Shifting burdens: heart failure and pneumonia mortality patterns in the United States, 1999–2020

Abstract

Heart failure (HF) and pneumonia are leading causes of mortality in the United States, yet limited research has examined deaths attributable to their co-occurrence. Understanding demographic and geographic disparities in these mortality trends is critical for guiding public health interventions. Using data from the CDC Wide-ranging Online Data for Epidemiologic Research database, this study analyzed mortality from 1999 to 2020 among individuals aged 25 years and older. Age-adjusted mortality rates (AAMRs) per 100 000 population were calculated by sex, race/ethnicity, region, and rural–urban classification, with temporal trends assessed via Joinpoint regression. A total of 542 805 deaths were attributed to HF and pneumonia. Mortality declined steadily from 1999 through 2019 but rose sharply thereafter. The overall AAMR was 11.4, consistently higher in men than in women. Racial and ethnic disparities were evident: White individuals had the highest AAMR (11.6), followed by Black (10.2), American Indian/Alaska Native (9.6), and Asian/Pacific Islander populations (6.5). Regionally, the Midwest had the highest rate (12.3), and rural areas (15.3) exceeded urban areas (10.5). State-level mortality was greatest in West Virginia, Kentucky, and Oklahoma. These findings highlight a reversal of declining trends and underscore persistent disparities, emphasizing the need for targeted prevention, improved healthcare access, and community-based interventions.

Introduction

Heart failure (HF) and pneumonia are two major health conditions that contribute significantly to mortality and morbidity in the United States. HF is a condition in which structural or functional impairment of the heart leads to difficulty in ventricular filling and effective blood ejection. It results in dyspnea, fatigue, reduced exercise tolerance, fluid retention, jugular venous distention, and pulmonary congestion due to pulmonary edema[1]. In contrast, pneumonia is defined as an acute respiratory infection of the lung parenchyma caused by bacterial, viral, or fungal pathogens. Its symptoms include fever, dyspnea, productive cough, and chest pain[2].

HIGHLIGHTS

• Reversal of mortality decline: After steady declines from 1999 to 2019, mortality from coexisting heart failure and pneumonia sharply increased post-2019, with 2020 showing the most dramatic rise.

• Exacerbated health disparities: Black or African American and American Indian/Alaska Native populations experienced the fastest mortality increases, highlighting widening racial health inequities.

• Regional and rural vulnerabilities: Mortality was highest in the Midwest and in non-metropolitan areas, underscoring the impact of geographic and healthcare access disparities.

• Implications for public health: Findings support targeted interventions, including vaccination campaigns, health literacy programs, rural hospital sustainability, and continuity-of-care strategies for chronic disease management during public health emergencies.

Pathophysiologically, the interaction between HF and pneumonia is multifactorial. Pneumonia induces systemic inflammation, hypoxemia, and increased metabolic demand, all of which can precipitate myocardial strain, destabilize previously compensated HF, and trigger acute decompensation[3]. Inflammatory cytokines released during infection may contribute to myocardial depression and plaque instability, increasing the risk of cardiac events[4]. Conversely, patients with pre-existing HF often exhibit pulmonary congestion, impaired mucociliary clearance, and reduced immune reserve, creating a favorable environment for lower respiratory tract infections[5]. Fluid overload and elevated left-sided filling pressures further compromise pulmonary function, increasing susceptibility to pneumonia and worsening gas exchange once infection occurs[6].

Despite having one of the world’s most advanced healthcare systems, diagnostic tools, preventive measures, and therapeutic interventions, HF and pneumonia continue to impose a substantial burden on healthcare resources in the United States. These conditions often coexist, especially among elders, leading to exacerbation of diseases and increased mortality rates[7]. HF affects more than 6 million Americans and is a leading cause of multiple hospitalizations among individuals aged 65 years and older[8]. Similarly, pneumonia accounts for more than 1 million hospitalizations and over 50 000 deaths annually in the United States[9].

