Why this paper matters
The long decline in cardiovascular mortality beginning in the 1960s is one of American public health's genuine success stories. This Joinpoint regression analysis, using national death certificate data, documents where and when that decline stopped. The answer is not simply the pandemic. The reversal extended through 2022, well after the acute phase of the public health emergency, and the excess deaths that accumulated represent something larger than a temporary disruption.
What they did
Using death certificate data from the National Vital Statistics System, researchers calculated age-adjusted cardiovascular mortality rates for adults aged 35 and older from 2010 through 2022. CVD was defined using ICD-10 codes covering cardiovascular disease broadly, heart disease, and stroke. Joinpoint regression identified statistically significant inflection points in the trend. Excess CVD deaths from 2020 to 2022 were estimated as the difference between observed deaths and what would have been expected had the 2010 to 2019 trend continued forward.
What they found
During 2010 to 2022, 10,951,403 CVD deaths occurred — 75.6% classified as heart disease and 16.9% as stroke. The national CVD age-adjusted mortality rate declined 8.9% from 2010 to 2019, falling from 456.6 to 416.0 per 100,000. It then increased 9.3% from 2019 to 2022, reaching 454.5 per 100,000 — a figure that approximated the 2010 rate of 456.6 per 100,000. From 2020 to 2022, 228,524 excess CVD deaths occurred, representing 9% more deaths than the pre-pandemic trend would have predicted.
What the numbers actually mean
A decade of progress undone in three years. The age-adjusted mortality rate returning to its 2010 level by 2022 is the number that should land, and it is not explained by COVID-19 direct deaths alone. Excess CVD deaths persisted through 2022 despite stabilization of the public health emergency, and it is important to note that the paper cannot establish the cause for this. Delayed and avoided care during the pandemic, post-COVID cardiovascular sequelae, and longer-standing gaps in hypertension and heart failure management in the outpatient setting are all plausible contributors, possibly in combination. Heart failure mortality trends deserve particular attention here. Prior research has shown increasing heart failure mortality across multiple subgroups, reflecting both better survival from acute MI leaving more patients with damaged myocardium, and persistent gaps in uptitration of guideline-directed therapy outside the hospital.
Limitations worth knowing
- —Death certificate coding introduces variability in cause-of-death attribution for CVD, which affects trend reliability at the margins.
- —This analysis used provisional 2022 mortality data, which may differ from final death certificate figures.
- —The analysis is national in scope. The data were not stratified by US census region or county level, so the findings may understate the geographic and demographic dimensions of the observed trends.
- —The excess death calculation assumes the 2010 to 2019 linear trend would have continued, which is a reasonable but not certain methodological assumption.
The bottom line
Cardiovascular mortality in the United States is higher than pre-2020 trends would have predicted, and the gap is measurable in hundreds of thousands of excess deaths. This should be the starting point for any honest conversation about cardiovascular care priorities in the coming decade.
Paper reviewed
Woodruff RC, Tong X, Khan SS, Schieb L, Vaughan AS, Kramer MR. "Trends in Cardiovascular Disease Mortality Rates and Excess Deaths, 2010–2022." American Journal of Preventive Medicine. 2024;66(4):582–589. Available free full text at: https://pmc.ncbi.nlm.nih.gov/articles/PMC10957309/