An Excess of Heart Failure–Related Deaths Seen in Rural Counties

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Heart failure has been shown to be a contributing factor in more deaths in rural vs urban counties in which cardiovascular disease was pinpointed as the underlying cause of death.

Heart failure has been shown to be a contributing factor in more deaths in rural vs urban counties in which cardiovascular disease (CVD) was pinpointed as the underlying cause of death from January 1, 2011, to December 31, 2018, according to study findings published in PLoS One.

Previous research has not put an exact number on the disparity between heart failure–related deaths in urban and rural counties, the authors highlight, even though “cardiovascular disease is more prevalent among adults living in rural US counties than those in urban counties, and that deaths attributed to heart failure have risen nationwide since 2011,” according to a statement on the findings.

For their study, the investigators from Northwestern University’s Feinberg School of Medicine culled county-level data from the CDC’s Wide-Ranging Online Data for Epidemiologic Research Multiple Cause of Death Online Database. Adults aged 35 to 64 years and 65 to 84 years from all 50 states and the District of Columbia whose primary and secondary causes of death were CVD and heart failure, respectively, were included.

Overall, larger increases were seen in younger adults (aged 35-64 years) compared with older adults (aged 65-84 years), with the rural vs urban county difference especially notable in the South and primarily affected by socioeconomic and clinical risk factors. Broken down by race/ethnicity, young Black men had the largest annual mortality increase: 6.1% (95% CI, 3.7%-8.5%).

The research also revealed these findings:

  • There were more total heart failure–related deaths in urban vs rural counties, at 580,305 vs 162,314, but higher age-adjusted mortality rates (AAMRs; per 100,000 adults) in rural counties: 73.2 (95% CI, 72.2-74.2) vs 57.2 (95% CI, 56.8-57.6).
  • Young Black men had the highest overall AAMR in 2018: 131.1 (95% CI, 123.3-138.9).
  • A higher incident rate ratio, following multivariable negative binomial regression, among younger patients in rural compared with urban counties: 1.10 (95% CI, 1.04-1.16) vs 1.04 (95% CI, 1.02-1.07).
  • Persistent overall year-over-year increases in annual heart failure–related deaths:
    • Rural counties: 1.3% (95% CI, 0.9%-1.8%)
    • Urban counties: 1.2% (95% CI, 0.7%-1.7%).
  • Sizeable yearly increases among younger vs older adults in rural and urban counties:
    • Younger adults: rural, 4.6% (95% CI, 3.7-5.5%); urban, 4.4% (95% CI, 4.0-4.9%)
    • Older adults: rural, 1.3% (95% CI, 0.9%-1.8%); urban, 1.2% (95% CI, 0.7%-1.7%).
  • Notable AAMR race/sex differences in rural counties in 2018:
    • Black women: 32.7 (95% CI, 28.8-36.7)
    • White women: 11.0 (95% CI, 10.3-11.6)
    • Black men: 52.3 (95% CI, 47.4-57.3)
    • White men: 20.8 (95% CI, 19.8-21.7).
  • AAMR was 2.3 times greater in counties at the 90th vs the 10th percentile: 100.3 vs 43.6.
  • No practicing cardiologists in 51.1% and 74.9% of rural counties, when looking at those with the most younger and older adult deaths, respectively.

County-level data were provided by the US Census Bureau Population and Housing Unit Estimates, Small Area Income and Poverty Estimates Program, Small Area Health Insurance Estimates Program files, US Bureau of Labor Statistics Local Area Unemployment Statistics file, CDC Behavioral Risk Factor Surveillance System, and the Health Resources and Services Administration Area Health Resources File.

The authors note that their findings are especially important because they highlight the ever-increasing gap between rural and urban counties for heart failure–related deaths, especially in the South, and show a correlation with that region of the United States and its higher rates of diabetes and obesity.

They also identify a great need for community-level prevention efforts, as well as highlight social and economic differences in the 2 county types, including that rural counties experience disproportionately higher rates of hospital closures.

Future studies should investigate the effects of the Affordable Care Act on heart failure–related mortality rates and access to physicians and hospitals, because hospital closure rates have been lower in states that expanded Medicaid coverage. Investigators should also examine differences in heart failure–related mortality in smaller areas.

“Differences in county-level factors may account for a significant amount of the observed variation in heart failure–related mortality between rural and urban counties,” the authors concluded. “Efforts to reduce the rural-urban disparity in heart failure–related mortality rates will likely require diverse public health and clinical interventions targeting the underlying causes of this disparity.”


Pierce JB, Shah NS, Petito LC, et al. Trends in heart failure-related cardiovascular mortality in rural versus urban United States counties, 2011–2018: a cross-sectional study. PLoS One. Published online March 3, 2021. doi:10.1371/journal.pone.0246813