US Rural Communities Face Disparities in Heart Disease Outcomes

Two new studies underscore health disparities in rural United States affecting mortality rates associated with cardiovascular disease (CVD), especially for younger women and individuals with heart failure (HF).^1,2

Published in the Journal of the American Heart Association, the first study indicated that women who live in rural areas are more likely to die prematurely of coronary artery disease (CAD) compared with their urban counterparts.¹

Despite a leveling off of premature mortality due to CAD overall, the prevalence of CVD risk factors have increased in rural communities.

For the study, the researchers analyzed and compared changes from 1999 to 2017 in premature deaths from coronary artery disease (CAD) among women under the age of 65 living in rural areas and more populated areas.¹

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Overall, the findings showed that premature CADS were consistently higher in rural areas, regardless of sex, race, or age group, according to the study. Deaths did not increase among men overall; however, the rate of CAD deaths in those aged 55 to 64 years of age stopped improving in small to medium towns in 2011, and rural areas in 2008.¹

CAD rates increasing significantly among women in rural communities for the following groups:¹

• Women aged 55 to 64 years of age from 2019 to 2017 (estimated annual percentage change +1.4%, cumulatively +11.3%)

• Women aged 45 to 54 years of age from 1999 to 2017 (estimated annual percentage change +0.6%, cumulatively +11.4%).

According to Federico Moccetti, MD, senior author of the study, the significant increase in CAD deaths among young women in rural areas is likely due to disparities in the prevention and control of CVD risk factors in these communities.³

“Since the increase in deaths is among younger women, this means that it is the result of exposure to risk factors that occurred during young adulthood, adolescence, and even childhood,” Dr Moccetti said in a press release.³

Additionally, although the researchers considered the distance as a factor that may contribute to poorer outcomes, the increase in distance did not affect men, they noted.³

“This leads to the inevitable conclusion that an intensification of the public health efforts aimed at increasing cardiovascular health of rural women, during young adulthood, adolescent, and childhood are necessary,” Dr Moccetti said.³

In a separate study, researchers found that individuals residing in rural areas, or who have other social factors known to influence health, were less likely to survive after hospitalization for heart failure (HF).²

The study used electronic health records of 690 patients aged 65 years or older who had been hospitalized for HF while participating in a larger study about racial and geographic differences in the stroke belt.²

Overall, the study focused on whether an individual’s total number of social factors was associated with the likelihood of dying within 90 days after hospital discharge for HF.²

After adjusting for age, the analysis showed:²

• Seventy-nine patients died within 90 days of discharge;

• Patients with 1 social determinant of health (SDOH) factor were nearly 3 times more likely to die as those who had no social factors;

• Patients with 2 or more SDOHs were also approximately 3 times more likely to die as those who had none.

“I think the powerful influence of these social determinants of health is incredible and underappreciated,” lead study author Madeline R. Sterling, MD, MPH, MS, assistant professor of medicine in the Division of General Internal Medicine and an internist at NewYork-Presbyterian/Weill Cornell Medical Center in New York, said in a press release.³ “Our findings add to a growing body of research that suggests social determinants matter. In fact, assessing them may serve as a new marker for identifying, intervening, and providing supports to the most vulnerable heart failure patients after discharge.”

References:

1. Moccetti F, Bossard M, Latifi Y, et al. Increasing mortality from premature coronary artery disease in women in the rural United States. Journal of the American Heart Association. April 22, 2020. Doi: https://doi.org/10.1161/JAHA.119.015334

2. Sterling MR, Ringel JB, Pinheiro LC, et al. Social determinants of health and 90-day mortality after hospitalization for heart failure in the REGARDS study. Journal of the American Heart Association. April 22, 2020. Doi: https://doi.org/10.1161/JAHA.119.014836

3. Health disparities in rural US: higher coronary artery disease death in women under 65 and people with heart failure. News Release. American Heart Association; Published April 22, 2020. Accessed April 22, 2020. https://newsroom.heart.org/news/health-disparities-in-rural-us-higher-coronary-artery-disease-death-in-women-under-65-and-people-with-heart-failure?preview=e84c