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  • Research article
  • Open Access
  • Open Peer Review

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

BMC Cardiovascular DisordersBMC series – open, inclusive and trusted201717:192

https://doi.org/10.1186/s12872-017-0630-2

  • Received: 24 March 2017
  • Accepted: 12 July 2017
  • Published:
Open Peer Review reports

Abstract

Background

The long-term downward national U.S. trend in heart disease-related mortality slowed substantially during 2011–2014 before turning upward in 2015. Examining mortality trends in the major subgroups of heart disease may provide insight into potentially more targeted and effective prevention and treatment approaches to promote favorable trajectories. We examined national trends between 2000 and 2015 in mortality attributed to major heart disease subgroups including ischemic heart disease, heart failure, and all other types of heart disease.

Methods

Using the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (WONDER) data system, we determined national trends in age-standardized mortality rates attributed to ischemic heart disease, heart failure, and other heart diseases from January 1, 2000, to December 31, 2011, and from January 1, 2011, to December 31, 2015. Annual rate of changes in mortality attributed to ischemic heart disease, heart failure, and other heart diseases for 2000–2011 and 2011–2015 were compared.

Results

Death attributed to ischemic heart disease declined from 2000 to 2015, but the rate of decline slowed from 4.96% (95% confidence interval 4.77%–5.15%) for 2000–2011 to 2.66% (2.00%–3.31%) for 2011–2015. In contrast, death attributed to heart failure and all other causes of heart disease declined from 2000 to 2011 at annual rates of 1.94% (1.77%–2.11%) and 0.64% (0.44%–0.82%) respectively, but increased from 2011 to 2015 at annual rates of 3.73% (3.21% 4.26%) and 1.89% (1.33–2.46%). Differences in 2000–2011 and 2011–2015 decline rates were statistically significant for all 3 endpoints overall, by sex, and all race/ethnicity groups except Asian/Pacific Islanders (heart failure only significant) and American Indian/Alaskan Natives.

Conclusions

While the long-term decline in death attributed to heart disease slowed between 2011 and 2014 nationally before turning upward in 2015, heterogeneity existed in the trajectories attributed to heart disease subgroups, with ischemic heart disease mortality continuing to decline while death attributed to heart failure and other heart diseases switched from a downward to upward trend. While systematic efforts to prevent and treat ischemic heart disease continue to be effective, urgent attention is needed to address the challenge of heart failure.

Keywords

  • Mortality rate
  • Heart disease
  • Coronary heart disease
  • Heart failure
  • Epidemiology

Background

We recently reported that the rate of decline of death attributed to total cardiovascular disease (CVD) and to heart disease (HD) in the U.S. had decelerated substantially between 2011 and 2014 [1], with the annualized percent decline in CVD and HD mortality decreasing from 3.79% and 3.69% respectively for 2000–2011 to 0.65% and 0.76% for 2011–2014. We suggested that HD mortality might increase in 2015 [1] which was confirmed by the recent report of a 0.9% increase from 167.0 to 168.5 per 100,000 person-years from 2014 to 2015, the first year-to-year increase since 1992–93 [2, 3].

HD-related death encompasses a wide range of heart conditions. Thus, from both prevention and intervention perspectives, it is important to further delineate trends in subcategories of HD-related death. We studied mortality trends in the two largest subgroups of HD (ischemic heart disease [IHD] and heart failure [HF]) and in all other HD combined.

Methods

Mortality rates between 2000 and 2015 were ascertained using the U.S. Centers for Disease Control and Prevention’s Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) dataset, which includes the assigned cause of death from all death certificates filed in the 50 states and the District of Columbia [3]. Categorization of the presumed cause of death used International Statistical Classification of Diseases and Related Health Problems, Tenth Edition codes as follows: HD (codes I00-I09, I11, I13, and I20-I51), IHD (I20-I25), HF (I50), and all other causes of HD (I00-I09, I11, I13, I26-I49, and I51).

This study did not require institutional review board approval because it analyzes government-issued public use data without individual identifiable information.

Age-standardized mortality rates (AAMR) were calculated using the direct method, with the 2000 U.S. Census as the standard population using the following age categorization: younger than 1 year, 1 to 4, 5 to 14, 15 to 24, 25 to 34, 35 to 44, 45 to 54, 55 to 64, 65 to 74, 75 to 84, and 85 years or older [4]. Poisson regression with allowance for overdispersion was used for point and interval estimation of age-adjusted annual rates of change for January 1, 2000, to December 31, 2011, and January 1, 2011, to December 31, 2015.

