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. Author manuscript; available in PMC: 2023 Jul 19.
Published in final edited form as: Circulation. 2022 Jul 18;146(3):211–228. doi: 10.1161/CIRCULATIONAHA.122.060199

Disparities in Cardiovascular Mortality Between Black and White Adults in the United States, 1999 to 2019

Ashley N Kyalwazi 1,2, Eméfah C Loccoh 3, LaPrincess C Brewer 4,5, Elizabeth O Ofili 6, Jiaman Xu 1, Yang Song 1, Karen E Joynt Maddox 7, Robert W Yeh 1, Rishi K Wadhera 1
PMCID: PMC9310198  NIHMSID: NIHMS1814676  PMID: 35861764

Abstract

Background

Black adults experience a disproportionately higher burden of cardiovascular (CV) risk factors and disease in comparison to White adults in the US. Less is known about how gender-based disparities in CV mortality between these groups have changed on a national scale over the past 20 years, particularly across geographic determinants of health and residential racial segregation.

Methods

We used CDC WONDER to identify Black and White adults age ≥25 years in the US from 1999 to 2019. We calculated annual age-adjusted CV mortality rates (per 100,000) for Black and White women and men, as well as absolute rate differences and rate ratios to compare the mortality gap between these groups. We also examined patterns by US census region, rural vs urban residence, and degree of neighborhood segregation.

Results

From 1999 to 2019, age-adjusted mortality rates declined overall for both Black and White adults. There was a decline in age-adjusted CV mortality among Black (602.1 to 351.8 per 100,000 population) and White women (447.0 to 267.5), and the absolute rate difference (ARD) between these groups decreased over time (1999: ARD 155.1 [95% CI, 149.9–160.3]; 2019: ARD 84.3 [81.2–87.4]). These patterns were similar for Black (824.1 to 526.3 per 100,000) and White men (637.5 to 396.0) (1999: ARD 186.6 [178.6–194.6]; 2019: ARD 130.3 [125.6–135.0]). Despite this progress, CV mortality in 2019 was higher for Black women (rate ratio [RR] 1.32 [1.30–1.33]) - especially in the younger (age<65 years) subgroup (RR 2.28 [2.23–2.32]) - as well as for Black men (RR 1.33 [1.32–1.34]), compared to their respective White counterparts. There was regional variation in CV mortality patterns, and the Black-White gap differed across rural and urban areas. CV mortality rates among Black women and men were consistently higher in communities with high levels of racial segregation, compared to those with low to moderate levels.

Conclusion

Over the past 2 decades, age-adjusted CV mortality declined significantly for Black and White adults in the US, as did the absolute difference in death rates between these groups. Despite this progress, Black women and men continue to experience higher CV mortality rates than their White counterparts.

Keywords: Cardiovascular mortality, Black adults, White adults, Racial disparities, Gender, Rural, Racial segregation

Introduction

Racial and ethnic disparities in cardiovascular (CV) disease mortality remain pervasive across the United States (US).1,2,3 While prior research has shown that Black adults have higher mortality rates due to heart failure,4 stroke,5 and acute myocardial infarction6 compared to other racial and ethnic groups, gender-based disparities in CV disease have not been well-defined on a national scale. Black women and men disproportionately face social, economic, and environmental barriers, as well as structural racism, which contribute to a higher burden of cardiovascular risk factors and mortality.1,7,8,9 Uniquely, Black women experience challenges at the intersection of both racism and sexism, as well as adverse maternal outcomes due to CV disease, which adversely impacts their cardiovascular health.1,10

Although prior studies have observed disparities in CV death rates for Black adults, gender-based analyses have been limited in their focus on small-scale and/or community-based cohorts,11,12 or have not included more recent years of data.13,14,15 Therefore, a comprehensive investigation of national trends in CV mortality among Black and White women and men across multiple sociodemographic domains is timely. In addition, it is unclear how disparities in CV mortality between these groups have changed over time across key geographic determinants of health, including US region and rurality, and residential racial segregation— a direct manifestation of structural racism. Understanding these patterns is critically important and could inform community, health system, public health, and policy strategies to address racial inequities in CV mortality.

Therefore, in this study, we aimed to answer 3 questions. First, how did overall CV mortality rates change for Black and White women and men between 1999 and 2019? Second, did gaps between Black and White women, as well as Black and White men, narrow or widen over time? And third, did these patterns differ across the US by region, rural-urban location, and residential racial segregation?

Methods

The data used in this study are publicly-available to researchers from the Centers for Disease Control and Prevention. Analytic methods and study materials can be made available to other researchers by request to the corresponding author for purposes of reproducing the results or replicating the procedure. IRB approval from Beth Israel Deaconess Medical Center was not required due to the use of publicly-available deidentified data, as per institutional policy.

Data Sources and Study Population

We used National Center for Health Statistics (NCHS) data from 1999 to 2019 provided by the Centers for Disease Control and Prevention’s Wide-Ranging ONline Data for Epidemiologic Research (CDC WONDER) database.16 Mortality data are based on the death certificates for U.S. residents, which identify a single underlying cause of death, as denoted by the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10).17

Our study population included Black and White adults age 25 years or older living in the US. Deaths due to cardiovascular disease were identified using ICD-10 codes I00–199 (diseases of the circulatory system).2,18 For subgroup analyses focused on geographic determinants of health, we classified US regions according to the US Census Bureau Divisions. In addition, we used the 2013 NCHS Urban-Rural Classification Scheme to classify counties as urban and rural.19 The degree of residential racial segregation was measured using the Black-White Index of Dissimilarity, which was linked at the county level with death data from CDC WONDER. The Index of Dissimilarity is a demographic measure of the evenness of spread between populations across census tracts which measures the degree of residential racial segregation using 5-year U.S. county data (i.e. 2015–2019). Index values >60 representing areas with high segregation, 30–59 representing areas of moderate segregation, and <30 representing areas of low segregation, consistent with prior studies that have examined the effects of residential racial segregation.20,21,22

Statistical Analyses

For Black and White adults, age-adjusted CV mortality rates per 100,000 population and standard errors were obtained from CDC WONDER for each respective year. Age-adjusted absolute rate differences for CV mortality were calculated by subtracting the age-adjusted mortality rate of White adults from that of Black adults, and 95% confidence intervals were calculated using normal approximation. To assess whether age-adjusted rate differences changed across years, the fixed effect meta-analytic method was used. Variance-weighted least square regression was performed with age-adjusted rate differences included as the dependent variable, calendar year included as a continuous predictor variable, and weights calculated as the reciprocal of variance of age-adjusted rate differences at each year.

