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Adverse Heart Failure Outcomes Linked to Rural Residence in Southeast


Using data from the Southern Community Cohort Study, investigators compared outcomes between Black and White participants for heart failure risk.

Among individuals who did not have heart failure (HF) at study enrollment, having residence in a rural location in the Southeast region of the United States has been linked to a higher risk of developing HF, even after adjusting for cardiovascular disease (CVD) risk factors and socioeconomic status (SES).

This outcome was seen primarily among women and Black men, with the findings published online today in JAMA Cardiology. The prospective cohort study, a subanalysis of date from the Southern Community Cohort Study (SCCS), compared potential outcomes between Black (n = 18,647) and White (n = 8468) participants for HF risk, considering contributions from CVD and SES. All participants received care from CMS and were enrolled in the SCCS between 2002 and 2009 from Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Virginia, and West Virginia. Self-reported data on face, demographics, SES, health behaviors, and medical history were analyzed from October 2021 through November 2022 after follow-up ended on December 31, 2016. Their median (IQR) age was 54 (47-65) years.

“Rural populations experience an increased burden of HF mortality compared with urban populations. Whether HF incidence is greater among rural individuals is less known,” the study investigators wrote. “Additionally, the intersection between racial and rural health inequities is understudied.”

Just 20% of the study population included in the present analysis lived in a rural location, but still their age-adjusted incidence of HF (per 1000 person-years) was 23% higher compared with urban residents: 36.5 (95% CI, 34.9-38.3) vs 29.6 (95% CI, 28.9-30.5; P < .001). Further, Black men had the highest age-adjusted incidence rate of all groups evaluated, at 40.4 (95% CI, 36.8-44.3).

The risk of HF was elevated by 19% among rural vs urban residents (HR, 1.19; 95% CI, 1.13-1.26) overall. This elevated risk was highest among Black men, at 34% (HR, 1.34; 95% CI, 1.19-1.51); White women, at 22% (HR, 1.22; 95% CI, 1.07-1.39); and Black women, at 18% (HR, 1.18; 95% CI, 0.81-1.16). In contrast, White men who lived in a rural location did not have an elevated HF risk compared with White men who lived in an urban location (HR, 0.97; 95% CI, 0.81-1.16).

With the exception of depression, which was seen among 32.8% of urban residents vs 28.4% of rural residents at baseline, all comorbidities evaluated were seen in higher rates among the rural residents included in the study:

  • Hypertension: 67.2% vs 61.3%
  • Diabetes: 29.1% vs 25.9%
  • Coronary disease: 9.5% vs 8.4%
  • Hyperlipidemia: 42.2% vs 38.9%
  • Stroke: 9.9% vs 9.5%
  • Body mass index: 29.7 (25.5-35.1) vs 29.0 (24.7-34.5)

Regarding smoking status, those living in rural locations accounted for fewer current smokers (42.2% vs 31.6%) but more former smokers (24.7% vs 37.6%). And although income levels (< $15,000; $15,000-$24,999; > $25,000) were equivalent between the 2 location types, when neighborhood deprivation index (NDI) rankings were considered, fewer rural residents lived in NDI quartile 1 (least deprived) areas, at 27.6% vs 16.4%, while more urban residents lived in NDI quartile 4 (most deprived) areas, at 25.5% vs 21.3%. More rural residents also had less than a high school education compared with urban residents (37.2% vs 43.2%) and fewer had a high school diploma (54.4% vs 48.1%).

Overall, for the 4 models utilized by the study investigators to evaluate potential rurality-associated risk of incident HF—demographic-, biological-, behavioral-, and sociocultural environment–related—Black men had the highest risks in each model and White men the lowest.

“Our study population reflected the demographics of rural America, namely older age, lower educational attainment, and greater burden of CV disease and comorbidities,” the authors underscored, pointing to the strength of the SCCS data, “which enabled extensive adjustment.”

They consider potential reasons for their findings to include that the higher risk among rural residents is multifactorial—driven by societal, community, and interpersonal factors—and extends beyond individual-level causes to structural racism and health care inequities.

“Our hypothesis-generating results suggest a need to personalize prevention, focusing on rural women and rural Black men as key groups and to elucidate the mechanism by which rurality is associated with HF risk,” they concluded. “These inequities highlight the intersectionality of race and sex and rurality and the need for further investigation into the rurality-associated risk of HF to guide public health efforts aimed at HF prevention among rural populations.”


Turecamo SE, Xu M, Dixon D, et al. Association of rurality with risk of heart failure. JAMA Cardiol. Published online January 25, 2023. doi:10.1001/jamacardio.2022.5211

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