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Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease logoLink to Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease
. 2025 Sep 11;14(18):e040340. doi: 10.1161/JAHA.124.040340

Demographics and Trends of Sudden Cardiac Death‐Related Mortality in the United States, 1999 to 2022

Vikash Jaiswal 1, Danisha Kumar 2, Yusra Mashkoor 2, Fakhar Latif 2, Sai Gautham Kanagala 3, Anupam Halder 4, Akash Jaiswal 5, Dhrubajyoti Bandyopadhyay 6, Adrija Hajra 7, Amey Joshi 8,✉, Wilbert S Aronow 9, Gregg C Fonarow 10
PMCID: PMC12554413  PMID: 40932104

Abstract

Background

There is a paucity of data regarding mortality trends among individuals experiencing sudden cardiac death (SCD). Therefore, we aimed to investigate the trends in SCD‐related mortality across all age groups in the United States.

Methods

This retrospective cohort analysis used the US Centers for Disease Control and Prevention Wide‐ranging Online Data for Epidemiologic Research data from 1999 to 2022. The study focused on patients of all age groups with SCD listed as either a contributing or underlying cause of death. Age‐adjusted mortality rates per 100 000 were calculated and stratified by sex, race, ethnicity, region, state, and place of death.

Results

A total of 311 218 SCD‐related deaths were reported. Overall, age‐adjusted mortality rates declined from 4.52 (95% CI, 4.44–4.60) in 1999 to 3.51 (95% CI, 3.43–3.56) in 2022. A downward trend was observed from 1999 to 2018 (APC, –1.94 [95% CI, −2.23 to −1.69]), followed by a sharp rise from 2018 to 2022 (APC, 7.07 [95% CI, 3.38–9.46]). Men consistently had higher age‐adjusted mortality rates than women (5.23 versus 2.71). Non‐Hispanic Black individuals had the highest age‐adjusted mortality rates (5.66), and Non‐Hispanic Asians had the lowest (1.23). Mortality rates were greater in nonmetropolitan and southern US regions. States in the upper 90th percentile (eg, Mississippi, North Carolina) had markedly higher mortality burdens than those in the lower 10th percentile (eg, Arizona, Maryland). Individuals aged ≥85 years had the highest crude mortality rate (51.3).

Conclusions

Although SCD‐related mortality declined over 2 decades, rates have risen significantly since 2018. Persistent disparities by sex, race, geography, and age call for urgent, targeted public health interventions.

Keywords: cardiac arrest, disparities, mortality, sudden cardiac death

Subject Categories: Sudden Cardiac Death

Nonstandard Abbreviations and Acronyms

AAMR

age‐adjusted mortality rates

APC

annual percentage change

CDC

Centers for Disease Control and Prevention

CMR

crude mortality rate

NH

Non‐Hispanic

Clinical Perspective.

What Is New?

  • This study revealed that after a steady decline from 1999 to 2018, sudden cardiac death‐related mortality surged from 2018 to 2022, with the highest burden in men, Non‐Hispanic Black population, older adults (≥85 years), nonmetropolitan areas, and southern US regions.

What Are the Clinical Implications?

  • The increase in sudden cardiac death‐related mortality highlights poor cardiometabolic risk factor control (obesity, diabetes, hypertension) and underscores the need for targeted interventions, improved cardiopulmonary resuscitation/automated external defibrillator training, and equitable access to preventive cardiac care.

  • Advancing early detection strategies, genetic screening for inherited arrhythmias, and cardiac magnetic resonance imaging for myocardial fibrosis assessment could help reduce future sudden cardiac death risks, especially in high‐risk populations.

Sudden cardiac death (SCD), which is defined as an unexpected death within 1 hour of symptom onset from cardiovascular cause, is a common cause of death with a high mortality rate. 1 SCD is responsible for 10%to 15% of deaths globally, and an estimated number of more than 356 000 individuals have out‐of‐hospital cardiac arrests (OHCA) in the United States annually. 2 , 3 There are multiple challenges in comprehending the epidemiology of cardiac arrest in the United States. Although it is a major cause of death, there is no defined surveillance for tracking the incidence and outcomes of cardiac arrest. SCD can be due to arrhythmic or nonarrhythmic causes, such as coronary artery disease, hypertrophic cardiomyopathy, or myocarditis, and often the diagnosis is made during an autopsy. 4