To compare the relative difference in CV mortality between Black and White adults for each year, we calculated an age-adjusted rate ratio by dividing the age-adjusted mortality rate for Black adults by that of White adults. Corresponding 95% confidence intervals were calculated on the natural log scale, and then converted back by exponentiating the 95% lower and upper bound of the estimated age-adjusted rate ratio. Delta method was used to derive the standard error of natural log of age-adjusted rates, and normal approximation was used for the natural log of age-adjusted ratio ratios, for Black and White adults. To examine whether age-adjusted rate ratios changed over the study period, the fixed effect meta-analytic method was used. We performed all analyses for the overall population, and separately by gender, and also examined younger (< 65 years) and older (≥ 65 years) subgroups. We also examined trends according to US census region and rural vs. urban county of residency.

For the analysis focused on neighborhood segregation, we restricted the study population to Black adults living in metropolitan statistical areas between 2010 and 2019, as these areas contain a significant majority of Black adults living in the US.23 We categorized metropolitan counties according to degree of segregation (high, moderate, low), and then determined annual age-adjusted CV mortality rates for Black women and men residing in high vs. low or moderate segregation areas. We combined moderate and low segregation areas to provide stable results, due to the limited number of counties with low levels of segregation. Age-adjusted rate differences and rate ratios comparing CV mortality among Black women (and men) living high vs moderate or low racially segregated neighborhoods were calculated using the methods described above. We intentionally chose to not include earlier years of data (e.g. 1999 to 2009), to avoid misclassification of levels of segregation due to the gentrification of neighborhoods over time.

A p-value threshold of <0.05 was used to determine statistical significance. All statistical analyses were conducted using SAS version 9.4 (SAS Institute, Cary, NC).

Results

Between 1999 and 2019, there were 2,118,841 CV deaths among Black adults and 15,238,471 deaths among White adults in the United States. [Table 1]. Age-adjusted mortality rates declined for Black adults (693.2 to 426.8 per 100,000) and White adults (529.6 to 326.5 per 100,000) from 1999–2019. The absolute rate difference for CV mortality between Black and White adults decreased over the study period [ARD 1999: 163.6 (159.2–168.0); 2019: 100.4 (97.7–103.0)] [eFigure 1]. The rate ratio (RR) for CV mortality was consistently higher for Black adults compared with White adults (reference group) throughout the study period [RR: 1.31 (95% CI: 1.30,1.32) to 1.31 (95% CI: 1.30–1.32)] [eFigure 2].

Table 1.

Cardiovascular Deaths among Black and White Adults in the United States, 1999–2019.

Variable Black women White women Black men White men
Total Deaths 1,085,660 7,820,054 1,033,181 7,418,417
Age group
25–54y 130899 283514 205969 671007
55–64y 142388 438045 224830 962174
65–74y 194749 888980 239875 1428813
75–84y 278585 2119083 224276 2182769
85+ y 339039 4090432 138231 2173654
Census Region
Northeast 184887 1672575 161982 1450918
Midwest 201827 1945665 197361 1788434
South 605948 2739620 577682 2707532
West 92998 1462194 96156 1471533
Rurality
Rural 66902 713131 64216 703300
Urban 505830 1910651 472341 1776697
Residential Racial Segregation
Low-Moderate (30–60) 236461 - 247026 -
High (>60) 171858 - 165267 -
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Age-Adjusted Mortality by Gender

Black and White Women

Age-adjusted CV mortality rates declined for both Black (602.1 to 351.8 per 100,000) and White (447.0 to 267.5 per 100,000) women from 1999 to 2019. [Figure 1 Panel A]. The absolute rate difference for CV mortality between Black and White women also decreased over this period [1999: 155.1 (149.9–160.3); 2019: 84.3 (81.2–87.4)] [eFigure 3]. Rate ratios for Black and White women overall are shown in eFigure 4.

Figure 1: Age-Adjusted Cardiovascular Mortality Rates for Black and White Adults, 1999–2019.

Figure 1:

Figure 1:

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Panel A. Women

Panel B: Men

Overall age-adjusted cardiovascular mortality rates for Black women (blue) and White women (red) are shown from 1999 to 2019 (Panel A). Overall age-adjusted cardiovascular mortality rates for Black men (blue) and White men (red) are shown from 1999 to 2019 (Panel B).

Among the younger subgroup of women (age<65 years), age-adjusted mortality also declined for Black (145.2 to 99.2 per 100,000) and White (53.9 to 43.6 per 100,000) women [Figure 2 Panel A], as did the absolute rate difference between these groups [1999: 91.3 (88.7–94.0); 2019: 55.6 (53.8–57.3)] [eFigure 5A]. The rate ratio for CV mortality was higher among younger Black women compared with younger White women in both 1999 [2.70 (95% CI: 2.64, 2.75)] and 2019 [2.28 (95% CI: 2.23, 2.32)], indicating that Black women continue to experience higher rates of premature deaths from CVD [eFigure 6A]. The age-adjusted CV mortality rate also declined for older Black (2483.1 to 1391.6 per 100,000) and White (2065.5 to 1189.1 per 100,000) women [Figure 2 Panel B], as did the absolute rate difference between these groups [1999: 417.6 (393.5–441.7); 2019: 202.5 (188.3–216.7)] [eFigure 5B]. Rate ratios for older Black and White women are shown in eFigure 6B.

Figure 2. Age-Adjusted Cardiovascular Mortality Rates for Black and White Adults by Gender and Age, 1999–2019.

Figure 2.

Figure 2.

Figure 2.

Figure 2.

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Panel A: Younger Women (age <65 Years)

Panel B: Older Women (age ≥65 Years)

Panel C: Younger Men (age <65 Years)

Panel D: Older Men (age ≥65 Years)

Age-adjusted cardiovascular mortality rates for younger women, age <65 years (Panel A) and older women, age ≥65 years (Panel B) are also shown from 1999 to 2019. Age-adjusted cardiovascular mortality rates for younger men, age <65 years (Panel C) and older men, age ≥65 years (Panel D) are also shown from 1999 to 2019.

Black and White Men

Age-adjusted CV mortality rates declined for both Black (824.1 to 526.3 per 100,000) and White (637.5 to 396.0 per 100,000) men from 1999 to 2019 [Figure 1 Panel B]. The absolute rate difference for CV mortality between Black and White men also decreased over the study period [186.6 (95% CI: 178.6,194.6) to 130.3 (95% CI: 125.6,135.0)] [eFigure 7]. The rate ratio for CV mortality (Black vs. White men) was 1.29 (95% CI: 1.28,1.31) in 1999 and 1.33 (95% CI: 1.32,1.34) in 2019 [eFigure 8].