Results

Mortality rates from 2000 to 2015 for HD and HD subgroups are shown in Table 1, with the largest subgroup being IHD. Compared to 2014, in 2015, an increase in overall HD occurred in men (0.4%), women (1.4%), and in all racial-ethnic groups except NH Blacks in which HD mortality decreased by 0.3%. The 2015 mortality rate for each HD subgroup was higher in men than in women. By race-ethnicity, NH blacks had the highest mortality rate for each HD subcategory, followed by NH whites, NH American Indian/Alaskan Natives, Hispanics, and NH Asian/Pacific Islanders.
Table 1

Age-adjusted mortality rates for all heart disease, ischemic heart disease, heart failure, and all other CHD, United States, 2000–2015

  

Heart disease

Ischemic HD

Heart failure

All other HD

Year

N = Population

n = deaths

AAMRa

n = deaths

AAMR

n = deaths

AAMR

n = deaths

AAMR

2000

281,421,906

710,760

257.6

515,204

186.8

55,704

20.3

139,852

50.6

2001

284,968,955

700,142

249.5

502,189

179.0

56,934

20.4

141,019

50.2

2002

287,625,193

696,947

244.6

494,382

173.5

56,494

19.9

146,071

51.2

2003

290,107,933

685,089

236.3

480,028

165.6

57,448

19.9

147,613

50.9

2004

292,805,298

652,486

221.6

451,326

153.2

57,120

19.5

144,040

48.9

2005

295,516,599

652,091

216.8

445,687

148.2

58,933

19.7

147,471

49.0

2006

298,379,912

631,636

205.5

425,425

138.3

60,337

19.7

145,874

47.5

2007

301,231,207

616,067

196.1

406,351

129.2

56,565

18.0

153,151

48.8

2008

304,093,966

616,828

192.1

405,309

126.1

56,830

17.7

154,689

48.3

2009

306,771,529

599,413

182.8

386,324

117.7

56,410

17.2

156,679

47.9

2010

308,745,538

597,689

179.1

379,559

113.6

57,757

17.3

160,373

48.2

2011

311,591,917

596,577

173.7

375,295

109.2

58,309

16.9

162,973

47.7

2012

313,914,040

599,711

170.5

371,469

105.4

60,341

17.1

167,901

48.0

2013

316,128,839

611,105

169.8

370,213

102.6

65,120

18.0

175,772

49.1

2014

318,857,056

614,348

167.0

364,593

98.8

68,626

18.6

181,129

49.6

2015

321,418,820

633,842

168.5

366,801

97.2

75,251

19.9

191,790

51.4

Abbreviations: HD heart disease, AAMR age-adjusted mortality rate

aAge-adjusted mortality rate per 100,000 person-years, directly standardized to the 2000 U.S. population

The rate of decline in death attributed to IHD slowed in 2011–2015, with mean annual rate of change of −2.66% compared to −4.96% for 2000–2011 (Table 2 , Fig. 1). The difference in the rate of change between the two time periods was statistically significant overall, in each sex and, among NH whites, NH blacks, and Hispanics.
Table 2

Age-adjusted mortality rates and annual rates of change for ischemic heart disease, heart failure, and other heart disease for time periods 2000–2011 and 2011–2015, United States

 

AAMR

Annual rate of change (%)a

Year(s)

2000

2011

2015

2000–2011

2011–2015

p-valueb

Ischemic heart disease

 Total

186.8

109.2

97.2

−4.96 (−5.15 to −4.77)

−2.66 (−3.31 to −2.00)

<0.001

 Total male

241.4

145.6

131.2

−4.63 (−4.82 to −4.44)

−2.10 (−2.75 to −1.45)

<0.001

 Total female

146.5

81.0

70.5

−5.49 (−5.69 to −5.29)

−3.69 (−4.29 to −2.88)

<0.001

 NH White

186.6

111.1

99.7

−4.85 (−5.05 to −4.64)

−2.34 (−3.05 to −1.63)

<0.001

 NH Asian/PI

109.7

63,2

55.1

−4.71 (−5.03 to −4.43)

−3.75 (−4.64 to −2.85)

0.08

 Hispanic

153.2

84.2

74.5

−5.38 (−5.64 to −5.12)

−3.39 (−4.21 to −2.58)

<0.001

 NH Black

220.4

127.9

111.3

−5.06 (−5.26 to −4.86)

−3.16 (−3.93 to −2.49)

0.003

 NH AI/AN

142.7

104.8

95.2

−3.04 (−3.55 to −2.52)

−1.23 (−2.79 to 0.36)