Moreover, emerging scholarly evidence underscores a bidirectional relationship between HF and pneumonia, wherein each condition exacerbates the other and amplifies adverse outcomes. In patients hospitalized with community-acquired pneumonia, approximately 17% develop new-onset congestive HF or other cardiac complications within 30 days, and these patients experience a fivefold higher early mortality compared to pneumonia patients without cardiac sequelae[10]. Conversely, pre-existing HF significantly worsens pneumonia prognosis, with 30-day mortality rates as high as 24.4% among individuals with HF versus 14.4% in those without HF[11]. A longitudinal study found that pneumonia substantially increases the long-term risk of developing HF across ages and severity levels, suggesting a persistent impact beyond the acute infection phase[12].

Although HF and pneumonia have been widely studied individually, the mortality burden associated with their co-occurrence remains underexplored. By specifically focusing on deaths where HF and pneumonia coexist, this study addresses a critical gap in the literature, highlighting a vulnerable patient population at heightened risk of complications and mortality. Understanding mortality trends in this coexisting population provides added value beyond prior single-disease studies, offering insights that can inform clinical management, healthcare resource allocation, and targeted public health interventions.

This study investigates long-term mortality patterns from 1999 to 2020 among U.S. adults aged 25 years and above who died due to both HF and pneumonia, utilizing data sourced from the CDC WONDER platform. By examining demographic, regional, and temporal patterns, this research offers important insights into how death rates have shifted over the last 20 years and highlights key areas where focused public health efforts may be needed.

Methods

Research setting and population

To analyze death rate trends of HF and pneumonia among individuals aged 25 years and older, we extracted data from the CDC WONDER database[13]. This is an online, freely available mortality database containing data for all the states of the United States. ICD-10 (10th Revision of the International Classification of Diseases) codes used for HF were I11.0, I13.0, I13.2, and I50.x, and for pneumonia were J12 to J18. Only death certificates reporting both HF and pneumonia as either underlying or contributing causes of death were included, ensuring comprehensive capture of relevant cases. Multiple studies have used the same ICD-10 codes for analyzing mortality rates^[14,15^]. The study used public records containing multiple causes of death for the selected population of HF- and pneumonia-associated deaths. In accordance with TITAN 2025, AI tools did not influence study design, data gathering, or analysis; their use was limited to editing the manuscript’s language[16]. For compiling this analysis, we followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Ethical review and informed consent were not required because the study used de-identified, publicly available government data.

Data abstraction

Using the CDC WONDER database, data were abstracted for year, demographics, population size, geographical regions, and urban-rural classification. Mortality data from 1999 to 2020 were used, as data from 2020 onwards are provisional and subject to future revisions. Sex, age, race, and place of death were categorized under the demographic data. Places of death included long-term care facilities, hospices, homes, nursing homes, and medical facilities. Races included in the study were White, American Indian or Alaska Native, Asian or Pacific Islander, and Black or African American. Different studies have used these data before as well[14]. Urban–rural regions were classified according to the National Center for Health Statistics Urban–Rural Classification Scheme, based on the Census of 2013 in the U.S., into large, medium/small, and rural metropolitan areas. Large metropolitan regions had a resident population of ≥1 000 000, whereas medium/small metropolitan regions had a resident population between 50 000 and 999 999, and non-metropolitan regions had <50 000[17]. Using Census Bureau of U.S. guidelines, the regions were grouped into Northeast, South, Midwest, and West.

Data analysis

For the investigation of mortality trends in HF and pneumonia, we calculated crude rates and age-adjusted mortality rates (AAMRs) per 100 000 population with 95% confidence intervals (CIs). To measure crude rates, we divided the number of deaths in both groups, HF and pneumonia, by the corresponding population for that year in the United States. Deaths were standardized using the U.S. population in the year 2000 to calculate AAMRs[18]. Joinpoint regression analysis was conducted using the Joinpoint Regression Program (version 5.0.2)[19]. The models employed log-linear regression, and the permutation test method was used to select the optimal number of joinpoints. Annual percent changes (APCs) were calculated. A rising slope means deaths are increasing, and a falling slope means deaths are decreasing. A P-value was considered significant only if its value was < 0.05. Given the relatively small population sizes of some subgroups, such as American Indian/Alaska Native adults, we acknowledge that the joinpoint estimates for these groups may be less stable, and caution is warranted when interpreting these results.