Despite substantial efforts, the overall survival rate to hospital discharge remains low at 11% for those treated by emergency medical services. However, outcomes have shown improvement over the past decade compared with earlier periods. Enhanced survival rates in these patients are due to advancements in medical devices like implantable cardioverter‐defibrillators and a structured approach to postcardiac arrest care, including procedures like percutaneous coronary intervention, arrhythmia management, hemodynamic support, therapeutic hypothermia, metabolic stabilization, and ventilator support. 5 According to the latest statistics, SCD trends in the United States show notable variations and complexities. In 2019, primary‐cause SCD mortality was 18 581, and any‐mention SCD mortality reached 370 494. 6 As of now, ischemic heart disease remains the most common cause of SCD, but recent trends show a decrease in incidence and a rise in cases related to cardiomyopathy with myocardial fibrosis and left ventricular hypertrophy.

The main challenge in SCD burden is identifying the small, high‐risk subgroups with no diagnosed disease but who are at risk of sudden cardiac arrest (SCA) as their first cardiac event. 7 Despite some progress in SCD risk prediction, this remains a significant obstacle. Although survival rates for SCD have improved over recent decades, there has been a concurrent increase in the health care burden. The health care expenses linked to initial hospitalization following cardiac arrest are adding an increasing financial strain on the US health care system. An estimated total cost of out‐of‐hospital cardiac arrests in the United States is $33 billion per year, with 17% of that cost coming from initial hospitalizations after cardiac arrest. 8 In this present study, we aimed to evaluate temporal trends in SCD‐related deaths from 1999 to 2022.

METHODS

Data Source

The authors declare that all supporting data are available within the article and its online supplementary files. The analysis was based on the data sourced from the Centers for Disease Control and Prevention Wide‐Ranging Online Data for Epidemiologic Research (WONDER) database, which includes causes of mortality from the death certificates from 50 states and the District of Columbia in the United States. 9 We analyzed multiple cause‐of‐death public use record death certificates to identify deaths related to SCD. The study included the following International Classification of the Diseases, Tenth Revision (ICD‐10) code to identify SCD: I46.1. 10 The study did not require institutional review board approval because it exclusively analyzed publicly available, deidentified government‐issued data. Furthermore, the study was conducted in adherence to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines. 11

Data Extraction

The number of SCD‐related deaths and population sizes were extracted from 1999 to 2022. The data on age, sex, race and ethnicity, region, state, and place of death were also obtained. The patients of all ages were selected and divided into 10‐year age groups. For race and ethnicity, patients were stratified into Hispanic, Non‐Hispanic (NH) White, NH Black, NH Asian/Pacific Islander, and NH American Indian/Alaskan Native. Regions were categorized into Northeast, Midwest, South, and West, following the Census Bureau‐defined regional divisions. The population was additionally classified into metropolitan, nonmetropolitan, and rural counties in accordance with the National Center for Health Statistics Urban–Rural Classification Scheme. 12

Statistical Analysis

Crude mortality rates (CMRs) and age‐adjusted mortality rates (AAMRs) per 100 000 population were calculated for SCD‐related deaths. CMRs were derived by dividing the number of SCD‐related deaths by the corresponding US population for that specific year. AAMRs were determined by standardizing the SCD‐related deaths to the year 2000 US population. 13 Trends in both crude and age‐adjusted mortality rates were analyzed using the Joinpoint Regression Program (Version 4.9.0.0, National Cancer Institute), which models consecutive linear segments on a log scale connected by joinpoints, where the segments converge. 14 The Joinpoint Regression Program identifies significant changes in linear trends by applying Monte Carlo permutation testing to determine the number and location of joinpoints. Annual percentage changes (APCs) were estimated using log‐linear models, and statistical significance was defined by 95% CIs that excluded zero.

RESULTS

A total of 311 218 SCD‐related deaths occurred between 1999 and 2022 (Table S1). Information for the location of death was available for 311 197 deaths. Of these, 39.4% were in medical facilities, 41.6% occurred at homes, 13.5% occurred within nursing homes/long‐term care facilities, and 4.9% occurred in places other than these (Table S2).