0.06

Heart failure

 Total

20.3

16.9

19.9

−1.94 (−2.11 to −1.77)

3.73 (3.21 to 4.26)

<0.001

 Total male

21.5

18.7

22.5

−1.51 (−1.70 to −1.31)

4.58 (4.00 to 5.17)

<0.001

 Total female

19.2

15.6

17.9

−2.26 (−2.44 to −2.09)

2.99 (2.43 to 3.56)

<0.001

 NH White

20.7

17.5

20.8

−1.86 (−2.02 to −1.70)

4.10 (3.60 to 4.61)

<0.001

 NH Asian/PI

7.8

6.4

7.3

−0.95 (−1.68 to −0.22)

4.14 (2.28 to 6.04)

<0.001

 Hispanic

10.9

10.7

11.3

−0.94 (−1.40 to −0.48)

1.87 (0.65 to 3.11)

<0.001

 NH Black

22.4

19.1

23.3

−1.66 (−1.98 to −1.34)

4.40 (3.43 to 5.37)

<0.001

 NH AI/AN

16.7

14.9

15.0

−1.12 (−2.14 to −0.09)

−2.08 (−4.95 to 0.89)

0.60

Other heart disease

 Total

50.6

47.7

51.4

−0.63 (−0.82 to −0.44)

1.89 (1.33 to 2.46)

<0.001

 Total male

57.1

53.9

58.1

−0.59 (−0.79 to 0.39)

2.04 (1.45 to 2.63)

<0.001

 Total female

45.1

42.1

45.2

−0.69 (−0.90 to −0.49)

1.73 (1.11 to 2.36)

<0.001

 NH White

48.1

47.1

51.5

−0.34 (−0.55 to −0.22)

2.52 (1.87 to 3.17)

<0.001

 NH Asian/PI

28.6

24.2

24.2

−1.70 (−2.06 to −1.33)

−0.38 (−1.37 to 0.61)

0.04

 Hispanic

31.9

31.4

31.9

−0.93 (−1.19 to −0.66)

0.78 (−0.06 to 1.51)

<0.001

 NH Black

85.7

72.1

75.5

−1.51 (−1.67 to −1.35)

0.42 (−0.06 to 0.91)

<0.001

 NH AI/AN

38.5

41.3

44.8

0.55 (−0.24 to 1.34)

2.57 (0.41 to 4.78)

0.14

Abbreviations: AAMR age-adjusted mortality rate, NH non-Hispanic, PI Pacific Islander, AI/AN American Indian/Alaskan Native

aAnnual rate of change age-adjusted by Poisson regression

b p-value for difference in annual rate of change between 2000 and 2011 and 2011–2015 time periods

Fig. 1
Fig. 1

Age-adjusted mortality in U.S., 2000–2015 by sex and race-ethnicity. Legend: Total, Male, Female, NH White, NH Asian/Pacific Islander, Hispanic, NH Black, NH American Indian/Alaskan Native (NH – Non-Hispanic)

In sharp contrast, mortality rates attributed to HF and all other HD declined from 2000 to 2011, but then increased from 2011 to 2015 (Table 2, Fig. 1). These patterns were evident in both sexes (Tables 3 and 4 and Fig. 1) and in all race-ethnicity groups except NH American Indian/Alaskan Natives (Tables 5, 6, 7, 8 and 9 , Fig. 1). From 2011 to 2015, the mean annual rate of increase was 3.73% for HF-related mortality and 1.89% for all other HD mortality in the total population. The difference in the rate of change between the two time periods was statistically significant overall in each sex, and in all race-ethnicity groups except NH American Indian/Alaskan Natives for HF and other HD mortality as well as NH Asian/Pacific Islander for other HD mortality (Table 2 ). Trends in crude mortality rates (Table 10) for HD and each HD subgroup were similar to age-standardized mortality trends.
Table 3

Males (age-adjusted)

Trends in mortality in United States from 2000 to 2015 by gender and race-ethnicity

  

Heart disease

Ischemic HD

Heart failure

All other HD

Year

(n = Population)

(n = deaths)

AAMR

(n = deaths)

AAMR

(n = deaths)

AAMR

(n = deaths)