Results

In the United States, 542 805 adults aged 25 years and above died from HF and pneumonia between 1999 and 2020 (Table 1 and Supplemental Digital Content Table 1, available at: http://links.lww.com/MS9/B201). Of these, 67.1% of the deaths were reported in medical facilities, followed by 22.0% in nursing care, 6.2% at home, and 2.6% in hospice care. For the remaining 1.9%, the exact place of death was unknown (Table 1 and Supplemental Digital Content Table 2, available at: http://links.lww.com/MS9/B202).

Table 1.

Demographic characteristics of deaths due to HF and pneumonia in the United States, 1999–2020.

Variable	Heart failure and pneumonia-related deaths	AAMRs/CMRs (95% CI) per 1 00 000
Overall	542 805 (100%)	11.4 (11.4–11.4)
Sexa
Male	245 371 (45.2%)	13.5 (13.4–13.6)
Female	297 434 (54.8%)	10.0 (10.0–10.1)
Census regiona
Northeast	104 936 (19.3%)	10.7 (10.7–10.8)
Midwest	136 059 (25.1%)	12.3 (12.3–12.4)
South	192 562 (35.5%)	11.4 (11.3–11.4)
West	109 248 (20.1%)	10.9 (10.8–10.9)
Race/Ethnicitya
American Indian or Alaska Native	2652 (0.5%)	9.6 (9.3–10.0)
Asian or Pacific Islander	10 674 (2.0%)	6.5 (6.4–6.7)
Black or African American	42 163 (7.8%)	10.2 (10.1–10.3)
White	487 316 (89.8%)	11.6 (11.6–11.7)
Ageb
25–34 years	859 (0.2%)	0.1 (0.1–0.1)
35–44 years	2388 (0.4%)	0.3 (0.2–0.3)
45–54 years	7700 (1.4%)	0.8 (0.8–0.8)
55–64 years	23 013 (4.2%)	3.0 (2.0–4.0)
65–74 years	61 353 (11.3%)	12.0 (11.9–12.1)
75–84 years	162 135 (29.9%)	54.3 (54.1-54.6)
85+ years	285 357 (52.6%)	238.8 (237.9–239.6)
Urbanizationa
Metropolitan	412 844 (76.0%)	10.5 (10.5–10.6)
Nonmetropolitan	129 961 (24.0%)	15.3 (15.2–15.4)
Place of deathc
Medical facility	364 846 (67.1%)	-
Decedent’s home	33 692 (6.2%)	-
Hospice facility	14 117 (2.6%)	-
Nursing home/long-term care facility	119 673 (22.0%)	-
Others	10 477 (1.9%)	-

^aAge adjusted mortality rates (AAMRs) are utilized.

^bCrude mortality rates (CMRs) are used for all age dependent analysis.

^cAge adjusted mortality rates (AAMRs) is not applicable for place of death.

Year-wise stratification of AAMR related to HF and pneumonia:

The AAMR for HF and pneumonia was 18.9 (95% CI: 18.6 to 19.1) in 1999 and dropped to 11.4 (95% CI: 11.3 to 11.5) in 2020, with an APC of −4.32 (95% CI: −5.43 to −3.54, P < 0.000001). The rate initially declined to 15.7 in 2005, then further decreased to 9.7 in 2009, and continued dropping steadily to 7.9 in 2018. However, after 2019, it sharply increased to 11.4 in 2020, with an APC of 21.05 (95% CI: 10.27 to 27.73, P < 0.000001) (Fig. 1; Supplemental Digital Content Figure 1, available at: http://links.lww.com/MS9/B200; Supplemental Digital Content Table 3, available at: http://links.lww.com/MS9/B203; and Supplemental Digital Content Table 4, available at: http://links.lww.com/MS9/B204).

