JAMA Finds Cardiac Deaths Drop; County-Level Data Reveal Clusters

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The sharp decline in cardiovascular deaths is the good news. The connection between clusters of high death rates and high rates of poverty, limited education, poor diets, and lack of access to care remains the bad news.

A county-by-county analysis of deaths from cardiovascular disease over a 25-year period appearing in JAMA this week showed that while the death rate has fallen sharply, the cardiovascular death rate remains unevenly distributed.

Cardiovascular disease remains the leading cause of death in the United States, but mortality has been but in half in the past generation—from 507.4 deaths per 100,000 persons in 1980 to 252.7 deaths per 100,000 in 2014, for a relative decline of 50.2%. According to the study in JAMA appearing Tuesday, cardiovascular disease caused 846,000 deaths and the loss of 11.7 million lost years of life in 2014.

The decline stems from multiple factors—advances in treatments, both surgical and therapeutic, better care after cardiac events, and the payoff from decades of public health efforts to combat smoking. Widespread efforts to ban smoking from indoor spaces, including airplanes and workplaces, began with the efforts of US Surgeon General C. Everett Koop in the 1980s.


Still, the authors find that county-level data show that there remain concentrations of counties with high cardiovascular disease mortality, which extend from southeastern Oklahoma along the Mississippi River Valley to eastern Kentucky. In 2014, there was a 4-fold difference in hypertensive heart disease mortality in counties at the 90th percentile and those at the 10th percentile (17.9 deaths vs 4.3 deaths per 100,000 persons).

Some clusters of cardiovascular disease conditions were found outside the South, including areas with high rates of atrial fibrillation in Oregon, aortic aneurysm in in Minnesota and Wisconsin, and endocarditis in the Mountain West and Alaska. Mississippi and Alabama had multiple counties with high rates of rheumatic heart disease.

The lowest cardiovascular mortality rates were found in the counties around San Francisco, California, central Colorado, northern Nebraska, central Minnesota,, northeastern Virginia, and southern Florida.

In an accompanying editorial, authors George Mensah, MD; David C. Goff, MD, PhD; and Gary H. Gibbons, MD, notes that the swaths of the country with high rates of cardiovascular death also have high levels of unhealthy behaviors—smoking, lack of physical activity, poor diet—and high risk factors like elevated levels of low-density lipoprotein cholesterol, hypertension, obesity, and diabetes.

“Geographic variation in the social determinants of cardiovascular health is a compelling explanation for much of the variation described by Roth and colleagues,” they wrote. “These social determinants include factors related to social status, such as poverty, income, education, occupation, and lifestyle behaviors … housing quality, neighborhood environment, environmental pollution, and access to quality healthcare.”

Besides the overall drop in cardiovascular mortality, the mortality gap between counties narrowed in some key categories: ischemic heart disease, stroke, and aortic aneurysm, the commentators noted. This reflects public health efforts, and shows they can work.


Roth GA, Dwyer-Lindgren L, Bertozzi-Villa A, et al. Trends and patterns of geographic variation in cardiovascular mortality among US counties, 1980-2014. JAMA; 2017; 317(19):1976-1992. doi:10.1001/jama.2017.4150.