AAMR

2000

138,053,563

344,807

320.0

260,574

241.4

21,175

21.5

63,058

57.1

2001

139,891,492

339,095

307.8

254,005

230.2

21,632

21.4

63,458

56.1

2002

141,230,559

340,933

303.4

252,760

224.7

21,698

21.1

66,475

57.6

2003

142,428,897

336,095

292.3

246,342

213.9

22,427

21.3

67,326

57.1

2004

143,828,012

321,973

274.1

233,538

198.4

22,292

20.8

66,143

54.9

2005

145,197,078

322,841

268.2

232,115

192.3

23,026

20.8

67,700

55.0

2006

146,647,265

315,706

254.9

224,510

180.7

23,918

21.0

67,278

53.2

2007

148,064,854

309,821

243.7

216,050

169.2

22,914

19.5

70,857

55.0

2008

149,489,951

311,201

238.5

216,248

165.1

23,017

19.0

71,936

54.3

2009

150,807,454

307,225

229.4

210,069

156.2

23,563

18.9

73,593

54.2

2010

151,781,326

307,384

225.1

207,580

151.3

24,385

19.2

75,419

54.6

2011

153,290,819

308,398

218.1

206,908

145.6

24,609

18.7

76,881

53.9

2012

154,492,067

312,491

214.7

206,685

141.1

26,036

19.1

79,770

54.5

2013

155,651,602

321,347

214.5

208,515

138.2

28,513

20.2

84,319

56.1

2014

156,936,487

325,077

210.9

207,412

133.5

30,339

20.9

87,326

56.5

2015

158,229,297

335,002

211.8

209,298

131.2

33,667

22.5

92,037

58.1

Age-adjusted mortalilty rate per 100,000 person-years, directly standardized to the 2000 U.S. population

Table 4

Female (age-adjusted)

Trends in mortality in United States from 2000 to 2015 by gender and race-ethnicity

  

Heart disease

Ischemic HD

Heart failure

All other HD

Year

(n = Population)

(n = deaths)

AAMR

(n = deaths)

AAMR

(n = deaths)

AAMR

(n = deaths)

AAMR

2000

143,368,343

365,953

210.9

254,630

146.5

34,529

19.2

76,794

45.1

2001

145,077,463

361,047

205.4

248,184

140.9

35,302

19.4

77,561

45.0

2002

146,394,634

356,014

200.3

241,622

135.7

34,796

19.0

79,596

45.6

2003

147,679,036

348,994

193.7

233,686

129.4

35,021

18.8

80,287

45.4

2004

148,977,286

330,513

181.5

217,788

119.4

34,828

18.6

77,897

43.5

2005

150,319,521

329,250

177.5

213,572

115.0

35,907

18.8

79,771

43.7

2006

151,732,647

315,930

167.2

200,915

106.3

36,419

18.6

78,596

42.3

2007

153,166,353

306,246

159.0

190,301

98.8

33,651

16.9

82,294

43.4

2008

154,604,015

305,627

155.9

189,061

96.3

33,813

16.6

82,753

42.9

2009

155,964,075

292,188

146.6

176,255

88.4

32,847

15.9

83,086

42.3

2010

156,964,212

290,305

143.3

171,979

84.9

33,372

15.9

84,954

42.5

2011

158,301,098

288,179

138.7

168,387

81.0

33,700

15.6

86,092

42.1

2012

159,421,973

287,220

135.5

164,784

77.8

34,305

15.5

88,131

42.2

2013

160,477,237

289,758

134.3

161,698

74.9

36,607

16.3

91,453

43.0

2014

161,920,569

289,271

131.8

157,181

71.6

38,287

16.8

93,803

43.4

2015

163,189,523

298,840

133.6

157,503

70.5

41,584

17.9

99,753

45.2

Age-adjusted mortalilty rate per 100,000 person-years, directly standardized to the 2000 U.S. population

Table 5

Non-Hispanic White (age-adjusted)

Trends in mortality in United States from 2000 to 2015 by gender and race-ethnicity

  

Heart disease

Ischemic HD

Heart failure

All other HD

Year

(n = Population)

(n = deaths)

AAMR

(n = deaths)

AAMR

(n = deaths)

AAMR

(n = deaths)