Figure 1.

Year- and gender-stratified AAMR per 100 000 in the United States, 1999–2020.

APC = annual percent change, AAMR = age-adjusted mortality rate, α = 0.05

HF and pneumonia AAMR stratified by gender

Gender analysis revealed that men’s death rates were higher than women’s during the study. Among men, the overall AAMR was 13.5 per 100 000 (95% CI: 13.4 to 13.6), with an APC of −3.68 (95% CI: −5.34 to −1.96; P < 0.000001). For women, the overall AAMR was 10.0 per 100 000 (95% CI: 10.0 to 10.1), with a slightly more pronounced APC of −4.66 (95% CI: −5.72 to −3.96; P < 0.00001).

In men, the AAMR declined from 22.6 (95% CI: 22.3 to 23.0) in 1999 to 16.6 (95% CI: 16.3 to 16.9) in 2006, with an APC of −3.47 (95% CI: −5.14 to 0.89; P < 0.07). This was followed by a steep drop to 11.5 (95% CI: 11.2 to 11.7) in 2009, with a significant APC of −13.32 (95% CI: −16.02 to −7.34; P < 0.006). From 2009 to 2018, the decline continued more gradually, reaching 9.6 (95% CI: 9.4 to 9.8), with an APC of −2.46 (95% CI: −4.62 to 0.55; P < 0.08). However, post-2019, this trend reversed sharply as the AAMR increased to 14.5 (95% CI: 14.3 to 14.7) in 2020, corresponding to an APC of 24.09 (95% CI: 13.03 to 31.06; P < 0.000001).

A similar trend was observed in women. The AAMR decreased from 16.6 (95% CI: 16.4 to 16.9) in 1999 to 13.9 (95% CI: 13.7 to 14.2) in 2005, with an APC of −2.77 (95% CI: −3.88 to −1.15; P < 0.007), and further dropped to 8.5 (95% CI: 8.4 to 8.7) in 2009 with a steeper APC of −10.89 (95% CI: −14.28 to −8.15; P < 0.002). The decline persisted until 2018, reaching 6.6 (95% CI: 6.5 to 6.8), with an APC of −3.33 (95% CI: −5.38 to −0.87; P < 0.01). Following this period, the trend shifted after 2019, with a sharp increase in AAMR to 9.1 (95% CI: 9.0 to 9.3) in 2020, representing an APC of 17.47 (95% CI: 5.81 to 23.95; P < 0.0004) (Fig. 1, Supplemental Digital Content Table 3, available at: http://links.lww.com/MS9/B203, and Supplemental Digital Content Table 4, available at: http://links.lww.com/MS9/B204).

HF and pneumonia AAMR stratified by race/ethnicity

Racial analysis showed that the White adults had the highest AAMR of 11.6 (95% CI: 11.6 to 11.7) with an APC of −4.40 (95% CI: −5.55 to −3.63, P < 0.000001), followed by the Black or African American adults [10.2 (95% CI: 10.1 to 10.3) with an APC of −2.32 (95% CI: −4.10 to −0.44, P < 0.01)], the American Indian or Alaska Native adults [9.6 (95% CI: 9.3 to 10.0) with an APC of −3.27 (95% CI: −4.66 to −1.61, P < 0.000001)], and the Asian or Pacific Islander adults [6.5 (95% CI: 6.4 to 6.7) with an APC of −4.25 (95% CI: −5.21 to −3.12, P < 0.000001)].

For White adults, the AAMR decreased from 19.2 (95% CI: 18.9 to 19.4) in 1999 to 16.1 (95% CI: 15.9 to 16.3) in 2005 with an APC of −2.65 (95% CI: −3.81 to −0.88, P < 0.01), followed by a sharp decline to 9.8 (95% CI: 9.6 to 9.9) in 2009 with an APC of −11.17 (95% CI: −14.73 to −8.19, P < 0.001), and then a steady decline to 8.0 (95% CI: 7.9 to 8.1) in 2018 with an APC of −2.81 (95% CI: −4.93 to −0.30, P < 0.03). After 2019, the AAMR rose suddenly to 11.2 (95% CI: 11.1 to 11.4) with an APC of 18.89 (95% CI: 7.16 to 25.52, P < 0.000001) in 2020.

