Cardiac arrhythmias, of which atrial fibrillation (AF) is the most common, are associated with significant cardiovascular disease (CVD) morbidity and mortality in the United States. Age-adjusted mortality rates (AAMR) from AF-related CVD increased significantly between 2011–2018. This burden is projected to grow given an aging population and increasing prevalence of cardiovascular risk factors including obesity and diabetes.1–3 Recent work suggests that trends in arrhythmia-related CVD mortality are increasing for younger adults and racial disparities have persisted, with the higher AAMR observed for Black individuals, followed by White individuals, and the lowest AAMR for all other groups.3 However, it is unclear how the burden of arrhythmia-related CVD mortality differs among individual Asian, Native Hawaiian, and Other Pacific Islander (AANHPI) groups.4,5 Therefore, we quantified proportional mortality from CVD related to AF and additional arrhythmias among disaggregated AANHPI groups in the US using national vital statistics data from 2018 to 2023.
We examined mortality among adults age ≥20 years using Center for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) data from 2018–2023 (all data are publicly available at https://wonder.cdc.gov). AF-related CVD mortality was defined using International Classification of Diseases, Tenth Revision (ICD-10) diagnostic code I48 as a contributing cause of death, with I00-I99 (Diseases of the Circulatory System) as the underlying cause, consistent with prior work.1,3 Secondary analysis included diagnostic codes I44 (atrioventricular and left bundle-branch block), I45 (other conduction disorders), I47 (paroxysmal tachycardia), and I49 (other cardiac arrhythmias) as additional contributing causes to quantify overall arrhythmia-related CVD mortality.3 We calculated proportional mortality as the percentage of all-cause deaths attributed to AF or arrhythmia-related CVD mortality for individual Non-Hispanic AANHPI groups (Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, Other Asian, Native Hawaiian, Guamanian, Samoan, and Other Pacific Islander) compared with Non-Hispanic (American Indian or Alaskan Native [AIAN], Black, and White) and Hispanic groups. All analyses were conducted in R Statistical Software version 4.2.3. This study was exempt from review by Northwestern University institutional review board due to the use of de-identified, publicly-available data.
Between 2018 and 2023, 633,337 (3.4%) of the 18,610,374 deaths analyzed in the United States from all causes among adults age ≥20 years were CVD deaths related to AF. Proportional mortality from AF-related CVD was higher among Native Hawaiian and other Pacific Islander (NHOPI) and Asian groups compared with AIAN, Black, and Hispanic groups, but lower compared with Non-Hispanic White individuals (Figure A). Among disaggregated AANHPI groups (Figure B), proportional mortality was higher among Filipino, Japanese, and Chinese groups compared with the aggregated Asian group, and higher for Native Hawaiian and Guamanian groups compared with the aggregated NHOPI group. Proportional mortality was lowest for Asian Indian, Korean, and Other Asian groups. Similar patterns were observed by sex (data not shown).
Figure: Proportional mortality from atrial fibrillation and arrhythmia related cardiovascular disease from 2018 to 2023.
Proportional mortality was calculated as the percentage of total deaths from all causes (n, as indicated) attributed to atrial fibrillation-related CVD (panels A, B) or overall arrythmia-related CVD (panels C, D). Abbreviations include Non-Hispanic (NH) American Indian or Alaskan Native (AIAN), or Native Hawaiian and Pacific Islander (NHOPI).
Inclusion of additional diagnostic codes to quantify overall arrhythmia-related CVD mortality identified 908,179 decedents (4.9% of all deaths), with similar patterns in proportional mortality from arrhythmia-related CVD across disaggregated AANHPI groups (Figure C, D). However, the relative contribution of additional arrhythmias and conduction disorders to overall arrythmia-related CVD mortality varied by AANHPI groups, with nearly twice as many deaths compared to when examining AF only for the Asian Indian group. After accounting for additional arrhythmias, proportional mortality was higher for Chinese, Filipino, Japanese, Native Hawaiian, Guamanian, and Samoan groups compared with aggregated data for Asian and NHOPI groups, with the lowest proportional mortality observed for the Korean group.
Among decedents between 2018–2023, proportional mortality from CVD related to AF and additional arrhythmias varied markedly across AANHPI groups, particularly among Native Hawaiian, Filipino, Guamanian, Japanese, Chinese, and Samoan groups. This study extends prior work by specifying the burden of CVD mortality specifically related to AF and additional arrythmias, which has not been previously described for disaggregated AANHPI groups. Our findings are consistent with known differences in upstream risk factors among these groups.4,5 Additionally, we found that the Asian Indian group experienced a relatively greater burden of additional arrhythmias and conduction disorders, which may be masked by examining AF only.
Although death certificates are subject to potential miscoding of demographic characteristics or cause of death data, and the data available in WONDER preclude calculation of AAMR, our findings have implications for the management of AF and other arrhythmias. The observed differences in arrhythmia-related CVD mortality should inform strategies for tailored and directed clinical quality improvement to address disparities related to arrhythmias among AANHPI adults. Future work should identify the upstream risk factors that may result in specific AANHPI groups experiencing higher burden of arrhythmia-related mortality. Investigation is also warranted to evaluate whether these findings persist among groups defined by AANHPI genetic ancestry, and how the prevalence of genetic variants that increase arrhythmia risk varies among groups defined by AANHPI genetic ancestry. Ultimately, these findings may underlie approaches that promote equitable identification and management of CVD among AANHPI adults.
Sources of Funding:
This work was supported in part by NIH grant K23HL157766 to NSS.
Nonstandard Abbreviations and Acronym
- AAMR
Age-adjusted mortality rates
- AIAN
American Indian or Alaskan Native
- AANHPI
Asian, Native Hawaiian, and Other Pacific Islander
- CDC WONDER
Center for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research
- ICD10
International Classification of Diseases, Tenth Revision
- NHOPI
Native Hawaiian and other Pacific Islander
Footnotes
Disclosures: None
References:
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