Annual Trends for SCD‐Related AAMR

The AAMR for SCD‐related deaths was 4.52 (95% CI, 4.44 to 4.60) in 1999 and 3.51 (95% CI, 3.43–3.56) in 2022. The overall AAMR declined from 1999 to 2018 (APC, −1.94; 95% CI, −2.23 to −1.69), followed by an increase from 2018 to 2022 (APC, 7.07; 95% CI, 3.38–9.46) (Figure 1, Table S1). The year 2018 was identified as a statistically significant joinpoint using the Joinpoint Regression Program, which determines inflection points by testing whether additional joinpoints improve model fit using a Monte Carlo permutation method. Although 2019 had a slightly lower rate than 2018, the model found a statistically significant upward trend beginning in 2018. As this joinpoint is derived from the same data set used to estimate effect sizes, results should be interpreted cautiously to avoid overprecision.

Figure 1. Sudden cardiac death‐related mortality trends along the years, 1999 to 2022.

Figure 1

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SCD‐Related AAMR Stratified by Sex

Over the study duration, men consistently exhibited higher AAMRs than women (overall AAMR males, 5.23 [95% CI, 5.11–5.35]), (overall AAMR women, 2.71 [95% CI, 2.63–2.78]). Specifically, in 1999, the AAMR for men was 6.18 (95% CI, 6.03–6.33), which steadily declined to 4.34 (95% CI, 4.24–4.44) in 2018 (APC, −1.95 [95% CI, −2.26 to −1.69]). This was followed by a significant incline from 2018 to 2022 (APC, 3.67 [95% CI, 1.37–8.25]) (Figure 2, Table S3).

Figure 2. Sudden cardiac death‐related mortality trends stratified by sex, in 1999 to 2022.

Figure 2

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AAMR indicates age‐adjusted mortality rates.

On the other hand, the AAMR for men showed a period of decline from 1999 to 2010 (APC, −1.47 [95% CI, −1.93 to 0.01]). This was followed by a period of further decline from 2010 to 2017 (APC, −3.52 [95% CI, −6.69 to −2.46]). Eventually, the AAMRs showed an incline from 2017 to 2022 (APC, 2.94 [95% CI, 1.14–5.99]) (Figure 2, Table S3).

SCD‐Related AAMR Stratified by Race and Ethnicity

When stratified by race and ethnicity, variations in AAMRs for SCD‐related deaths were evident. The AAMRs were found to be highest in the NH Black population with a rate of 5.66 (95% CI, 5.39–5.93), followed by NH White at 3.98 (95% CI, 3.90–4.05), NH American Indian at 3.48 (95% CI, 2.64–4.52), and Hispanic population at 1.53 (95% CI, 1.36–1.69). The lowest AAMRs were observed in the NH Asian population, with a rate of 1.20 (95% CI, 1.00–1.40) (Figure 3).

Figure 3. Sudden cardiac death‐related mortality trends stratified for differential racial groups in 1999 to 2022.

Figure 3

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In brief, the AAMRs for NH American Indian or Alaska Native population declined steadily from 1999 to 2022 (APC, −2.74 [95% CI, −3.49 to −1.94]). Similarly, the AAMRs for NH Asian or Pacific Islander population declined from 1999 to 2022 (APC, −1.22 [95% CI, −1.80 to −0.53]). Moreover, the AAMRs for the Hispanic population significantly declined from 1999 to 2017 (APC, −2.55 [95% CI, −4.07 to −1.70]). This was followed by a sharp increase in the AAMRs from 2017 to 2022 (APC, 4.84 [95% CI, 0.52–14.85]). With respect to NH Black population, AAMRs increased from 1999 to 2006 (APC, 2.44 [95% CI, 0.41–5.84]) with a subsequent decrease from 2006 to 2018 (APC, −4.09 [95% CI, −6.27 to −3.22]). This was followed by a significant rise from 2018 to 2022 (APC, 6.37 [95% CI, 1.65–15.05]). Among the NH White population, a steady decline in AAMRs was observed from 1999 to 2018 (APC, −1.57 [95% CI, −1.77 to −1.40]). This was followed by a sharp increase during the 2018 to 2020 period (APC, 3.95 [95% CI, 2.25–6.53]) (Figure 3, Table S4).