For Black or African American adults, the AAMR decreased from 16.7 (95% CI: 16.0 to 17.4) in 1999 to 7.5 (95% CI: 7.2 to 7.9) in 2018, with an APC of −5.08 (95% CI: −5.84 to −4.46, P < 0.000001). After 2019, it increased sharply to 14.6 (95% CI: 14.2 to 15.1) in 2020, with an APC of 52.22 (95% CI: 32.45 to 63.02, P < 0.000001).

For American Indian or Alaska Native adults, the AAMR decreased from 14.9 (95% CI: 12.0 to 18.4) in 1999 to 7.2 (95% CI: 6.0 to 8.4) in 2018, with an APC of −5.02 (95% CI: −6.72 to −3.81, P < 0.0004). After 2019, it sharply rose to 11.6 (95% CI: 10.2 to 13.1) in 2020, with an APC of 31.89 (95% CI: 7.69 to 49.92, P < 0.006).

For Asian or Pacific Islander adults, the AAMR decreased from 11.8 (95% CI: 10.6 to 13.1) in 1999 to 4.5 (95% CI: 4.1 to 4.9) in 2018, with an APC of −5.42 (95% CI: −6.55 to −4.59, P < 0.004). After 2019, it sharply rose to 6.4 (95% CI: 6.0 to 6.9) in 2020, with an APC of 19.89 (95% CI: 2.95 to 29.30, P < 0.025) (Fig. 2; Supplemental Digital Content Table 8, available at: and Supplemental Digital Content Table 5, available at: http://links.lww.com/MS9/B205).

Figure 2.

AAMR stratified by race per 100,000 in the United States, 1999–2020.

APC = annual percent change, AAMR = age-adjusted mortality rate, α = 0.05

HF and pneumonia AAMR stratified by geographic region:

According to regional data, the Midwest recorded the highest AAMR of 12.3 (95% CI: 12.3 to 12.4) with an APC of −3.92 (95% CI: −5.26 to −2.48, P < 0.000001), followed by the South [11.4 (95% CI: 11.3 to 11.4) with an APC of −3.53 (95% CI: −5.15 to −1.91, P < 0.000001)], the West [10.9 (95% CI: 10.8 to 10.9) with an APC of −4.73 (95% CI: −5.97 to −3.47, P < 0.000001)], and the Northeast [10.7 (95% CI: 10.7 to 10.8) with an APC of −3.85 (95% CI: −4.96 to −2.68, P < 0.000001)].

State-level AAMR variations were also noted. West Virginia had the highest AAMR of 18.6 (95% CI: 18.2 to 19.1), followed by Kentucky [18.2 (95% CI: 17.8 to 18.5)] and Oklahoma [18.1 (95% CI: 17.7 to 18.4)], whereas Arizona had the lowest AAMR of 6.0 (95% CI: 5.8 to 6.1), followed by Florida [6.1 (95% CI: 6.0 to 6.2)] and Nevada [7.4 (95% CI: 7.1 to 7.7)].

Throughout the trend, non-metropolitan areas had a higher AAMR than metropolitan areas. The analysis showed that the AAMR for non-metropolitan areas decreased from 24.3 (95% CI: 23.7 to 24.8) in 1999 to 21.2 (95% CI: 20.7 to 21.6) in 2005 with an APC of −1.98 (95% CI: −3.16 to −0.27, P < 0.03), followed by a further decline to 12.9 (95% CI: 12.6 to 13.3) in 2009 with an APC of −11.26 (95% CI: −14.36 to −8.70, P < 0.0004). It continued to decline to 10.3 (95% CI: 10.0 to 10.6) in 2018, with an APC of −3.08 (95% CI: −4.70 to −1.25, P < 0.006). The trend reversed after 2019, as the AAMR rose to 14.4 (95% CI: 14.0 to 14.7) in 2020, with an APC of 18.90 (95% CI: 9.43 to 24.64, P < 0.000001).