AAMR

2000

197,324,684

594,465

255.5

434,505

186.6

48,782

20.7

111,178

48.1

2001

197,842,671

582,349

247.2

420,959

178.5

49,788

20.8

111,602

47.7

2002

198,101,982

577,761

242.5

413,230

173.2

49,162

20.4

115,369

48.8

2003

198,289,486

565,808

234.2

400,101

165.5

49,788

20.3

115,919

48.4

2004

198,619,903

537,512

220.1

374,900

153.3

49,628

20

112,984

46.7

2005

198,880,984

535,101

215.5

368,505

148.3

50,835

20.1

115,761

47.1

2006

199,200,396

516,883

204.5

350,356

138.6

52,125

20.2

114,402

45.8

2007

199,492,421

502,683

195.5

334,047

129.9

48,480

18.4

120,156

47.2

2008

199,783,797

503,096

192.4

333,378

127.4

48,518

18.1

121,200

46.8

2009

199,993,079

485,779

182.9

315,810

118.9

48,156

17.7

121,813

46.4

2010

200,127,372

483,973

179.9

309,492

115.0

49,253

17.8

125,228

47.0

2011

200,423,243

482,979

175.6

305,486

111.1

49,605

17.5

127,888

47.1

2012

200,698,847

481,991

172.3

300,439

107.4

50,922

17.7

130,630

47.2

2013

200,918,513

488,817

171.8

297,501

104.6

54,787

18.7

136,529

48.6

2014

201,048,793

489,926

169.9

291,879

101.2

57,522

19.3

140,525

49.4

2015

201,242,281

503,172

171.9

291,850

99.7

62,649

20.8

148,673

51.5

Age-adjusted mortalilty rate per 100,000 person-years, directly standardized to the 2000 U.S. population

Table 6

Non-Hispanic Asian/Pacific Islander (age-adjusted)

Trends in mortality in United States from 2000 to 2015 by gender and race-ethnicity

  

Heart disease

Ischemic HD

Heart failure

All other HD

Year

(n = Population)

(n = deaths)

AAMR

(n = deaths)

AAMR

(n = deaths)

AAMR

(n = deaths)

AAMR

2000

11,355,553

8949

146.1

6689

109.7

418

7.8

1842

28.6

2001

11,983,178

9291

139.5

6916

104.5

392

6.7

1983

28.3

2002

12,472,384

9814

139.2

7159

102.3

445

7.1

2210

29.9

2003

12,942,337

9934

132.5

7221

96.5

474

7.1

2239

28.9

2004

13,406,530

9756

123.4

6954

88.2

475

6.6

2327

28.5

2005

13,888,295

10,281

119.8

7329

85.7

519

6.8

2433

27.3

2006

14,375,996

10,457

115.7

7430

82.3

556

6.8

2471

26.6

2007

14,854,701

10,394

108.6

7292

76.1

504

5.8

2598

26.7

2008

15,336,181

10,951

108.1

7705

76.1

606

6.5

2640

25.5

2009

15,793,995

11,134

103.8

7616

70.9

638

6.4

2880

26.5

2010

16,133,872

11,254

101.1

7683

69

694

6.7

2877

25.4

2011

16,579,709

11,406

93.8

7712

63.2

714

6.4

2980

24.2

2012

17,175,596

12,068

92.7

7959

61

825

6.8

3284

24.9

2013

17,693,870

13,064

93.2

8477

60.3

954

7.1

3633

25.7

2014

18,436,908

13,021

86.4

8360

55.3

1029

7.2

3632

23.8

2015

19,116,557

13,974

86.6

8921

55.1

1124

7.3

3929

24.2

Age-adjusted mortalilty rate per 100,000 person-years, directly standardized to the 2000 U.S. population

Table 7

Hispanic (age-adjusted)

Trends in mortality in United States from 2000 to 2015 by gender and race-ethnicity

  

Heart disease

Ischemic HD

Heart failure

All other HD

Year

(n = Population)

(n = deaths)

AAMR

(n = deaths)

AAMR

(n = deaths)

AAMR

(n = deaths)

AAMR

2000

35,305,818

25,819

196

19,744

153.2

1270

10.9

4805

31.9

2001

37,144,096

27,090

193.7

20,664

151.1

1364

10.8

5062

31.9

2002

38,617,620

27,887

188.8

20,941

144.7

1412

10.8

5534

33.2

2003

40,049,429

28,298

182.1

20,783

136.8

1606

11.5

5909

33.8

2004

41,501,375

27,788

169.1

20,482

127.4

1545

10.5

5761

31.2

2005

43,023,614

29,555

170.4

21,774

127.9

1721

11.3

6060

31.3

2006

44,606,305

28,921

157.8

20,939

116.4

1830

11.3

6152

30.1

2007

46,196,853

29,021

149.5

20,452

107.5

1890

10.9

6679

31.1

2008

47,793,785

28,951

141.4

20,261

100.8

1966

10.7

6724

30.0

2009

49,327,489

29,611

135.8

20,228

94.7

2013

10.2

7370

30.9

2010

50,477,594

30,006

132.8

20,494

92.3

2024

10

7488

30.6

2011

52,045,277

30,385

123.9

20,326

84.2

2233

10.1

7826

29.6

2012

53,027,708

31,595

122

20,751

81.1

2404

10.2

8440

30.7

2013

54,071,370

33,243

121.2

21,788

80.3

2544

10.1

8911

30.7

2014

55,387,539

34,021

116

21,871

75.3

2742

10.2

9408

30.5

2015

56,592,793

36,401

116.9

23,055

74.5

3239

11.3

10,107

31.9

Age-adjusted mortalilty rate per 100,000 person-years, directly standardized to the 2000 U.S. population