Among the younger age group (age<65 years), CV mortality declined for both Black (262.3 to 191.5 per 100,000) and White men (127.1 to 98.8 per 100,000) [Figure 2 Panel C], and the absolute difference in mortality decreased between these groups (1999: 135.2 (131.3–139.1); 2019: 92.7 (90.1–95.3) [eFigure 9A]. These patterns were similar among older Black (3136.8 to 1904.4 per 100,000) and White men (2738.5 to 1619.5 per 100,000) [Figure 2 Panel D] ([ARD 1999: 398.3 (360.5–436.1); 2019: 284.9 (263.4–306.5)] [eFigure 9B]. Similar to women, the relative gap between Black and White men was greatest in the younger subgroups, indicating higher rates premature deaths from CVD for Black men [eFigure 10].

U.S. Census Regions

Across all four U.S. census regions, Black women and men consistently experienced higher age-adjusted CV mortality rates than White women and men [Figure 3A–H]. From 1999–2019, age-adjusted CV mortality rates in the Northeast declined for all groups [Figure 3A–B], with a decrease in the absolute rate difference between Black and White women [1999: 80.8 (69.7–91.8); 2019: 55.4 (48.7–62.0)], and between Black and White men [1999: 84.2 (66.2–102.2); 2019: 78.9 (68.4–89.3)] over the study period [eFigure 11A–B]. The Midwest, in comparison, generally had the highest age-adjusted CV mortality rates, with declines occurring over time for all groups [Figure 3 C–D]. The absolute rate difference also decreased for both Black and White women [1999: 168.6 (156.4–180.7); 2019: 112.7 (104.8–120.6)] and for Black and White men [1999: 208.6 (189.8–227.5); 2019: 167.6 (155.7–179.5)] living in the Midwest [eFigure 11C–D]. In the South, there were declines in age-adjusted CV mortality rates for all groups [Figure 3E–F], and similar to other regions, absolute rate differences between Black and White women [1999: 160.9 (153.6–168.1); 2019: 75.7 (71.3–80.0)] and Black and White men [1999: 196.7 (185.5–207.9); 2019: 122.6 (116.1–129.1)] decreased over the study period [eFigure 11 E–F]. Trends for all groups were largely similar in the West [Figure 3G–H]. Rate ratios for CV mortality by Census Region for Black vs. White adults across all years are shown in eFigure 12.

Figure 3. Age-adjusted Cardiovascular Mortality Rates for Black and White Adults by Gender and U.S. Census Region, 1999–2019.

Figure 3.

Figure 3.

Figure 3.

Figure 3.

Figure 3.

Figure 3.

Figure 3.

Figure 3.

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Panel A. Northeast - Women

Panel B. Northeast – Men

Panel C. Midwest- Women

Panel D. Midwest- Men

Panel E. South- Women

Panel F. South- Men

Panel G. West- Women

Panel H. West- Men

Age-adjusted cardiovascular mortality rates for Black women (blue) and White women (red) in the Northeast (Panel A), Midwest (Panel C), South (Panel E), and West (Panel G) are shown from 1999 to 2019. Age-adjusted cardiovascular mortality rates for Black men (blue) and White men (red) in the Northeast (Panel B), Midwest (Panel D), South (Panel F), and West (Panel H) are shown from 1999 to 2019.

Rural and Urban Areas

From 1999–2019, age-adjusted CV mortality rates among Black women living in urban areas declined from 601.6 to 358.3 per 100,000 and among White women from 451.6 to 250.1 per 100,000 [Figure 4A]. The absolute rate difference between Black and White women in urban areas decreased over the study period [1999: 150.0 (142.4–157.7); 2019: 108.2 (103.3–113.0)] [eFigure 13A]. In addition, both Black men (829.8 to 547.8 per 100,000) and White men (644.0 to 380.1 per 100,000) living in urban areas experienced a decline in CV mortality [Figure 4B], and the absolute rate difference between these groups decreased [eFigure 13B]. Rate ratios for mortality among Black vs. White adults living in urban areas increased over the study period for both women [1999: 1.33 (1.32–1.35); 2019: 1.43 (1.41–1.45)] and men [1999: 1.29 (1.27–1.31); 2019: 1.44 (1.42–1.46)] [eFigures 14A–B].

Figure 4. Age-adjusted Cardiovascular Mortality Rates for Black and White Adults in Rural and Urban Areas of the US, 1999–2019.

Figure 4.

Figure 4.

Figure 4.

Figure 4.

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Panel A. Urban Women

Panel B. Urban Men

Panel C. Rural Women

Panel D. Rural Men

Age-adjusted cardiovascular mortality rates for Black women (blue) and White women (red) in both Urban (Panel A) and Rural (Panel C) areas are shown from 1999 to 2019. Age-adjusted cardiovascular mortality rates for Black men (blue) and White men (red) in both Urban (Panel B) and Rural (Panel D) areas are shown from 1999 to 2019.

In rural areas, age-adjusted CV mortality rates among Black women declined from 644.9 to 401.3 per 100,000 and among White women from 471.3 to 306.7 per 100,000 [Figure 4C], and there was a decrease in the absolute rate difference between these groups [1999: 173.6 (152.5–194.6); 2019: 94.6 (79.0–110.3)] [eFigure 13C]. Black men living in rural areas also experienced a decline in mortality from 916.1 to 593.8 per 100,000, as did White men (683.9 to 452.7 per 100,000) [Figure 4D], and the absolute rate difference also decreased between these groups [eFigure 13D]. Rate ratios for mortality between Black and White adults living in rural areas are shown by gender in eFigures 14C–D. Notably, Black women and men in rural areas experienced the highest CV mortality rates in the country.

Residential Racial Segregation

The analysis of residential racial segregation was restricted to Black adults living in metropolitan statistical areas between 2010 and 2019. From 2010 to 2019, age-adjusted CV mortality rates for Black women decreased in areas with high (407.0 to 365.4 per 100,000), and low-moderate (385.8 to 342.8 per 100,000) levels of residential racial segregation [Figure 5A]. The absolute rate difference for mortality between Black women in high vs. low-moderate segregation areas did not meaningfully change from 2010 [21.3 (−4.4, 47.0)] to 2019 [22.6 (4.8, 40.4)] [eFigure 15]. For Black men, age-adjusted CV mortality rates declined in areas of high (593.6 to 566.5 per 100,000) and low-moderate (541.7 to 505.9 per 100,000) levels of residential racial segregation [Figure 5B]. However, the absolute rate difference for mortality between Black men in high vs. low-moderate segregation areas did not narrow from 2010 [52.0 (−12.4, 116.4)] to 2019 [60.6 (17.2, 104.0)] in 2019 [eFigure 16]. Changes in rate ratios for Black vs. White adults by residential racial segregation are shown in eFigures 17 and 18.

