'Dramatic Shift' in US Map of Heart-Disease Mortality

Marlene Busko

March 28, 2016

ATLANTA, GA — Whereas 40 years ago, people living in the Northeast United States had the highest rates of death from heart disease, this has changed "dramatically," so that now this is true for people living in the Deep South, according to new research[1]. Moreover, the difference between the counties with the greatest vs smallest decline in cardiac deaths has doubled.

"The sweeping geographic changes in heart-disease mortality observed over a relatively short period of time, with a shift of high-rate counties from the Northeast to the Deep South, suggest that systematic changes may have occurred in a variety of biomedical, behavioral, and socioenvironmental factors," Dr Michele Casper (Centers for Disease Control and Prevention, Atlanta, GA) and colleagues write in their article that was published March 21, 2016 in Circulation.

"These results . . . provide important information for tailoring clinical heart-disease prevention and treatment services and policies to communities with the greatest burdens," according to the authors.

Continuing socioeconomic and racial disparities in behavioral risk factors and the experience of inequality underlie these geographic changes, Dr Donald A Barr (Stanford University School of Medicine, CA) writes in an accompanying editorial[2]. "As physicians we need to be able to incorporate this understanding into our own practice, while also ensuring that future physicians will gain this understanding as part of their medical education," he urges.

AHA spokesperson Dr Martha L Daviglus (University of Illinois at Chicago) told heartwire from Medscape that "the key implications of these findings are that use of national data alone can mask key patterns in heart-disease disparities." Thus, in addition to national strategies to try to lower the rate of death from heart disease, targeted, local strategies are needed.

Regional Differences in Heart-Disease Deaths

Although the dramatic decline in deaths from heart disease in the US over the past 4 decades is well documented, it is still the leading cause of death, and no study has systematically zoomed in on long-term regional differences.

Casper and colleagues analyzed deaths from heart disease (defined as excluding stroke) during 1973 to 2010 in individuals who were 35 or older and lived in 3099 counties in the 48 contiguous states.

At the beginning of the study (1973–1974), the counties with the highest age-standardized heart-disease death rates (top quintile) were located in the Northeast through much of Appalachia, the Midwest, and coastal areas of North Carolina, South Carolina, and Georgia.

By the end of the study (2009–2010), many counties in the South and southern Appalachians had the highest heart-disease mortality rates.

The percentage of counties with the highest heart-disease mortality fell in the North (from 48% to 4%) and the Midwest (from 17% to 6%), but increased in the South (from 24% to 38%).

Counties with the slowest declines in heart-disease mortality (9.2%–49.6%) were mainly in the southern states of Alabama, Mississippi, Louisiana, Arkansas, Oklahoma, and parts of Texas. Counties with the fastest declines (64.1%–83.4%) were largely in the northern part of the United States, as well as Florida and South Carolina.

Although Casper et al did not delve into reasons behind the geographic differences in death rates, Barr points to racial and socioeconomic disparities and a slower decline in heart failure.

As a result of declining rates of smoking, better control of cholesterol levels, and rising rates of obesity, diabetes, and hypertension, deaths from heart disease are increasingly due to heart failure as opposed to coronary heart disease, he writes. Further, "this shift disproportionately impacts blacks and others with lower levels of education, population groups found disproportionately in southern states," he explains.

The authors have no relevant financial relationships. Barr receives royalties from Johns Hopkins University Press for three textbooks he has written that relate to the material discussed in the article.

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