Table 8

Non-Hispanic Black (age-adjusted)

Trends in mortality in United States from 2000 to 2015 by gender and race-ethnicity

  

Heart disease

Ischemic HD

Heart failure

All other HD

Year

(n = Population)

(n = deaths)

AAMR

(n = deaths)

AAMR

(n = deaths)

AAMR

(n = deaths)

AAMR

2000

35,091,809

76,706

328.4

50,659

220.4

4936

22.4

21,111

85.7

2001

35,638,389

76,794

322.6

50,295

215.0

5094

22.7

21,405

84.9

2002

36,049,904

76,694

317.1

49,522

208.5

5143

22.7

22,029

85.9

2003

36,422,205

76,452

309.6

48,617

200.8

5294

22.9

22,541

85.9

2004

36,848,991

73,373

290.9

46,064

186.0

5198

22.2

22,111

82.8

2005

37,270,736

73,302

282.4

45,435

178.1

5570

23

22,297

81.3

2006

37,719,495

71,461

268.2

43,992

168.0

5524

22.2

21,945

78.1

2007

38,184,699

70,443

257.4

42,152

156.5

5464

21.4

22,827

79.4

2008

38,651,733

69,918

248.1

41,373

149.4

5415

20.6

23,130

78.2

2009

39,104,815

68,811

236.4

39,956

139.8

5290

19.3

23,565

77.3

2010

39,437,133

68,215

229.5

39,047

133.4

5497

19.8

23,671

76.2

2011

39,944,896

67,595

219.3

38,928

127.9

5492

19.1

23,175

72.1

2012

40,391,388

69,147

216.3

39,005

123.4

5879

19.6

24,263

73.3

2013

40,802,086

71,102

215.5

39,199

119.9

6518

21

25,385

74.7

2014

41,316,519

71,894

210.8

38,843

114.8

6962

21.6

26,089

74.4

2015

41,777,483

74,093

210.1

39,054

111.3

7772

23.3

27,267

75.5

Age-adjusted mortalilty rate per 100,000 person-years, directly standardized to the 2000 U.S. population

Table 9

Non-Hispanic American Indian/Alaskan Native (age-adjusted)

Trends in mortality in United States from 2000 to 2015 by gender and race-ethnicity

  

Heart disease

Ischemic HD

Heart failure

All other HD

Year

(n = Population)

(n = deaths)

AAMR

(n = deaths)

AAMR

(n = deaths)

AAMR

(n = deaths)

AAMR

2000

2,344,042

2350

197.8

1688

142.7

171

16.7

491

38.5

2001

2,360,621

2353

190.6

1672

135.6

163

15.9

518

39.1

2002

2,383,303

2421

195.7

1744

141.3

182

16.8

495

37.6

2003

2,404,476

2634

201.6

1855

143.5

176

16.0

603

42.2

2004

2,428,499

2524

192.8

1795

138.9

187

16.6

542

37.2

2005

2,452,970

2576

185.7

1738

126.0

216

18.3

622

41.4

2006

2,477,720

2630

182.7

1810

127.6

208

16.6

612

38.4

2007

2,502,533

2557

171.6

1719

117.0

180

14.1

658

40.6

2008

2,528,470

2549

163.6

1671

108.0

230

17.4

648

38.2

2009

2,552,151

2654

164.2

1737

107.8

230

16.5

687

39.9

2010

2,569,567

2656

161.6

1747

106.3

217

16.0

692

39.3

2011

2,598,792

2805

161

1836

104.8

222

14.9

747

41.3

2012

2,620,501

2823

153.7

1878

101.7

201

12.7

744

39.3

2013

2,643,000

3002

155.5

1949

100.4

230

13.8

823

41.2

2014

2,667,297

3118

153.3

2009

97.8

233

13.4

876

42.2

2015

2,689,706

3303

154.9

2044

95.2

286

15.0

973

44.8

Age-adjusted mortalilty rate per 100,000 person-years, directly standardized to the 2000 U.S. population

Table 10

Crude mortality rate, total population rates (per 100,000 person years)

 