SCD‐Related AAMR Stratified by Geographic Region

Rural–Urban Classification

In a consistent pattern through the majority of the study period, metropolitan areas witnessed a lower AAMRs related to SCD than nonmetropolitan areas, with overall AAMRs of 3.09 (95% CI, 3.07–3.10) and 7.30 (95% CI, 7.26–7.35), respectively. Furthermore, the AAMRs of nonmetropolitan areas showed a period of stability from 1999 to 2006 (APC, −0.05 [95% CI, −0.91 to 4.33]), which was then followed by a significant decrease from 2006 to 2018 (APC, −1.52, [95% CI, −5.41 to −1.13]). After that, there was a sharp increase from 2018 to 2020 (APC, 7.00 [95% CI, 0.35–10.88]). Similarly, AAMRs of metropolitan areas exhibited a steady decline from 1999 to 2013 (APC, −1.87 [95% CI, −2.08 to −1.49]). Subsequently, the AAMRs further decreased from 2013 to 2018 (APC, −3.77 [95% CI, −5.80 to −2.81]), followed by a sharp increase from 2018 to 2020 (APC, 8.52 [95% CI, 5.03–11.30]) (Figure 4, Table S5).

Figure 4. Sudden cardiac death‐related mortality trends stratified for metropolitan vs nonmetropolitan.

Figure 4

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AAMR indicates age‐adjusted mortality rates.

States

Across various states, a significant disparity in SCD‐related AAMRs has been observed, with the figures spanning from 27.42 (95% CI, 27.03–27.82) in Mississippi to 0.90 (95% CI, 0.85–0.94) in Maryland (Figure 5A, Table S6). The states in the top 90th percentile of SCD‐related AAMRs included Mississippi, Louisiana, Wyoming, Tennessee, and Alabama, and the bottom 10th percentile included Connecticut, Rhode Island, the District of Columbia, Nevada, and Maryland. These rankings reflect descriptive differences in mortality rates, and statistical comparisons should be interpreted cautiously as they derive from the same data set.

Figure 5. Sudden cardiac death‐related mortality trends.

Figure 5

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A, Stratified across 50 states, (B) Stratified for different census regions.

Census Regions

When stratified by census regions, variations in AAMRs for SCD‐related deaths were evident. Southern regions consistently exhibited higher AAMRs compared with other regions. Specifically, AAMRs in the Northeast declined from 1999 to 2008 (APC, −2.71 [95% CI, −4.34 to −2.11]), followed by a period of stability from 2008 to 2011 (APC, 2.39 [95% CI, −0.75 to 4.23]). This was followed by another decline from 2011 to 2016 (APC, −4.07 [95% CI, −7.39 to −2.53]) and a further increase from 2016 to 2020 (APC, 2.64 [95% CI, 1.344.72]). The AAMRs of Southern regions stabilized from 1999 to 2008 (APC, −0.28 [95% CI, −1.08–0.82]), followed by a decline from 2008 to 2017 (APC, −4.45 [95% CI, −6.21 to −3.60]). Subsequently, the AAMRs in the Southern region increased from 2017 to 2022 (APC, 4.44 [95% CI, 2.33–7.48]). Midwestern regions displayed a decline in AAMRs between 1999 and 2009 (APC, −2.74 [95% CI, −4.65 to −1.92]), followed by a slight incline from 2009 to 2022 (APC, 0.30 [95% CI, −0.88 to 0.84]). Likewise, the Western region exhibited an initial period of stability from 1999 to 2019 (APC, −1.04 [95% CI, −2.14 to −0.52]), followed by an eventual sharp increase from 2019 to 2022 (APC, 8.05 [95% CI, 0.84–16.51]) (Figure 5B, Table S7).

SCD‐Related AAMR Stratified by 10‐Year Age Group

During the study period, as expected, patients aged ≥85 years had the highest CMR (51.3), reflecting the cumulative burden of cardiovascular risk and comorbidities in older adults. This is followed by patients between the ages 75 to 84 (CMR: 23.5), 65 to 74 years (CMR: 11.8), 55 to 64 years (CMR: 6.38), 45 to 54 years (CMR: 2.85), 35 to 44 years (CMR: 0.96), 25 to 34 years (CMR: 0.31), and 15 to 24 years (CMR: 0.13) (Table S8).