Figure 5. Age-Adjusted Cardiovascular Mortality Rates for Black Adults in Low to Moderate versus High Areas of Residential Racial Segregation by Gender, 2010–2019.

Figure 5.

Figure 5.

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Panel A. Black Women

Panel B. Black Men

Age-adjusted cardiovascular mortality rates for Black women living in areas of low to moderate (red) versus high (blue) areas of residential racial segregation from 2010 to 2019 (Panel A), and for Black men living in areas of low to moderate (red) versus high (blue) areas of residential racial segregation from 2010 to 2019 (Panel B).

Discussion

In this nationwide analysis, age-adjusted cardiovascular mortality declined for Black and White adults from 1999 to 2019, and the absolute difference in death rates between these groups also decreased. These patterns were similar for both women and men. Although there was marked geographic variation in mortality patterns, declines in cardiovascular death rates for Black and White adults occurred across all US regions, as well as in rural and urban areas, although differences persisted across levels of residential racial segregation (among Black adults). Despite significant gains over the last 20 years, Black individuals continue to experience higher cardiovascular mortality rates than their White counterparts. Notably, younger Black women remain >2-times more likely to experience premature death from cardiovascular causes than White women, and Black women and men living in rural areas experience the highest cardiovascular mortality rates in the country.

Declines in cardiovascular mortality for both Black and White adults over the past 2 decades reflect substantial progress in cardiovascular disease prevention, advancements in medical therapies and technology for cardiovascular conditions,24,25 as well as national efforts to promote awareness of risk factors impacting cardiovascular health.26 At the same time, improvements in health insurance coverage, access to health care services, and care delivery and quality have enhanced primary and secondary preventive care for cardiovascular disease, and hospital care for acute conditions, and contributed to decreases in mortality.27,28 Despite this progress, we find that significant disparities in absolute rates of cardiovascular mortality between Black and White adults continue to persist.

Perhaps most concerning is our finding that Black-White gaps in mortality remain most pronounced in both younger women and men, indicating higher rates of premature death among Black adults in the United States. Although differences in mortality between younger Black and White adults have narrowed, our finding that younger Black women are still >2-times more likely than White women to die of cardiovascular causes is very concerning, and parallels well-documented racial/ethnic disparities in maternal health outcomes,29 for which cardiovascular disease is the leading cause of death in the US.30,31 These disparities were similar, albeit more modest, between Black and White men. The markedly higher premature mortality rates from cardiovascular disease for Black adults is a critically important public health issue, and there is a pressing need for concerted community, health system, state and federal initiatives to advance the prevention and treatment of cardiovascular risk factors and disease for younger populations.

The ongoing gap in cardiovascular mortality between Black and White adults has likely been driven by systemic inequities and structural racism.32 Black adults disproportionately experience social, economic, and environmental barriers towards achieving optimal health. Numerous studies have found that poverty,33 food insecurity,34 chronic stress, and other environmental factors adversely affect the cardiovascular health of Black individuals. Black women experience high levels of racism, sexism, and discrimination in comparison to other groups,10,35 while the mass incarceration of Black men across the country has created an inherent barrier to their health, having already been linked to a higher risk of cardiovascular disease.7 Beyond social risk factors, Black adults continue to face worse access to health care, numerous barriers towards access to equitable and timely cardiovascular care,36 ,35 and are also more likely to receive care at lower quality practices and hospitals,37,38 compared with their White counterparts. In addition, the dissemination of novel cardiovascular therapeutics lags behind in Black communities.24,39,40 Even among those with adequate access to health care, the implicit and explicit biases of healthcare providers and systems may lead to lower quality care (i.e. cardiovascular disease risk assessment, screening41,42 and treatment recommendations).35,43,44

Notably, we observed marked geographic variation in cardiovascular mortality in the US. For example, the Northeast region had the lowest overall mortality rates for Black women and men, which may be related to regional factors including a higher degree of physical activity, more concentrated medical resources, and ease of transportation.1 In contrast, Black women and men living in the Midwest had the highest death rates in the country, consistent with prior work focused on heart failure and stroke,45,46 while the South also experienced high mortality rates. These patterns may be due to the higher burden of food insecurity47 and other cardiovascular risk factors (tobacco use, obesity, diabetes) in these regions.48

We also found that Black adults had higher mortality rates than their White counterparts in both rural and urban areas of the country. While absolute rate differences between Black and White adults across urban areas of the country declined over the study period, relative reductions in mortality were most pronounced among White individuals. Given the strong association between income and cardiovascular outcomes,49 one potential explanation is the rising income inequality across urban areas of the US,50 which disproportionately affects Blacks women and men.51 In addition, Black communities in urban areas are increasingly being exposed to environmental stressors (e.g., air pollution, climate change), which are associated with cardiovascular mortality.52,53 Collectively, our findings demonstrate improvements in CV mortality rates across rural and urban areas of the country, while also suggesting the ongoing need for geographically-tailored public health and policy initiatives to reduce disparities in cardiovascular outcomes between Black and White adults in the US.

Residential racial segregation is the direct manifestation of racist policies designed to diminish Black peoples’ access to educational, housing, and employment opportunities. Segregation contributes to as well as reinforces healthcare disparities.22,54,55,56 We found that in metropolitan statistical areas across the country, cardiovascular mortality rates were higher for Black women and men residing in highly segregated communities relative to those living in communities of low-moderate segregation by the end of the study period, consistent with previous work documenting an association between neighborhood segregation and the cardiovascular health of Black adults and youth.57,58 The magnitude of these differences, however, were modest and further study will help to identify community-level and policy-level factors that impact such differences.

Over the last twenty years, cardiovascular mortality rates for Black and White adults across the US have showed encouraging declines. However, ongoing racial disparities in cardiovascular mortality in the U.S. highlight the importance of concerted community, health system, state and federal initiatives focusing on disease screening, prevention, and treatment in Black communities. Cardiovascular health education and screening programs that can be molded within Black communities (e.g. screening for high blood pressure in barbershops),59,60,61 have been shown to be highly effective, and should be rapidly expanded on a national scale. In addition to the provision of higher quality care, initiatives that focus on the equitable and timely distribution of guideline-directed therapies for Black adults are also needed.40,62 For Black women in particular, additional funding is needed to prioritize maternal education and health advocacy during prenatal, antepartum, and postpartum periods (i.e. education on risk assessment, disparities, individual cardiovascular health, routine check-ups).63,64,65 At the policy level, more initiatives are needed to protect Black men from deleterious systems that perpetuate poor cardiovascular health outcomes (i.e. the criminal justice system and mass incarceration of Black men7).