Heart disease

Ischemic HD

Heart failure

All other HD

2000

252.6

183.1

19.8

49.7

2001

245.7

176.2

20.0

49.5

2002

242.3

171.9

19.6

50.8

2003

236.1

165.5

19.8

50.9

2004

222.8

154.1

19.5

49.2

2005

220.7

150.8

19.9

49.9

2006

211.7

142.6

20.2

48.9

2007

204.5

134.9

18.8

50.8

2008

202.8

133.3

18.7

50.9

2009

195.4

125.9

18.4

51.1

2010

193.6

122.9

18.7

51.9

2011

191.5

120.4

18.7

52.3

2012

191.0

118.3

19.2

53.5

2013

193.3

117.1

20.6

55.6

2014

192.7

114.3

21.5

56.8

2015

197.2

114.1

23.4

59.7

Five specific ICD-10 codes accounted for 63% of deaths attributed to other HD during 2011–2015. There was an increase in age-standardized mortality rates per 100,000 person-years from 9.7 to 11.1 for hypertensive HD (ICD-10 code I11), 5.2 to 6.3 (p < 0.001) for atrial fibrillation and flutter (ICD-10 code I48), and a decrease from 6.8 to 6.3 (p < 0.001) for cardiomyopathy (I42). Changes were not statistically significant for nonrheumatic aortic valve disorders (I35), 4.5 to 4.6 (p = 0.45); and cardiac arrest (I46), 4.4 to 4.3 (p = 0.48).

Discussion

The increase in death attributed to HD in 2015 represents a notable landmark denoting a time where the impact of prevention efforts has been at least temporarily stalled. HD mortality increased across both sexes and most race-ethnicity groups. Although a slight decline was noted for NH blacks, HD-related death rates in this subgroup remain substantially higher than in other racial/ethnic groups.

While the continued decline in IHD mortality is encouraging, the rate of decline decreased by nearly 50% during the 2011–2015 period compared to 2000–2011. The decades-long epidemic of obesity and diabetes mellitus are likely important factors contributing the deceleration of the rate of decline of cardiovascular mortality nationally [1]. A recent study analyzing data from several cohort studies demonstrated a substantial decrease in the incidence of new-onset IHD between two time periods, with baseline exams conducted from 1983 to 1990 and 1996 to 2001, and showed that the fraction of CHD attributable to diabetes decreased over time [5]. However, the prevalence of diabetes has risen considerably from the time period that diabetes was assessed for these studies, [6] and populations now living with longer duration of diabetes have higher risk of CHD [7]. Additionally, follow-up ended in 2011, the year that the IHD mortality trend change occurred, so that the findings regarding the decreasing fraction of CHD attributable to diabetes are likely to not be as relevant to the current time period.

Several U.S.-based studies have shown decline in the incidence of acute myocardial infarction with follow-up through 2008–2011, [811] with one reporting additional follow-up showing continued decline through 2014 [12]. On the other hand, the prevalence of HF is on the rise [13]. The mortality trends for ischemic heart disease and HF since 2011 parallel these findings and are therefore plausible.

CVD remain a major cause of health loss internationally. Per the recent GBD (Global Burden of Disease) study, although dramatic declines in CVD occurred in regions with high socioeconomic status, only a gradual decrease or no change was noted in most other regions [14]. Of note, the data analyzed in our study used common groupings of ICD-10 codes to define heart disease and its subtypes such as IHD and all other HD in National Vital Statistics reports for the U.S. [15] that may be slightly different than codes used in GBD studies to define CVD and subtypes [16]. Therefore, the mortality numbers may vary. Similarly, in another study, trends in CHD and CVD mortality continue to be less favorable in Latin America than in Canada and in the U.S. [17].

The National Center for Health Statistics recently reported that deaths considered HF-related (i.e., HF reported anywhere on the death certification) declined from 2000 to 2012 but increased from 2012 to 2014 [18]. It is possible that HF is being inappropriately designated as the underlying cause of death in many instances [19]. This report noted that IHD was the underlying cause of death in 2014 for 23.9% of HF-related deaths in adults aged 45 years and older but did not report on the frequency of IHD as a listed cause of death when HF was recorded as the underlying cause of death. This might slightly attenuate the downward trend in the IHD mortality rate if HF is being designated as the underlying cause of death when it is due to IHD.

Another potential cause of misclassification of HF-related mortality is competing mortality with a non-CVD cause. While it is possible that declining cancer rates could result in the recent increasing trend in HF mortality and this year’s increase in HD mortality, it is unlikely since cancer mortality has been declining at a fairly stable rate of 1.5% per year since 2000 [1]. The most plausible sources for competing non-CVD mortality are diabetes (E10-E14) and chronic lower respiratory diseases (J40–47) which have declined minimally from 2011 to 2015 (data not shown).

