US heart failure deaths in 2021 reached levels not seen since 1999
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Key takeaways:
- Age-adjusted heart failure mortality in the U.S. in 2021 was at rates not seen since 1999.
- The largest increases were observed in those younger than 45 years, aged 45 to 64 years and Black individuals.
Decades of declining heart failure mortality in the U.S. has reversed, and exceeded rates recorded more than 20 years ago, according to overall population-level data published in JAMA Cardiology.
“Recent data suggest plateaus or reversals after long-standing declines in cardiovascular mortality, particularly for HF-related mortality,” Ahmed Sayed, MBBS, of the faculty of medicine at Ain Shams University in Cairo, and colleagues wrote. “There is little data on the association of the COVID-19 pandemic with these trends and the net change in contemporary HF mortality rates and disparities. Accordingly, we investigated the current status of HF mortality rates in relation to historical declines and whether they vary across sociodemographic subgroups.”
Using data from the CDC Wide-ranging Online Data for Epidemiological Research (WONDER), Sayed and colleagues evaluated age-adjusted HF mortality rates per 100,000 people in the overall population and stratified by age, sex, race/ethnicity, urbanization status and census region. Annual percentage change in age-adjusted HF mortality rates were calculated for five time periods from 1999 to 2021.
HF-related mortality declined from 1999 to 2005 with an annual percentage change of –1.62%; declined even further from 2005 to 2009 with an annual percentage change of –3.29%; and plateaued –0.95% from 2009 to 2012.
From 2012 to 2019, HF-related mortality increased with an annual percentage change of 1.82% and accelerated further in 2020 and 2021 with an annual percentage change of 7.06%.
Sayed and colleagues reported that the increases in HF-related mortality from 2012 to 2021 were substantially larger than the initial declines in prior periods, translating to a 103.2% reversal in HF-related mortality.
Moreover, the reversals in HF-related mortality were observed in all subgroups but varied in magnitude, with the greatest reversals seen in:
- those younger than 45 years (906.3%);
- those aged 45 to 64 years (384.7%);
- Black individuals (166.5%);
- men (119%);
- those living in the South (118.2%);
- those living in the Midwest (115.3%); and
- those living in rural areas (92.3%).
Results were similar when restricted to HF as the underlying cause of death, according to the study.
“The origins of these reversals preceded the COVID-19 pandemic, although the larger increases in 2020 to 2021 indicate that the pandemic may have accelerated them due to limitations to health care access and possible cardiac involvement,” the researchers wrote. “An important limitation of this analysis is the reliance on death certificate data, which may misattribute some deaths, particularly in cases where symptoms of HF cannot be easily differentiated from those of other causes (eg, COVID-19) and the inability to disaggregate race and ethnicity in a more granular manner.
“Additionally, changes in diagnostic methods, coding patterns and longer survival for patients with conditions that predispose to heart failure (eg, ischemic heart disease) may lead to an increase in the prevalence of HF, thereby increasing the observed HF mortality rate,” they wrote.
Perspective
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This study confirms previous findings indicating that:
No. 1, mortality rates due to HF have been on the rise since 2012, with a particularly alarming acceleration in mortality since 2020.
No. 2, the most significant increases are observed in individuals under 45 years old, followed by those aged 45 to 64, compared with older demographics.
No. 3, non-Hispanic Black individuals exhibit the highest rates of HF mortality and the most significant increases since 2012, surpassing other racial and ethnic groups.
No. 4, rural areas, particularly in the Southern and Midwestern regions of the U.S., show the highest HF mortality rates and increases in mortality rates.
These results suggest that the adverse trends identified in the "Heart Failure Epidemiology and Outcomes Statistics" published in 2023 are persisting and getting worse (Bozkurt B, et al. J Card Fail. 2023;doi:10.1016/j.cardfail.2023.07.006.).
The lifetime risk for developing HF has risen from 1 in 5 to 1 in 4 individuals, attributed partly to advancements in treating ischemic, valvular, hypertensive and congenital heart diseases, leading to HF development along with increasing comorbidities. Thus, HF may be replacing other CVDs as a cause of CV death.
There may be an increase in coding HF as a cause of death on death certificates, potentially reversing previous underreporting. Historically, reported mortality rates underestimated HF-related deaths due to underreported cases. Clinicians may now be more apt to identify HF as a primary cause of death rather than a secondary factor.
Although one-third of all CV deaths are usually attributable to HF, the reported absolute number of deaths with HF as an underlying cause of death was only 85,855, while the total number of CV deaths were 928,741 deaths in the U.S. by 2020 (above reference). This underreporting may have been recognized and clinicians may be identifying HF as an underlying cause of death, rather than a mediator between death and diseases such as CAD, hypertension and cardiomyopathy. In the past, we assumed that 72% to 79% of deaths that could have been attributed to HF were not actually being reported or captured as HF-related deaths, and this may be changing with increased awareness.
The prevalence of comorbidities, especially hypertension, diabetes and obesity, along with their clustering in vulnerable populations, likely contributes to increased HF mortality rates.
Limited access to care and treatment in vulnerable populations, along with health inequities, is leading to marked increases in mortality among Black patients and for those individuals living in rural areas.
Despite clear indications, evidence, guidelines and performance measures, newer therapies for HF are not widely utilized, widening the treatment gap and resulting in increased mortality rates.
Increased exposure to cardiotoxic viruses, agents and therapies may also play a partial role in both individual and population-level mortality rates (eg, COVID-19, environmental pollutants, illicit drugs, cancer therapies and other biological agents).
I believe these adverse trends will persist unless patients receive correct diagnoses and are prescribed appropriate guideline-directed therapies promptly and uniformly for HF. Existing health care delivery models lack structured processes and incentivization for implementing guideline-directed medical therapy or care coordination throughout a patient's journey. Current models primarily focus on episodic care, such as hospitalization and Diagnosis-Related Group reimbursement, resulting in delays in care and discontinuation of treatment for a significant portion of patients. Additionally, with the closure of health care facilities and the consolidation of health networks in rural areas, access to care is diminishing, further contributing to increased mortality rates in these regions. These structural inequities, combined with the clustering of comorbidities such as hypertension and diabetes, contribute to disparities in increased mortality rates, especially among Black patients.
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