Limitations

This study has several limitations. First, CDC WONDER captures aggregate death information at the national and county levels, and individual information on decedents was not available. Nonetheless, our analysis provides a comprehensive, nationwide assessment of disparities in cardiovascular mortality between Black and White adults over the past 2 decades. Further research is needed to explore the specific factors contributing to the persistent gap between these groups over the past two decades. Second, cardiovascular mortality rates were determined based on death certificates and ICD-10 codes, which identify an underlying cause of death, and may be subject to misclassification. Third, mortality data from CDC WONDER is based on the death certificates by place of residence. In some cases, this categorization might not reflect the location that a given individual has spent the majority of their lifespan, making it difficult to assess the extent to which such geographic classification has impacted mortality data. Additionally, because this is an ecological study, the effects of geographic variation on the health of our study population are likely to reflect lifelong exposures that fluctuate over time with changes to place of residence, adaptations to health behaviors, and other factors that we are unable to fully capture. Finally, for the analysis focused on neighborhood segregation, we restricted the study sample to Black adults in metropolitan statistical areas between 2010 and 2019, because the dissimilarity index was based on index values assigned for U.S. counties between 2015–2019. We intentionally chose to not include earlier years of data, to avoid misclassification of levels of segregation due to the gentrification of neighborhoods over time.

Conclusion

Over the past 2 decades, age-adjusted CV mortality declined significantly for Black and White adults in the US, as did the absolute difference in death rates between these groups. Despite this progress, Black women and men continue to experience higher CV mortality rates than their White counterparts. Targeted health system, public health, and policy strategies are needed to reduce the risk of cardiovascular disease and mortality among Black adults in the United States.

Supplementary Material

Supplemental Publication Material

What is New?

  • In the United States, age-adjusted cardiovascular mortality declined for Black and White adults from 1999 to 2019, and the absolute difference in death rates between these groups also decreased. These patterns were similar for both women and men.

  • There was marked geographic variation in cardiovascular mortality, and Black women and men living in rural areas consistently experienced the highest mortality rates. In addition, mortality rates among Black adults were higher in highly-segregated areas compared to less-segregated areas.

What Are the Clinical Implications?

  • Despite substantial progress in reducing cardiovascular mortality rates for Black and White adults over the past 2 decades, death rates in 2019 remained significantly higher for Black women and men compared to their White counterparts, and these differences were most pronounced in younger age groups.

  • Targeted health system, community, and population health strategies are needed to reduce ongoing Black-White disparities in cardiovascular mortality.

Disclosures

Ms. Kyalwazi receives research support from the Sarnoff Cardiovascular Research Fellowship. Dr. Brewer was supported by the American Heart Association-Amos Medical Faculty Development Program (Grant No. 19AMFDP35040005), the National Institutes of Health (NIH)/National Institute on Minority Health and Health Disparities (NIMHD) (Grant No. R21 MD013490-01) and the Centers for Disease Control and Prevention (CDC) (Grant No. CDC-DP18-1817) during the implementation of this work. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH or CDC. Dr. Ofili is supported by the following NIH awards: National Institute on Minority Health and Health Disparities (Grant # U24MD015970, U24MD017138) and related awards (U01GM132771 and UL1TR002378). Dr. Joynt Maddox receives research support from the National Heart, Lung, and Blood Institute (R01HL143421) and National Institute on Aging (R01AG060935). Dr. Yeh receives research support from the National Heart, Lung and Blood Institute (R01HL136708 and R01HL157530) and the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology and receives personal fees from Biosense Webster, grants and personal fees from Abbott Vascular, AstraZeneca, Boston Scientific, and Medtronic, outside the submitted work. Dr. Wadhera receives research support from the National Heart, Lung, and Blood Institute (K23HL148525) at the National Institutes of Health. He currently serves as a consultant for Abbott and CVS Health, outside the submitted work. All other authors have no disclosures.

Sources of Funding:

National Heart, Lung, and Blood Institute (K23HL148525) at the National Institutes of Health.

Role of the Funder/Sponsor:

The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Nonstandard Abbreviations and Acronyms:

CDC WONDER

Centers for Disease Control and Prevention’s Wide-Ranging ONline Data for Epidemiologic Research

NCHS

National Center for Health Statistics

Footnotes

Supplemental Materials

eFigure 1. Absolute Rate Difference for Cardiovascular Mortality Among Black vs. White Adults (ref), 1999–2019

eFigure 2. Rate Ratios for Cardiovascular Mortality Among Black vs. White Adults (ref), 1999–2019

eFigure 3. Absolute Rate Difference for Cardiovascular Mortality Among Black vs. White Women (ref), 1999–2019

eFigure 4. Rate Ratios for Cardiovascular Mortality Among Black vs. White Women (ref), 1999–2019

eFigure 5. Absolute Rate Difference for Cardiovascular Mortality Among Black vs. White Women (ref) by Age Group, 1999–2019

eFigure 6. Rate Ratios for Cardiovascular Mortality Among Black vs. White Women (ref) by Age Group, 1999–2019

eFigure 7. Absolute Rate Difference for Cardiovascular Mortality Among Black vs. White Men (ref), 1999–2019

eFigure 8. Rate Ratios for Cardiovascular Mortality Among Black vs. White Men (ref), 1999–2019

eFigure 9. Absolute Rate Difference for Cardiovascular Mortality Among Black vs. White Men (ref) by Age Group, 1999–2019

eFigure 10. Rate Ratio for Cardiovascular Mortality Among Black vs. White Men (ref) by Age Group, 1999–2019

eFigure 11. Absolute Rate Difference for Cardiovascular Mortality Among Black vs. White Adults (ref) by US Census Region, 1999–2019

eFigure 12. Rate Ratios for Cardiovascular Mortality Among Black vs. White Adults (ref) by US Census Region, 1999–2019

eFigure 13. Absolute Rate Difference for Cardiovascular Mortality Among Black vs. White Adults (ref) in Rural and Urban Areas of the US, 1999–2019

eFigure 14. Rate Ratios for Cardiovascular Mortality Among Black vs. White Adults (ref) in Rural and Urban Areas of the US, 1999–2019

eFigure 15. Absolute Rate Difference for Cardiovascular Mortality Among Black Women in High vs. Low to Moderate Areas of Residential Racial Segregation, 2010–2019

eFigure 16. Absolute Rate Difference for Cardiovascular Mortality Among Black Men in High vs. Low to Moderate Areas of Residential Racial Segregation, 2010–2019

eFigure 17. Rate Ratio for Cardiovascular Mortality Among Black Women in High vs. Low to Moderate Areas of Residential Racial Segregation, 2010–2019

eFigure 18. Rate Ratio for Cardiovascular Mortality Among Black Men in High vs. Low to Moderate Areas of Residential Racial Segregation, 2010–2019