The AAMR for metropolitan areas decreased from 17.5 (95% CI: 17.3 to 17.7) in 1999 to 13.0 (95% CI: 12.8 to 13.1) in 2006, with an APC of −3.44 (95% CI: −4.34 to −1.99, P < 0.005), followed by a further decrease to 9.0 (95% CI: 8.8 to 9.1) in 2009, with an APC of −12.86 (95% CI: −15.22 to −8.16, P < 0.002). It continued to decrease until 7.4 (95% CI: 7.3 to 7.5) in 2018, with an APC of −2.58 (95% CI: −4.56 to 0.22, P < 0.06). After 2019, it rose sharply to 10.9 (95% CI: 10.7 to 11.0) in 2020, with an APC of 22.14 (95% CI: 10.83 to 29.02, P < 0.000001) (Figs 3–5; Supplemental Digital Content Table 3, available at: http://links.lww.com/MS9/B203; Supplemental Digital Content Table 6, available at: http://links.lww.com/MS9/B206; Supplemental Digital Content Table 7, available at: http://links.lww.com/MS9/B207; and Supplemental Digital Content Table 8, available at: http://links.lww.com/MS9/B208).

Figure 4.

AAMR stratified by Urban-rural status per 100 000 in the United States, 1999–2020.

APC = annual percent change, AAMR = age-adjusted mortality rate, α = 0.05

Figure 3.

AAMR stratified by region per 100 000 in the United States, 1999–2020.

APC = annual percent change, AAMR = age-adjusted mortality rate, α = 0.05

Figure 5.

AAMR stratified by State per 100 000 in the United States, 1999–2020.

Discussion

This analysis highlights a number of key features related to HF and pneumonia mortality trends from 1999 to 2020. Firstly, the mortality rate decreased from 18.9 to 7.6 per 100 000 between 1999 and 2019. However, from 2019 to 2020, this downward trend reversed sharply, with the mortality rate increasing to 11.4 per 100 000. Gender analysis showed a similar trend in both men and women. Secondly, the highest AAMRs were seen in White adults, whereas Asian or Pacific Islanders had the lowest. Post-2019, the sharpest rise was recorded among Black or African American and American Indian or Alaska Native groups. Thirdly, regional variations were also noted. Death rates were highest in the Midwest and lowest in the Northeast. Similarly, states like West Virginia, Kentucky, and Oklahoma had the highest AAMR. Urban-rural status showed that non-metropolitan areas had a higher AAMR than metropolitan areas (Central Illustration). These variations highlight critical gaps not only in public health structures and policies but also in broader socioeconomic and structural determinants of health, including access to care, education, income, and systemic inequities.

The declining trends from 1999 to 2019, particularly around 2009, can be attributed to the improvement in HF management, which includes the widespread use of evidence-based, life-prolonging therapies such as ACE inhibitors, beta blockers, angiotensin receptor–neprilysin inhibitors (ARNIs), and SGLT2 inhibitors, alongside preventive measures like pneumococcal and influenza vaccinations^[20,21^]. These interventions are supported by pivotal clinical trials and guideline recommendations, including the PARADIGM-HF trial for ARNIs and the DAPA-HF/EMPEROR-Reduced trials for SGLT2 inhibitors, which demonstrated significant reductions in HF-related morbidity and mortality^[22,23^]. A meta-analysis related to pneumonia mortality confirmed the declining trend across gender, age, and race[15]. The rising trend after 2019 may be related to the COVID-19 pandemic; however, it is important to note that the CDC WONDER dataset does not allow direct identification of COVID-19-related deaths. Other contributing factors may include disruptions in healthcare access, delayed hospitalizations, and a higher burden of comorbidities among vulnerable populations[24].