It is well-recognized that HF is a major and growing public health problem. Earlier estimates from projection models for the U.S. suggest that the prevalence of HF will increase by 46% from 2012 to 2030 [13]. It has been suggested that the absence of a national surveillance system significantly impedes the ability to track and manage this expected increase in HF [20]. Given this, present CDC mortality data becomes an important indicator for burden of HF. Another matter of importance is a rising proportion of patients having HF with preserved ejection fraction (HFpEF), accounting for more than 50% of incident HF cases, and no definitive treatment to so far, has been proven effective in reducing the morbidity and mortality of HFpEF [21]. Further concomitant multiple comorbid conditions are frequent in this patient population, [22] with a recent analysis from Denmark showing an increasing prevalence of comorbidities, including diabetes mellitus and hypertension, especially in younger patients with HF [23]. It is plausible that the increasing prevalence of these comorbidities and lower death rates after acute myocardial infarction are contributing to increased HF-related mortality rates. Whereas better risk factor control strategies to prevent HF may reduce the incidence, [24] more effective treatments for patients with established HF would be expected to reduce case-fatality.

Conclusions

While the mortality rate attributed to HD slowed substantially between 2011 and 2014 nationally before turning upward in 2015, trajectories among HD subgroups were heterogeneous, with IHD-related death continuing to decline while death attributed to HF and other causes of HD increased. While systematic efforts to prevent and treat IHD appear to be effective and require continued vigilance, an expanded focus on strategies to reduce deaths from HF and those attributed to other HD conditions appear needed. Finally, addressing the complex care of HF patients with multiple morbidities would likely need system-wide, multipronged health care interventions, with particularly urgent attention to developing more effective treatments for HFpEF [25].

Abbreviations

AAMR: 

Age-adjusted mortality rate

CVD: 

Cardiovascular disease

HD: 

Heart disease

HF: 

Heart failure

ICD-10: 

International Statistic Classification of Diseases and Related Health Problems, Tenth Edition

IHD: 

Ischemic heart disease

Declarations

Acknowledgements

Karin M. Winter for administrative and technical support.

Funding

Funding for this work was provided by the Cardiovascular Research Network (CVRN) with funding from the National Heart Lung and Blood Institute (NHLBI) (U19 HL91179–01) and the American Recovery and Reinvestment Act of 2009 (RC2 HL101666) (Sidney, Go).

Availability of data and materials

The source of data for determining all mortality rates for the study was the U.S. Centers for Disease Control and Prevention’s Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) dataset. CDC WONDER is a menu-driven system that makes the information resources of the Centers for Disease Control and Prevention (CDC) available to public health professionals and the public at large. For this study, the “Underlying Cause of Death, 1999–2015” section of CDC WONDER was accessed. For each cause of death noted in the paper, we entered an inquiry through the menu driven system for the number of deaths, crude death rate, and age-adjusted death rate for each of the years, 2000–2015. The link to the CDC “Underlying Cause of Death, 1999–2015” data system is https://wonder.cdc.gov/ucd-icd10.html.

Authors’ contributions

Dr. Sidney had full access to all of the data in the study and takes responsibility for the integrity of the data and the of the data analysis. Study concept and design: SS, JSR. Acquisition of data: SS, JSR. Analysis and interpretation of data: All authors. Drafting of the manuscript: SS, JSR. Critical revision of the manuscript: All authors. Statistical analysis: SS, CPQ, MES. Obtained funding: SS, ASG. Administrative, technical, or material support: SS. Study supervision: SS, JSR. All authors read and approved the final manuscript.

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

Relevant financial activities outside the submitted work included research grant support related to cardiovascular disease for Dr. Go from Astra-Zeneca, Sanofi, and CSL Behring. Dr. Rana reports receiving grant funding from Regeneron and Sanofi to his institution.

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Authors’ Affiliations

(1)
Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA
(2)
Department of Endocrinology, Kaiser Permanente South San Francisco Medical Center, South San Francisco, CA, USA
(3)
Departments of Epidemiology, Biostatistics and Medicine, University of California, San Francisco, San Francisco, CA, USA
(4)
Department of Health Research and Policy, Stanford University School of Medicine, Stanford, CA, USA
(5)
Department of Cardiology, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
(6)
Department of Medicine, University of California, San Francisco, San Francisco, CA, USA

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