References

  • 1.Tsao CW, Aday AW, Almarzooq ZI, Alonso A, Beaton AZ, Bittencourt MS, Boehme AK, Buxton AE, Carson AP, Commodore-Mensah Y, Elkind MSV, Evenson KR, Eze-Nliam C, Ferguson JF, Generoso G, Ho JE, Kalani R, Khan SS, Kissela BM, Knutson KL, Levine DA, Lewis TT, Liu J, Loop MS, Ma J, Mussolino ME, Navaneethan SD, Perak AM, Poudel R, Rezk-Hanna M, Roth GA, Schroeder EB, Shah SH, Thacker EL, VanWagner LB, Virani SS, Voecks JH, Wang N-Y, Yaffe K, Martin SS. Heart Disease and Stroke Statistics—2022 Update: A Report From the American Heart Association. Circulation. 2022. doi: 10.1161/CIR.0000000000001052. [DOI] [PubMed] [Google Scholar]
  • 2.Wadhera RK, Figueroa JF, Rodriguez F, Liu M, Tian W, Kazi DS, Song Y, Yeh RW, Maddox KEJ. Racial and Ethnic Disparities in Heart and Cerebrovascular Disease Deaths During the COVID-19 Pandemic in the United States. Circulation. 2021. doi: 10.1161/CIRCULATIONAHA.121.054378. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Graham GN, Jones PG, Chan PS, Arnold SV, Krumholz HM, Spertus JA. Racial Disparities in Patient Characteristics and Survival After Acute Myocardial Infarction. JAMA Network Open. 2018;1. doi: 10.1001/jamanetworkopen.2018.4240. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Glynn P, Lloyd-Jones DM, Feinstein MJ, Carnethon M, Khan SS. Disparities in Cardiovascular Mortality Related to Heart Failure in the United States. Journal of the American College of Cardiology. 2019;73:2354–2355. [DOI] [PubMed] [Google Scholar]
  • 5.Howard G, Moy CS, Howard VJ, McClure LA, Kleindorfer DO, Kissela BM, Judd SE, Unverzagt FW, Soliman EZ, Safford MM, Cushman M, Flaherty ML, Wadley VG. Where to Focus Efforts to Reduce the Black–White Disparity in Stroke Mortality: Incidence Versus Case Fatality? Stroke. 2016;47:1893–1898. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Blackston JW, Safford MM, Mefford MT, Freeze E, Howard G, Howard VJ, Naftel DC, Brown TM, Levitan EB. Cardiovascular Disease Events and Mortality After Myocardial Infarction Among Black and White Adults: REGARDS Study. Circ: Cardiovascular Quality and Outcomes. 2020;13. doi: 10.1161/CIRCOUTCOMES.120.006683. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Wang EA, Redmond N, Dennison Himmelfarb CR, Pettit B, Stern M, Chen J, Shero S, Iturriaga E, Sorlie P, Diez Roux AV. Cardiovascular Disease in Incarcerated Populations. Journal of the American College of Cardiology. 2017;69:2967–2976. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.Williams DR, Mohammed SA. Racism and Health I: Pathways and Scientific Evidence. American Behavioral Scientist. 2013;57:1152–1173. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Bureau of Labor Statistics USD of L. Employed persons by occupation, race, Hispanic or Latino ethnicity, and sex. 2020;:2. [Google Scholar]
  • 10.Chinn JJ, Martin IK, Redmond N. Health Equity Among Black Women in the United States. Journal of Women’s Health. 2021. doi: 10.1089/jwh.2020.8868. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.Colantonio LD, Gamboa CM, Richman JS, Levitan EB, Soliman EZ, Howard G, Safford MM. Black-White Differences in Incident Fatal, Nonfatal, and Total Coronary Heart Disease. Circulation. 2017;136:152–166. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Iantorno M, Rogers T, Torguson R, Kolm P, Gajanana D, Khalid N, Shlofmitz E, Khan JM, Chen Y, Musallam A, Weintraub WS, Waksman R. Racial Disparities in Clinical Characteristics and Outcomes of Women Undergoing Percutaneous Coronary Intervention. Cardiovascular Revascularization Medicine. 2019;20:1039–1042. [DOI] [PubMed] [Google Scholar]
  • 13.Gh T, Ph S, Je M, Sn W, Vg D, Wk P, Hw S, Jt W, As J, T R. Effects of gender and race on prognosis after myocardial infarction: adverse prognosis for women, particularly black women. Journal of the American College of Cardiology. 1987;9. doi: 10.1016/s0735-1097(87)80038-4. [DOI] [PubMed] [Google Scholar]
  • 14.Mortality From Congestive Heart Failure— United States, 1980–1990. JAMA. 1994;271:813–814. [PubMed] [Google Scholar]
  • 15.Mensah GA, Mokdad AH, Ford ES, Greenlund KJ, Croft JB. State of Disparities in Cardiovascular Health in the United States. Circulation. 2005. doi: 10.1161/01.CIR.0000158136.76824.04. [DOI] [PubMed] [Google Scholar]
  • 16.CDC WONDER. Available at https://wonder.cdc.gov/. Accessed December 9, 2021.
  • 17.Underlying Cause of Death 1999–2019. Available at https://wonder.cdc.gov/wonder/help/ucd.html#Age-Adjusted%20Rates. Accessed November 18, 2021.
  • 18.Cross SH, Mehra MR, Bhatt DL, Nasir K, O’Donnell CJ, Califf RM, Warraich HJ. Rural-Urban Differences in Cardiovascular Mortality in the US, 1999–2017. JAMA. 2020;323:1852–1854. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Data Access - Urban Rural Classification Scheme for Counties. Available at https://www.cdc.gov/nchs/data_access/urban_rural.htm. Accessed December 9, 2021.
  • 20.Bureau UC. Housing Patterns: Appendix B: Measures of Residential Segregation. Census.gov. Available at https://www.census.gov/topics/housing/housing-patterns/guidance/appendix-b.html. Accessed December 9, 2021.
  • 21.Adelman RM. Neighborhood Opportunities, Race, and Class: The Black Middle Class and Residential Segregation. City & Community. 2004;3:43–63. [Google Scholar]
  • 22.Cummings D, Patil S, Long L, Guo B. Does the Association Between Hemoglobin A1c and Risk of Cardiovascular Events Vary by Residential Segregation? The REasons for Geographic And Racial Differences in Stroke (REGARDS) Study. 2021;44:8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23.Racial and ethnic minorities made up about 22 percent of the rural population in 2018, compared to 43 percent in urban areas. Available at http://www.ers.usda.gov/data-products/chart-gallery/gallery/chart-detail/?chartId=99538. Accessed December 10, 2021.