DISCUSSION

The US health care system is witnessing a substantial annual incidence of SCD, ranging from 350 000 to 400 000 cases, 15 prompting a detailed examination of mortality trends. Analyzing 23 years of data from the Centers for Disease Control and Prevention, we observed noteworthy shifts in SCD‐related mortality rates. Initially, from 1999 to 2018, mortality rates declined but then increased from 2018 to 2022, particularly among men. Most SCD deaths occurred in home and medical facilities, whereas hospice facilities reported the lowest numbers. NH Black adults experienced the highest average annual mortality rates compared with other racial groups. Disparities were evident between metropolitan and nonmetropolitan areas, with consistently higher rates in the latter. States in the top 90th percentile, such as Mississippi and Wyoming, had descriptively higher average annual mortality rates compared with those in the bottom 10th percentile, including Arizona and Maryland. However, because these rankings and comparisons are derived from the same data source, inferential conclusions should be drawn with caution. Additionally, regional differences were notable, with an increased death rate in the Southern US regions. As expected, patients aged ≥85 years had the highest crude mortality rates, reflecting the cumulative burden of cardiovascular risk and comorbidities in older adults.

Our research indicated a decline in SCD‐related fatalities across the United States over most of the study period, likely due to advancements in identifying and managing this population. Although inherited arrhythmias and congenital heart diseases predominantly contribute to SCD in young individuals, 16 ischemic heart disease and nonischemic dilated cardiomyopathy are major causes in older adults, with 80% of cases linked to coronary artery disease (CAD). 17 Reductions in cholesterol, blood pressure, and smoking in the past few decades have contributed significantly to the decline in coronary events, including SCD. 18 Moreover, improved adherence to guideline‐directed medical therapy for heart failure, another significant SCD substrate, has led to decreased incidence of SCD in patients with heart failure over the past decade. 19 , 20 Furthermore, since its introduction in the 1980s, the implantable cardioverter‐defibrillator has shown its effectiveness in preventing SCD among survivors of SCA (secondary prevention) as well as in high‐risk patients with ischemic heart disease or nonischemic dilated cardiomyopathy (primary prevention). 21 , 22 , 23 As early cardiopulmonary resuscitation (CPR) and defibrillation are crucial for SCD survival, the increasing trend of bystander chest compressions and early use of automated external defibrillators have contributed to increased survival rates. 24 Additionally, SCD risk stratification based on myocardial late gadolinium enhancement on cardiac magnetic resonance imaging, and prediction using digitized ECG tracings, has further aided in declining mortality rates. 25

However, despite all these advancements, our current analysis has shown a concerning rise in SCD‐related mortality rates in recent years. Although causality cannot be established from the ecological data, existing literature suggests this trend may be largely driven by rising rates of cardiometabolic risk factors such as obesity, diabetes, and poor hypertension control. 26 , 27 The decline in health care access during the early COVID‐19 pandemic, marked by significant reductions in hospitalizations and visits for acute illnesses, likely contributed to this trend by delaying essential care. This exacerbated non‐COVID‐19 conditions, worsening health outcomes and increasing mortality rates. 28 Moreover, a study has also noted overlapping peaks in SCA and COVID‐19, particularly during the second wave of the pandemic (winter 2020–2021), with contributing factors including delayed care, late emergency medical services activation, and COVID‐19‐related thrombosis risk. The decreased rate of bystander CPR due to infection fears further compounded the issue, leading to more critical presentations upon emergency medical services arrival. 29 Additionally, another study found an unexpected rise in encounters for acute myocardial infarction, a major cause of SCD, particularly among those aged 85 and older in 2023, which may reflect earlier hospital avoidance during the pandemic. 30 These findings underscore the need for future research to assess the long‐term impact of delayed care and inform public health messaging in future pandemics, emphasizing the importance of seeking timely treatment for urgent health issues despite infectious risks.

Our analysis also demonstrated that a significant proportion of SCDs occurred at home. This indicates the importance of training family members of at‐risk individuals in hands‐only resuscitation, as it has been found to be as effective as conventional resuscitation and can be easily learned through instructional videos. 31 Furthermore, in consistency with prior research, 32 our analysis also found a higher mortality rate related to SCD in men compared with women. Limited data suggest that the underlying causes and risk factors for SCD differ between men and women. 33 The annual incidence of SCD in men is approximately double that of women, resulting in a significantly lower overall lifetime risk in women compared with men. 34

