Abstract
This study evaluates the Centers for Disease Control and Prevention’s Wide-Ranging Online Data for Epidemiologic Research to compare trends in heart disease, stroke, diabetes, and hypertension mortality rates by race and sex from 1999 to 2017.
While cardiovascular disease (CVD) death rates declined by approximately 36% from 2000 to 2014,1 CVD remains the leading cause of mortality among US adults.2 Annual declines in CVD mortality slowed between 2011 and 2014 (0.7% fewer CVD deaths per year),1,3 and it appears unlikely that strategic goals from the American Heart Association (20% reduction by 2020) will be achieved.4 To clarify the most recent national trends, we investigated CVD and other key cardiometabolic disease mortality rates overall, by sex, and by race from 1999 to 2017.
Methods
We determined mortality rates attributed to cardiometabolic diseases using death certificates from the Centers for Disease Control and Prevention’s Wide-Ranging Online Data for Epidemiologic Research (WONDER) from January 1, 1999, to December 31, 2017.2 Mortality rates in which the underlying cause of death was listed as heart disease (International Classification of Diseases, Tenth Revision [ICD-10] codes I00-I09, I11, I13, I20-I51), stroke (ICD-10 codes I60-I69), diabetes (ICD-10 codes E10-E14), or essential hypertension and hypertensive renal disease (ICD-10 codes I10, I12, I15) were age adjusted using the 2000 US standard population.1,2 Age-adjusted mortality rates (AAMRs) were examined overall (all decedents) and by sex-race (black and white only) groups. AAMR ratios quantifying racial disparities were calculated as number of deaths per 100 000 population in black individuals for every 1 death per 100 000 population in white individuals. The Joinpoint Regression Program (National Cancer Institute)5 was used to identify up to 1 inflection point in AAMR trends. Statistical trends and AAMR annual rate of change were identified using linear regression (SPSS version 21). Two-sided statistical significance was defined as P < .05. This study was determined to be exempt from review by the institutional review board at Northwestern University Feinberg School of Medicine.
Results
In 1999, total deaths by cause (AAMR per 100 000 population) were 725 192 (266.5) from heart disease, 167 366 (61.6) from stroke, 68 399 (25.0) from diabetes, and 16 968 (6.2) from hypertension. In 2017, total deaths by cause (AAMR per 100 000 population) were 647 457 (165.0) from heart disease, 146 383 (37.6) from stroke, 83 564 (21.5) from diabetes, and 35 316 (9.0) from hypertension. During 1999-2017, 12.3% of fatal cardiometabolic events occurred in black individuals and 85.1% in white individuals, and 51.3% occurred in women.
AAMRs from 1999-2017 experienced an inflection point in 2010 for deaths due to heart disease, stroke, and diabetes (Table). The rate of AAMR decline for heart disease before 2010 was β = −8.3 (95% CI, −8.8 to −7.8; P < .001), indicating 8.3 fewer deaths per 100 000 population per year, vs β = −1.8 (95% CI, −2.5 to −1.0; P = .001) after 2010. AAMR declines between 1999-2010 for stroke were β = −2.3 (95% CI, −2.5 to −2.1; P < .001) and for diabetes were β = −0.4 (95% CI, −0.6 to −0.3; P < .001). AAMRs did not significantly change for stroke or diabetes between 2010 and 2017. The hypertension AAMR experienced an inflection point in 2003 and increased less rapidly thereafter (1999-2003: β = 0.3 [95% CI, 0.3 to 0.4]; P = .001 and 2003-2017: β = 0.1 [95% CI, 0.04 to 0.1]; P < .001).
Table. Age-Adjusted Mortality Rates Attributable to Leading Cardiometabolic Underlying Causes of Death in the United States, 1999-2017.
| 1999 | 2003 | 2007 | 2011 | 2013 | 2015 | 2017 | |
|---|---|---|---|---|---|---|---|
| Heart Disease | |||||||
| Overall AAMRa | 266.5 | 236.3 | 196.1 | 173.7 | 169.8 | 168.5 | 165.0 |
| Subgroups | |||||||
| Black menb | 407.2 | 372.1 | 312.4 | 266.1 | 262.8 | 258.6 | 257.5 |
| White menb | 327.1 | 288.2 | 240.3 | 216.9 | 213.1 | 211.2 | 208.3 |
| AAMR ratioc | 1.24 | 1.29 | 1.30 | 1.23 | 1.23 | 1.22 | 1.24 |
| Black womenb | 283.7 | 258.5 | 209.8 | 176.2 | 172.1 | 165.7 | 161.9 |
| White womenb | 212.8 | 188.5 | 155.4 | 136.5 | 132 | 132.4 | 128.4 |
| AAMR ratioc | 1.33 | 1.37 | 1.35 | 1.29 | 1.30 | 1.25 | 1.26 |
| Trend periodd | 1999-2010 | 2010-2017 | |||||
| Rate of change, β (95% CI)e | −8.3 (−8.8 to −7.8) [P<.001] | −1.8 (−2.5 to −1.0) [P=.001] | |||||
| Stroke | |||||||
| Overall AAMRa | 61.6 | 54.6 | 43.5 | 37.9 | 36.2 | 37.6 | 37.6 |
| Subgroups | |||||||
| Black menb | 89.6 | 81.6 | 68.7 | 55.3 | 54.1 | 55.5 | 56.1 |