Studies have shown that HF mortality before COVID-19 was 2.6%, which rose to 24.2% after COVID-19[25]. The sharp reversal in declining HF and pneumonia mortality observed in 2020 is most plausibly explained by the COVID-19 pandemic, which acted through both direct and indirect pathways. Directly, SARS-CoV-2 infection can precipitate viral pneumonia and exacerbate pre-existing cardiovascular conditions through mechanisms including myocardial injury via ACE2 receptor-mediated pathways, systemic inflammation, arrhythmias, cytokine storm, and a hypercoagulable state. These pathophysiological effects increase susceptibility to adverse outcomes in patients with HF and respiratory comorbidities[26]. Similarly, COVID-19 pneumonia leads to higher cardiovascular mortality rates than non-COVID-19 pneumonia, underscoring the acute and long-term impacts of the disease[27]. Indirectly, it disrupted the healthcare system massively, leading to a reduced number of HF hospitalizations, delayed emergency care, overwhelmed ICUs, and limited access to outpatient departments. These factors also contributed massively to the rise in these mortality trends[28]. Collectively, these factors amplified mortality risk across all populations.

Men suffer from a higher rate of ischemic heart disease, earlier onset of HF, and higher complications from pneumonia, which may contribute to elevated mortality rates and risks compared to women. These are well-established risk factors for adverse outcomes[29]. Literature shows that men have 1.7-fold higher odds of having HF than women[30]. Similarly, smoking and alcohol use are more prevalent among men, and these behaviors are strongly linked to heart- and breathing-related deaths[31]. Men also have higher odds of death (adjusted OR ~ 1.19) from pneumonia compared to women[31]. Moreover, social factors and access to healthcare can also contribute to these trends. The observed sex differences are more plausibly explained by differences in comorbidity burden, health behaviors, healthcare utilization, and social factors. Women usually seek medical care earlier and also have a strong social network and support system, whereas men often delay preventive services and present later with worsening symptoms and diseases[32]. Collectively, these factors likely explain the higher mortality trends among men in our analysis.

Racial variations, which show that White adults have higher AAMR, may be due to several factors. The largest group of people in the U.S. are White, who also make up the biggest elderly population, which naturally leads to higher mortality counts when adjusted for age[33]. Additionally, White adults have higher rates of chronic diseases like coronary artery disease and HF, both of which can lead to higher mortality[34]. In contrast, post-2019, the most pronounced increases were observed among Black or African American and American Indian or Alaska Native adults, reflecting a devastating widening of health disparities. These disproportionate rises emphasize critical inequities exacerbated by both pandemic-related impacts and pre-existing inequities in healthcare access[35]. These trends underscore that while overall mortality remains highest among Whites due to population size and baseline comorbidities, the accelerated mortality increases in Black and American Indian/Alaska Native populations represent an urgent health equity crisis, likely driven by COVID-19 impacts, structural inequities, and differential access to care[36]. Moreover, adults in these populations do not have access to good quality chronic care, face limited access to preventive care, and are at higher risk of hypertension and diabetes, which may explain these mortality trends in this population[24]. Socioeconomic and structural factors such as lower income, limited insurance coverage, reduced access to preventive services, educational disparities, and historical systemic inequities likely compound these risks. These social determinants interact with geographic and healthcare barriers to produce slower declines and sharper mortality increases in these populations. Similarly, American Indian or Alaska Native adults face different kinds of challenges because of geographic isolation, poor healthcare infrastructure, and historical trauma, which exacerbate these health inequities[37]. These factors together explain why Black or African American and American Indian or Alaska Native adults experienced slower declines in HF and pneumonia mortality trends, followed by a sharp increase during the pandemic.