  • 24.S Ja, W H, V-E J, S Es, D Nr, R Js, V Ss, B R, K A, B Mj, B Rs, L-J D, N K. National Trends in Statin Use and Expenditures in the US Adult Population From 2002 to 2013: Insights From the Medical Expenditure Panel Survey. JAMA cardiology. 2017;2. doi: 10.1001/jamacardio.2016.4700. [DOI] [PubMed] [Google Scholar]
  • 25.Gu Q, Kit BK. Prescription Cholesterol-lowering Medication Use in Adults Aged 40 and Over: United States, 2003–2012. 2014;:8. [PubMed] [Google Scholar]
  • 26.Labarthe DR. From Cardiovascular Disease to Cardiovascular Health. Circulation: Cardiovascular Quality and Outcomes. 2012. doi: 10.1161/CIRCOUTCOMES.111.964726. [DOI] [PubMed] [Google Scholar]
  • 27.Wadhera RK, Joynt KE. Insurance and Cardiovascular Health. Circulation. 2017. doi: 10.1161/CIRCULATIONAHA.117.028618. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.Smolderen KG, Spertus JA, Tang F, Oetgen W, Borden WB, Ting HH, Chan PS. Treatment Differences by Health Insurance Among Outpatients With Coronary Artery Disease: Insights From the National Cardiovascular Data Registry. Journal of the American College of Cardiology. 2013. doi: 10.1016/j.jacc.2012.11.058. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29.Mehta LS, Sharma G, Creanga AA, Hameed AB, Hollier LM, Johnson JC, Leffert L, McCullough LD, Mujahid MS, Watson K, White CJ, Committee on behalf of the AHAAC. Call to Action: Maternal Health and Saving Mothers: A Policy Statement From the American Heart Association. Circulation. 2021. doi: 10.1161/CIR.0000000000001000. [DOI] [PubMed] [Google Scholar]
  • 30.ACOG Practice Bulletin No. 212: Pregnancy and Heart Disease. Obstetrics & Gynecology. 2019;133:e320–e356. [DOI] [PubMed] [Google Scholar]
  • 31.Petersen EE. Racial/Ethnic Disparities in Pregnancy-Related Deaths — United States, 2007–2016. MMWR Morb Mortal Wkly Rep. 2019;68. doi: 10.15585/mmwr.mm6835a3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32.Churchwell K, Elkind MSV, Benjamin RM, Carson AP, Chang EK, Lawrence W, Mills A, Odom TM, Rodriguez CJ, Rodriguez F, Sanchez E, Sharrief AZ, Sims M, Williams O, Association O behalf of the AH. Call to Action: Structural Racism as a Fundamental Driver of Health Disparities: A Presidential Advisory From the American Heart Association. Circulation. 2020. doi: 10.1161/CIR.0000000000000936. [DOI] [PubMed] [Google Scholar]
  • 33.Abdalla SM, Yu S, Galea S. Trends in Cardiovascular Disease Prevalence by Income Level in the United States. JAMA Network Open. 2020;3:e2018150–e2018150. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34.Irving SM, Njai RS, Siegel PZ. Food Insecurity and Self-Reported Hypertension Among Hispanic, Black, and White Adults in 12 States, Behavioral Risk Factor Surveillance System, 2009. Prev Chronic Dis. 2014;11:E161. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35.Brewer LC, Cooper LA. Race, Discrimination, and Cardiovascular Disease. AMA Journal of Ethics. 2014;16:455–460. [PMC free article] [PubMed] [Google Scholar]
  • 36.Nanna MG, Navar AM, Zakroysky P, Xiang Q, Goldberg AC, Robinson J, Roger VL, Virani SS, Wilson PWF, Elassal J, Lee LV, Wang TY, Peterson ED. Association of Patient Perceptions of Cardiovascular Risk and Beliefs on Statin Drugs With Racial Differences in Statin Use: Insights From the Patient and Provider Assessment of Lipid Management Registry. JAMA Cardiology. 2018;3:739–748. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37.Jha AK, Orav EJ, Epstein AM. Low-Quality, High-Cost Hospitals, Mainly In South, Care For Sharply Higher Shares Of Elderly Black, Hispanic, And Medicaid Patients. Health Affairs. 2017. doi: 10.1377/hlthaff.2011.0027. [DOI] [PubMed] [Google Scholar]
  • 38.Black Patients are More Likely Than White Patients to be in Hospitals with Worse Patient Safety Conditions. RWJF. Available at https://www.rwjf.org/en/library/research/2021/03/black-patients-are-more-likely-than-white-patients-to-be-in-hospitals-with-worse-patient-safety-conditions.html. Accessed March 17, 2022.
  • 39.Nathan AS, Yang L, Yang N, Eberly LA, Khatana SAM, Dayoub EJ, Vemulapalli S, Julien H, Cohen DJ, Nallamothu BK, Baron SJ, Desai ND, Szeto WY, Herrmann HC, Groeneveld PW, Giri J, Fanaroff AC. Racial, Ethnic, and Socioeconomic Disparities in Access to Transcatheter Aortic Valve Replacement Within Major Metropolitan Areas. JAMA Cardiol. 2022;7:150–157. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 40.Mosca L, Hammond G, Mochari-Greenberger H, Towfighi A, Albert MA. Fifteen-Year Trends in Awareness of Heart Disease in Women. Circulation. 2013. doi: 10.1161/CIR.0b013e318287cf2f. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 41.Eberly LA, Day SM, Ashley EA, Jacoby DL, Jefferies JL, Colan SD, Rossano JW, Semsarian C, Pereira AC, Olivotto I, Ingles J, Seidman CE, Channaoui N, Cirino AL, Han L, Ho CY, Lakdawala NK. Association of Race With Disease Expression and Clinical Outcomes Among Patients With Hypertrophic Cardiomyopathy. JAMA Cardiology. 2020;5:83–91. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 42.Hyland PM, Xu J, Shen C, Markson LJ, Manning WJ, Strom JB. Race, sex and age disparities in echocardiography among Medicare beneficiaries in an integrated healthcare system. Heart. 2021. doi: 10.1136/heartjnl-2021-319951. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 43.Schulman KA, Sistrunk S, Burke JE, Escarce JJ. The Effect of Race and Sex on Physicians’ Recommendations for Cardiac Catheterization. The New England Journal of Medicine. 1999;:9. [DOI] [PubMed] [Google Scholar]