| White menb | 60.8 | 52.9 | 41.3 | 36.2 | 35.0 | 36.1 | 36.2 |
| AAMR ratioc | 1.47 | 1.54 | 1.66 | 1.53 | 1.55 | 1.54 | 1.55 |
| Black womenb | 76.2 | 71.1 | 56.4 | 47.0 | 44.7 | 46.7 | 47.0 |
| White womenb | 58.0 | 51.3 | 41.2 | 36.2 | 34.2 | 35.9 | 35.7 |
| AAMR ratioc | 1.31 | 1.39 | 1.37 | 1.30 | 1.31 | 1.30 | 1.32 |
| Trend periodd | 1999-2010 | 2010-2017 | |||||
| Rate of change, β (95% CI)e | −2.3 (−2.5 to −2.1) [P<.001] | −0.1 (−0.5 to 0.2) [P=.38] | |||||
| Diabetes | |||||||
| Overall AAMRa | 25.0f | 25.5 | 22.8 | 21.6 | 21.2 | 21.3 | 21.5f |
| Subgroups | |||||||
| Black menb | 49.4 | 51.2 | 46.1 | 44.9 | 44.0 | 43.9 | 45.2 |
| White menb | 25.8 | 27.2 | 24.8 | 24.3 | 23.9 | 24.5 | 24.9 |
| AAMR ratioc | 1.91 | 1.88 | 1.86 | 1.85 | 1.84 | 1.79 | 1.82 |
| Black womenb | 49.5 | 47.9 | 40.6 | 35.8 | 34.3 | 31.9 | 31.8 |
| White womenb | 20.2 | 20.1 | 17.5 | 16.2 | 15.7 | 15.6 | 15.2 |
| AAMR ratioc | 2.45 | 2.38 | 2.32 | 2.21 | 2.18 | 2.04 | 2.09 |
| Trend periodd | 1999-2010 | 2010-2017 | |||||
| Rate of change, β (95% CI)e | −0.4 (−0.6 to −0.3) [P<.001] | 0.02 (−0.1 to 0.1) [P=.64] | |||||
| Hypertension | |||||||
| Overall AAMRa | 6.2 | 7.6 | 7.6 | 8.1 | 8.5 | 8.5 | 9.0 |
| Subgroups | |||||||
| Black menb | 17.3 | 19.1 | 17.8 | 17.4 | 18.3 | 17.9 | 18.5 |
| White menb | 5.2 | 6.2 | 6.5 | 7.2 | 7.7 | 7.9 | 8.5 |
| AAMR ratioc | 3.33 | 3.08 | 2.74 | 2.42 | 2.38 | 2.27 | 2.18 |
| Black womenb | 15.0 | 16.9 | 15.7 | 14.9 | 14.7 | 14.8 | 15.0 |
| White womenb | 5.2 | 6.6 | 6.6 | 7.1 | 7.4 | 7.3 | 7.6 |
| AAMR ratioc | 2.88 | 2.56 | 2.38 | 2.10 | 1.99 | 2.03 | 1.97 |
| Trend periodd | 1999-2003 | 2003-2017 | |||||
| Rate of change, β (95% CI)e | 0.3 (0.3 to 0.4) [P=.001] | 0.1 (0.04 to 0.1) [P=.001] | |||||
Abbreviation: AAMR, age-adjusted mortality rate.
The AAMR indicates rate per 100 000 population, directly standardized to the 2000 US Census population.
Race information of the decedent was reported as standard practice by the funeral director, as provided by an informant (often the surviving next of kin), or in the absence of an informant, on the basis of observation.2
AAMR ratio indicates a comparison of AAMRs by race within a sex group (eg, black men compared with white men).
Calculated using linear regression of overall population AAMR before and after inflection point, identified by Joinpoint analysis of heart disease, stroke, diabetes, or hypertension trend. P < .05 for comparison of linear trend of AAMR after vs before inflection point for all diseases.
P value for statistical significance of first and second linear regression around Joinpoint regression identified inflection point in overall AAMR trend. β coefficient represents change in AAMR per year.
The crude mortality rate was 24.5 per 100 000 in 1999 and 25.7 per 100 000 in 2017, but calculation of the weighted average based on the 2000 US Census population resulted in AAMRs of 25.0 per 100 000 in 1999 and 21.5 per 100 000 in 2017.
Between 1999 and 2017, the AAMRs for heart disease, stroke, and diabetes declined, but the AAMR for hypertension increased in most sex-race groups except in black women, for whom the hypertension AAMR remained generally unchanged. Black individuals consistently had higher AAMRs compared with whites. In 2017, the highest AAMR ratios were in black compared with white women due to diabetes (2.09) and in black compared with white men due to hypertension (2.18). Black men consistently had the highest AAMRs across all underlying causes of death.
Discussion
These findings demonstrate a continued but slower decline in AAMR for heart disease, a plateau in mortality rates from stroke and diabetes, and an increasing AAMR for hypertension (although hypertension as underlying cause of death remained relatively infrequent) between 2010 and 2017. Racial disparities in cardiometabolic causes of death persisted. Strengths of this study include up-to-date trends in cardiometabolic AAMRs and quantitative evaluation of slope change. Limitations include use of death certificate data, which may be subject to miscoding. Furthermore, these data do not identify if changes in AAMRs are due to changing disease incidence or case-fatality rates.
Clinical and public health efforts focusing on primordial and primary prevention throughout the life course, with an emphasis on identifying and addressing the causes of racial disparities, are needed to reverse the slowing of cardiometabolic mortality rate declines.
Section Editor: Jody W. Zylke, MD, Deputy Editor.
References
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