiovascular risk among working-age rural adults.
"Aggressive risk factor modification is needed to reverse these trends. Community health workers may be able strengthen the connection between rural adults and the health care team and resources that can help manage these chronic conditions. Finally, policy interventions that improve access to health care, make it more affordable and increase health insurance coverage for rural populations could go a long way in reducing the disparity in cardiovascular death," Marinacci said.
Study background and details:
- The study included death certificate data from the CDC WONDER database from 2010-2022.
- The study sample included 11,017,255 adults; 18.9% were ages 25-64; and 81.1% were ages 65 or older.
- Researchers analyzed overall cardiovascular deaths for adults living in rural, small to medium metropolitan and large metropolitan, or urban, areas of the United States.
- They further analyzed cardiovascular deaths for younger (ages 25-64) and older (age 65 and older) adults. All cardiovascular death rates were age-standardized to the 2010 U.S. population.
"Rural communities face a number of unique challenges when it comes to cardiovascular health, including a high burden of cardiovascular risk factors like Type 2 diabetes and hypertension, as well as worse access to specialty care and cardiovascular technologies," said Karen E. Joynt Maddox, M.D., M.P.H., FAHA, chair of the American Heart Association's Presidential Advisory Forecasting the Burden of Cardiovascular Disease and Stroke in the United States Through 2050. "We need new solutions, including cardiovascular-specific interventions like telehealth-based specialist visits, as well as policy interventions to improve the affordability of care, to help people in rural areas reverse these alarming trends."
A limitation of the study is that the findings are based on death certificate records, which may include errors in the underlying cause or causes of death. Some death records during the time period examined may also have been affected by the COVID-19 pandemic.
Co-authors, disclosures and funding sources are listed in the abstract.
Statements and conclusions of studies that are presented at the American Heart Association's scientific meetings are solely those of the study authors and do not necessarily reflect the Association's policy or position. The Association makes no representation or guarantee as to their accuracy or reliability. Abstracts presented at the Association's scientific meetings are not peer-reviewed, rather, they are curated by independent review panels and are considered based on the potential to add to the diversity of scientific issues and views discussed at the meeting. The findings are considered preliminary until published as a full manuscript in a peer-reviewed scientific journal.