  • 44.Eberly LA, Richterman A, Beckett AG, Wispelwey B, Marsh RH, Manchanda ECC, Chang CY, Glynn RJ, Brooks KC, Boxer R, Kakoza R, Goldsmith J, Loscalzo J, Morse M, Lewis EF. Identification of Racial Inequities in Access to Specialized Inpatient Heart Failure Care at an Academic Medical Center. Circulation: Heart Failure. 2019. doi: 10.1161/CIRCHEARTFAILURE.119.006214. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 45.Liao Y, Greenlund KJ, Croft JB, Keenan NL, Giles WH. Factors Explaining Excess Stroke Prevalence in the US Stroke Belt. Stroke. 2009. doi: 10.1161/STROKEAHA.109.561688. [DOI] [PubMed] [Google Scholar]
  • 46.Glynn PA, Molsberry R, Harrington K, Shah NS, Petito LC, Yancy CW, Carnethon MR, Lloyd‐Jones DM, Khan SS. Geographic Variation in Trends and Disparities in Heart Failure Mortality in the United States, 1999 to 2017. Journal of the American Heart Association. 2021. doi: 10.1161/JAHA.120.020541. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 47.Coleman-Jensen A, Rabbitt MP, Gregory CA, Singh A. Household Food Security in the United States in 2017. Available at http://www.ers.usda.gov/publications/pub-details/?pubid=90022. Accessed March 26, 2022.
  • 48.Hof JRV, Duval S, Luepker RV, Jones C, Hayes SN, Cooper LA, Patten CA, Brewer LC. Association of Cardiovascular Disease Risk Factors With Sociodemographic Characteristics and Health Beliefs Among a Community-Based Sample of African American Adults in Minnesota. Mayo Clinic Proceedings. 2022;97:46–56. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 49.Machado S, Sumarsono A, Vaduganathan M. Midlife Wealth Mobility and Long-term Cardiovascular Health. JAMA Cardiol. 2021;6:1152–1160. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 50.Bureau UC. A Comparison of Rural and Urban America: Household Income and Poverty. The United States Census Bureau. Available at https://www.census.gov/newsroom/blogs/random-samplings/2016/12/a_comparison_of_rura.html. Accessed December 10, 2021. [Google Scholar]
  • 51.O’Neil A, Thompson K, Russell JD, Norton R. Inequalities and Deteriorations in Cardiovascular Health in Premenopausal US Women, 1990–2016. 10.2105/AJPH.2020.305702. doi: 10.2105/AJPH.2020.305702. [DOI] [PMC free article] [PubMed]
  • 52.Brook RD, Franklin B, Cascio W, Hong Y, Howard G, Lipsett M, Luepker R, Mittleman M, Samet J, Sidney C. Smith J, Tager I. Air Pollution and Cardiovascular Disease. Circulation. 2004. doi: 10.1161/01.CIR.0000128587.30041.C8. [DOI] [PubMed] [Google Scholar]
  • 53.Strosnider H. Rural and Urban Differences in Air Quality, 2008–2012, and Community Drinking Water Quality, 2010–2015 — United States. MMWR Surveill Summ. 2017;66. doi: 10.15585/mmwr.ss6613a1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 54.Rothstein R. The color of law : a forgotten history of how our government segregated America, First edition. New York: Liveright Publishing Corporation, a division of W.W. Norton & Company; 2017. [Google Scholar]
  • 55.Williams DR, Collins C. Racial Residential Segregation: A Fundamental Cause of Racial Disparities in Health. Public Health Reports. 2001;116:13. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 56.Williams D, Cooper L. Reducing Racial Inequities in Health: Using What We Already Know to Take Action. IJERPH. 2019;16:606. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 57.Impact of change in neighborhood racial/ethnic segregation on cardiovascular health in minority youth attending a park-based afterschool program. Social Science & Medicine. 2018;205:116–129. [DOI] [PubMed] [Google Scholar]
  • 58.Kershaw KN, Osypuk TL, Do DP, Chavez PJD, Roux AVD. Neighborhood-Level Racial/Ethnic Residential Segregation and Incident Cardiovascular Disease. Circulation. 2015. doi: 10.1161/CIRCULATIONAHA.114.011345. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 59.Victor RG, Lynch K, Li N, Blyler C, Muhammad E, Handler J, Brettler J, Rashid M, Hsu B, Foxx-Drew D, Moy N, Reid AE, Elashoff RM. A Cluster-Randomized Trial of Blood-Pressure Reduction in Black Barbershops. N Engl J Med. 2018;378:1291–1301. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 60.Joseph JJ, Nolan TS, Williams A, McKoy A, Zhao S, Aboagye-Mensah E, Kluwe B, Odei JB, Brock G, Lavender D, Gregory J, Gray DM. Improving cardiovascular health in black men through a 24-week community-based team lifestyle change intervention: The black impact pilot study. Am J Prev Cardiol. 2022;9:100315. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 61.B Lc, K A, S C, J S, J C, H Sn, B L, C La, P Ca. A Cardiovascular Health and Wellness Mobile Health Intervention Among Church-Going African Americans: Formative Evaluation of the FAITH! App. JMIR formative research. 2020;4. doi: 10.2196/21450. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 62.Dorsch MP, Lester CA, Ding Y, Joseph M, Brook RD. Effects of Race on Statin Prescribing for Primary Prevention With High Atherosclerotic Cardiovascular Disease Risk in a Large Healthcare System. J Am Heart Assoc. 2019;8:e014709. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 63.Jackson EA, Ruppert K, Derby CA, Lian Y, Chae CU, Kazlauskaite R, Neal‐Perry G, Khoudary SRE, Harlow SD, Solomon DH. Is race or ethnicity associated with under‐utilization of statins among women in the United States: The study of women’s health across the nation. Clinical Cardiology. 2020;43:1388. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 64.R Nw, L J, H A, B S. Assessment of Racial Disparities in Aspirin Prophylaxis for Preeclampsia Prevention. American journal of perinatology. 2022. doi: 10.1055/s-0042-1743142. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 65.Bond RM, Gaither K, Nasser SA, Albert MA, Ferdinand KC, Njoroge JN, Parapid B, Hayes SN, Pegus C, Sogade B, Grodzinsky A, Watson KE, McCullough CA, Ofili E, Cardiologists on behalf of the A of B. Working Agenda for Black Mothers. Circulation: Cardiovascular Quality and Outcomes. 2021. doi: 10.1161/CIRCOUTCOMES.120.007643. [DOI] [PMC free article] [PubMed] [Google Scholar]

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