Clinical findings indicate that CAD is the most common cause of SCD across all age groups, but its proportion is lower in women. 35 The decline in SCD rates has been lower in women compared with men, suggesting that modifiable risk factors for CAD are more prevalent in men. Moreover, women are less likely to have a prior diagnosis of cardiac disease before experiencing SCD, often making SCD the first presentation of CAD among them. 36 Previous research has also indicated that SCD in women is more likely associated with nonischemic causes, such as primary myocardial fibrosis, compared with men. 36 Additionally, women with out‐of‐hospital SCA, a major cause of SCD, have a higher likelihood of return of spontaneous circulation compared with men. 37 Finally, women tend to have a longer life expectancy than men, which further contributes to sex‐based disparity in SCD‐related mortality rates observed in our analysis. 33

In consistency with previous studies, 15 , 38 our analysis revealed a decline in SCD‐related mortality rates across all racial groups, with the highest rates observed in NH Black adults. This discrepancy may stem from the lack of appropriate discussion on the risk for cardiac death with their physicians, limited access, and their reluctance to seek medical care. 38 , 39 Additionally, the underrepresentation of minority populations in research methodologies and lower detection rates may further exacerbate this issue. 40 Interestingly, as discussed before, CAD contributes to the majority of SCD cases; however, nonatherosclerotic pathologies such as cardiac hypertrophy and conduction abnormalities are predominantly documented at autopsy in NH Black SCD cases. 15

Furthermore, NH Black adults are more likely to present with SCD as the initial manifestation of cardiovascular disease, adding to the disparity. 15 Historically, NH Black patients have been less likely to have invasive cardiovascular procedures such as implantable cardioverter‐defibrillator implantation, influenced by perceived racial discrimination and lack of diversity and representation in the physician workforce. 39 In addition, barriers to CPR education, lack of health care literacy, and limited access contribute to the disparities. Multiple factors such as NH Black race, lower education, and socioeconomic status independently correlate with increased SCD incidence. 38

Moreover, our analysis highlighted significant variations in AAMRs of SCD among counties, particularly when considering urbanization criteria and US Census‐defined regions. Although improvements in SCD‐related mortality have been observed overall, progress has been slower in nonmetropolitan areas compared with their metropolitan counterparts. 41 This disparity might be attributed to a higher prevalence of cardiovascular risk factors such as smoking, diabetes, hyperlipidemia, excessive alcohol use, and poor diets in rural communities. 42 Nonmetropolitan areas also face challenges such as higher rates of poverty, uninsured individuals, longer emergency medical service response times, and limited access to specialized cardiac services, which have worsened with rural hospital closures and declining availability of cardiologists. 42 Addressing these issues requires geographically targeted public health strategies and policy solutions, such as incentivizing the expansion of visiting cardiology consultant clinics in rural communities and reimbursing community‐based cardiac diagnostic care. 43 , 44 Furthermore, expanding Medicaid coverage in nonmetropolitan states could improve access to health care services and alleviate financial strain on rural hospitals. 44

Our analysis also uncovered disparities in SCD‐related mortality at both state and national levels, with several possible explanations. Training programs aimed at educating communities on using automated external defibrillators and performing CPR have been effective in increasing bystander CPR rates, with states mandating such programs in high schools reporting lower SCD rates. 45 Additionally, some studies have noted higher mortality associated with CAD, a prevalent cause of SCDs, in Southern US regions compared with other regions, potentially due to lower physical activity levels, higher blood pressure, and the imbalanced intake of processed foods high in fat and salt. 46 Socioeconomic factors such as income, education level, quality of life, racial discrimination, and employment status also play a role in shaping mortality trends across different regions. 47

Additionally, we observed an increase in SCD‐related mortality rates with age, peaking in individuals over 85 years. This trend may be attributed to varying SCD epidemiology across age groups. 16 As discussed earlier, inherited arrhythmia disorders and congenital heart diseases are the main causes of SCD in individuals <35. Advances in cascade genetic testing, prenatal diagnosis, and surgical congenital heart diseases management over the past 2 decades have improved risk stratification and treatment, leading to lower mortality in younger populations. 16 Conversely, the growing older adult population, especially those aged 65 and older, combined with a higher prevalence of cardiometabolic risk factors, contributes to higher mortality rates in this age group. 48 , 49 Additionally, the rise in heart failure mortality and higher ischemic heart disease incidence, the leading SCD causes, further elevates mortality rates in older adults in the United States. 48 , 49