Regional analysis showed that non-metropolitan areas, particularly in the Midwest and South, had a higher mortality rate compared to urban areas for HF and pneumonia. Rural areas have limited emergency and hospital services, indicating that poor access to acute care can be associated with higher mortality for HF patients[38]. More than 130 hospitals have been closed in rural areas since 2010, which further contributes to increased inpatient mortality for pneumonia[39]. Similarly, vaccination for pneumococcal and influenza, which are critical for preventing these diseases, is often limited in rural areas[40]. Health literacy and public health awareness messaging are often much lower in non-metropolitan areas, which was clearly demonstrated during the COVID-19 pandemic, when we saw a sharp spike in rural respiratory mortality[41]. These rural-urban disparities are further magnified by socioeconomic constraints, including lower income, transportation barriers, and limited local healthcare resources, highlighting the need for policies targeting structural inequities.

To address the observed disparities in HF- and pneumonia-related mortality, policy recommendations should be organized to target these specific populations. High-risk populations, including men and Black or American Indian/Alaska Native adults, should benefit from expanded vaccination programs, targeted health education, and preventive care interventions. Geographic areas, such as rural and non-metropolitan regions, require improved access to acute care, strengthened telemedicine services, and enhanced public health outreach. Healthcare systems should integrate comprehensive cardiopulmonary management strategies and ensure adherence to guideline-directed HF therapies and early pneumonia interventions. Finally, broader public health measures should address structural inequities through improved insurance coverage, health literacy programs, and socioeconomic support, while also enhancing preparedness for emerging health crises.

Limitation

There are a few limitations in this study that need some attention. First, the ICD-10 codes we used for mortality trends of HF and pneumonia may result in omission or misclassification bias. Death certificate data are subject to inaccuracy, particularly in 2020, which may affect the reliability of reported trends. Secondly, we cannot derive any information regarding multiple clinical variables, such as echocardiographic findings, ejection fraction of the heart, severity of pneumonia, multiple risk factors, etc., from the database. Third, no information is provided on socioeconomic determinants of health, healthcare access, and preventive care utilization, all of which can influence the mortality rate of diseases. Additionally, the inability to distinguish COVID-19-related deaths from other causes post-2019 is a key limitation when interpreting the recent mortality surge. Fourth, as an ecological analysis, associations observed at the population level cannot establish causation (ecological fallacy). Fifth, the application of the 2013 Urban-Rural Classification Scheme across the entire 1999–2020 period may introduce misclassification bias, as county-level demographics and urbanization status changed over time.

Conclusion

We can easily conclude that the mortality rate of HF and pneumonia, which had been going down since 1999, started rising again after 2019. This increase has been especially observed among men, White adults living in the Midwest region, and in states like West Virginia. This worrying trend indicates that current efforts may not be working well for these groups. To address these disparities, public health strategies should include expanding vaccination programs (pneumococcal and influenza), improving access to acute care in rural and underserved areas, and integrating comprehensive cardiopulmonary management strategies across healthcare settings. Additionally, targeted health education and preventive care interventions for high-risk populations are essential to reduce morbidity and mortality.

Ethical approval

Not applicable.

Consent

Not applicable.

Sources of funding

The authors received no extramural funding for the study.

Author contributions

A.M.: conceptualization, project development, data collection, manuscript writing; F.L.: project development, data collection, manuscript writing; S.L.: project development, data collection, manuscript writing; M.K.: project development, data collection, manuscript writing; S.S.: figures, data analysis, manuscript writing; S.K.: figures, data analysis, manuscript writing; N.K.: table, manuscript writing; K.D.R.: data analysis, manuscript writing; A.K.S.: data analysis, manuscript writing; L.K.: figures, data analysis, manuscript writing; A.BS: supervision, manuscript writing, and editing; B.D.A.: supervision, manuscript writing, and editing; A.C.: supervision, manuscript writing, and editing.

Conflicts of interest disclosure

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Research registration unique identifying number (UIN)

Not applicable.

Guarantor

Aayush Chaulagain.

Provenance and peer review

This manuscript was not commissioned.

Data availability statement

The data we used in this study is publicly available from the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) database. Data can be accessed at https://wonder.cdc.gov. No special permissions were required to access this data.