Although our study primarily uses the Centers for Disease Control and Prevention WONDER database to analyze long‐term trends in SCD mortality, we also recognize the value of the CARES (Cardiac Arrest Registry to Enhance Survival) as a complementary source of data. 50 Unlike WONDER, which provides nationwide mortality statistics across all settings, CARES focuses on out‐of‐hospital cardiac arrests with detailed information on prehospital care, survival outcomes, and neurological recovery. 50 CARES also employs a more precise case definition for cardiac arrest, reducing potential misclassification. However, CARES data are limited in scope, covering only 49% of the US population and being restricted to participating regions. 50 This lack of national representation poses challenges in comparing its findings directly with our study, which spans 23 years and includes almost the entire US population. Additionally, CARES data have been collected only since 2004, whereas WONDER allows for a longer historical perspective, beginning in 1999. 9 , 50 These differences make the 2 databases complementary rather than directly comparable. Although CARES provides critical insights into out‐of‐hospital cardiac arrests and survival pathways, it cannot capture the broader epidemiological trends or the total burden of SCD that are the focus of this analysis. 50 Future studies combining insights from both databases could provide a more holistic understanding of SCD by integrating prehospital and population‐level perspectives.

Limitations

This study has several limitations. Our study relies on data from death certificates obtained via Centers for Disease Control and Prevention WONDER, which introduces inherent limitations, including potential bias and misclassification in the case definition of SCD. Death certificates tend to overestimate SCD rates, as cause‐of‐death information on these certificates can be unreliable due to the rarity of non‐forensic autopsies and varying autopsy protocols for suspected SCD cases. 51 Autopsy rates for SCDs are generally low, contributing to potential misclassification of SCD as a cause of death. 16 , 51 Additionally, the database lacks important information on individual factors such as witnessed versus unwitnessed SCD events, vital signs, laboratory values, and underlying heart conditions. Moreover, the database does not account for migration between states, affecting the accuracy of state‐specific mortality rates. 47 Furthermore, the database does not include data on received treatments or social determinants of health, which could influence access to care and mortality rates among different demographic groups. Additionally, the classification of race on death certificates is based on the information provided by the individual filling out the certificate, which may sometimes involve assumptions, particularly in cases where direct confirmation is unavailable, leading to potential misclassification bias in the reported racial and ethnic demographics. 16 , 51 Although these limitations are inherent to the study design, they underscore the need for caution in interpreting our findings and highlight areas for improvement in future research.

CONCLUSIONS

The findings of this study highlighted significant trends and disparities in SCD‐associated mortality rates across different demographic and geographic categories in the United States. Overall, there was a decline in SCD‐related mortality rates from 1999 to 2018, followed by a sudden increase from 2018 to 2022, with variations observed based on sex, race, ethnicity, urbanization status, state, and census region. Specifically, men, NH Black population, older adults (≥85 years), residents of nonmetropolitan areas, and individuals in Southern regions consistently experienced higher mortality rates compared with other groups. These findings underscore the need for targeted interventions to address the underlying factors contributing to SCD and mitigate the disparities observed across different populations and geographic areas.

Disclosures

Dr Fonarow reports consulting for Abbott, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Cytokinetics, Eli Lilly, Johnson & Johnson, Medtronic, Merck, Novartis, and Pfizer. The remaining authors have no disclosures to report.

Source of Funding

None.

Supporting information

Tables S1–S8

JAH3-14-e040340-s001.pdf (1.1MB, pdf)

Acknowledgments

Conceptualization: Vikash Jaiswal; methodology: Danisha Kumar; Formal analysis and investigation: Danisha Kumar, Fakhar Latif, Vikash Jaiswal; writing—original draft preparation: Vikash Jaiswal, Danisha Kumar, Yusra Mashkoor, Fakhar Latif, Sai Gautham Kanagala, Anupam Halder, Akash Jaiswal, Gregg C. Fonarow; writing—review and editing: Dhrubajyoti Bandyopadhyay, Wilbert S. Aronow, Anupam Halder, Gregg C. Fonarow.

This article was sent to Nadia R. Sutton, MD, MPH, Associate Editor, for review by expert referees, editorial decision, and final disposition.

For Disclosures, see page 10.

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Supplementary Materials

Tables S1–S8

JAH3-14-e040340-s001.pdf (1.1MB, pdf)

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