Abstract

Key Points

• The disparities in CVD-related mortality trends in Texas and the United States from 1999 to 2019 were assessed through analysis of the Multiple Causes of Death Files from the National Center for Health Statistics.

• Despite an initial period of decline, CVD-related mortality rates have plateaued in Texas and the United States.

• Higher AAMRs were observed in Texas than in the overall US population. Prevalent disparities also exist based on demographic and geographic subgroups, with the highest AAMRs reported in men, non-Hispanic Black people, and people 85 years of age and older in Texas and nationwide.

• Further investigation of these disparities and targeted efforts are needed to equitably counter these varying levels of mortality.

Abbreviations

AAMR

age-adjusted mortality rate

APC

annual percentage change

CVD

cardiovascular disease

Introduction

Cardiovascular disease (CVD) remains the leading cause of mortality in the United States.^1–4 Despite a notable decline in age-standardized CVD mortality rates between the 1970s and 2010s, recent years, even before the COVID-19 pandemic, have seen stagnation and even a reversal of this trend in certain demographic groups.^5–8 This shift may be explained partly by the simultaneous surge in the prevalence of obesity and diabetes.⁹ Nevertheless, it symbolizes a notable turning point in the century-old battle against heart disease. The distribution of CVD burden across the United States is uneven, with substantial variations based on geographic region, age, sex, race, and ethnicity.¹⁰ Evidence suggests that the southern region of the United States, historically associated with poor health outcomes, bears a sizeable portion of the CVD burden.^3,11 In-depth understanding of CVD mortality trends at the state level is crucial for planning targeted interventions and policy-making efforts at the local level.

The aim of this study was to provide an analysis of CVD-related mortality in Texas, the second-largest state in the United States. In 2022, adults in Texas exhibited a 9.0% prevalence of CVD (unadjusted), close to the overall US prevalence of 9.1%.¹² Furthermore, CVD prevalence in adults closely followed that of the overall United States in several preceding years. In addition, in 2021, heart disease hospitalizations were reported at a rate of 740.7 per 100,000 residents.¹³

To address the burden of CVD in Texas, which faces distinct challenges and implications regarding cardiovascular health, a nationwide database was queried for CVD-related mortality trends from 1999 to 2019. Subgroup analyses by sex, age, race, ethnicity, and geography were conducted. Trends within Texas were compared with overall trends in the United States during the same time period.

Patients and Methods

Deaths related to CVD occurring in Texas and the United States (including Texas) were extracted from the Centers for Disease Control and Prevention Wide-ranging ONline Data for Epidemiologic Research system.¹⁴ The Multiple Cause-of-Death Public Use record death certificates were used to analyze deaths in which CVD was mentioned as an underlying or contributing cause of death on nationwide death certificates. This database has previously been used in several other studies to determine trends in mortality of CVD.^15,16 Cardiovascular disease was identified with International Classification of Diseases, Tenth Revision, Clinical Modification codes I00-I99 (diseases of the circulatory system) in people at least 25 years of age (people with age “not stated” were not included in this analysis; CVD-related deaths n = 1,261 between 1999 and 2019). Mortality contributed by CVD subgroups was also studied: heart disease (I00-I09, I11, I13, and I20-I51), ischemic heart disease (I20-I25), cerebrovascular disease (I60-I69), heart failure or cardiomyopathy (I11.0, I13.0, I13.2, I50, I42, 090.3), and hypertension (I10-I15). Institutional review board approval was not sought because the Centers for Disease Control and Prevention Wide-ranging ONline Data for Epidemiologic Research system contains publicly available, anonymized data.

Deaths related to CVD, population sizes, and location in which death occurred (including medical facilities [outpatient, emergency department, inpatient, death on arrival, or status unknown], home, hospice, and nursing home or long-term care facility) were extracted. Demographics (sex, race and ethnicity, and age) and regional information (metropolitan or nonmetropolitan and state) were extracted from 1999 to 2019. Race and ethnicity were defined as non-Hispanic White, non-Hispanic Black or African American, and Hispanic or Latino. In the analysis stratified by race and ethnicity, non-Hispanic Asian or Pacific Islander and non-Hispanic Native American or Alaska Native populations (the other categories available in the database during the entire study period) were not evaluated, but these populations and those with Hispanic origin “not stated” were not excluded in any other analysis. Age groups were categorized as 25 to 39, 40 to 54, 55 to 69, 70 to 84, or 85 years and older. For urban-rural classifications, the 2013 National Center for Health Statistics Urban-Rural Classification Scheme was used to divide the counties into metropolitan (large central metropolitan, large fringe metropolitan, medium metropolitan, and small metropolitan) and nonmetropolitan (micropolitan and noncore) categories.¹⁷ The data on CVD-related mortality in border (within 100 km [62 miles] of the US-Mexico border) and nonborder counties in Texas were abstracted.¹⁸

Results

Between 1999 and 2019, a total of 29,455,193 CVD-related deaths were reported in the United States, of which 1,937,166 (6.6%) occurred in Texas (Supplemental Table I). In Texas, data for place of death were available for 1,869,185 deaths, of which 49.8% occurred in medical facilities, 20.6% occurred in nursing or long-term care facilities, 3.5% at hospice, and 26.1% at home. In the United States overall, of 28,173,194 deaths with data on place of death, 47.3% occurred in medical facilities, 23.8% in nursing or long-term care facilities, 3.2% in hospice, and 25.7% at home (Supplemental Table II).

Annual Trends in Mortality

Overall, the AAMR related to CVD in Texas was 802.5 per 100,000 (95% CI, 797.1-808.0) in 1999 and 615.2 in 2019 (95% CI, 611.5-618.8) (Table I). A decline in AAMR was noted from 1999 to 2009 (APC, −2.5 [95% CI, −2.8 to −2.1]), which appeared to plateau from 2009 to 2019 (APC, −0.2 [95% CI, −0.5 to 0.2]). Between 1999 and 2019, the overall AAMR related to CVD in Texas (674.1 [95% CI, 673.2-675.1]) was marginally higher than in the overall US population (654.0 [95% CI, 653.8-654.3]). In addition, Texas ranked 35th among all states in terms of CVD mortality, having the 17th-highest AAMR.

TABLE ICVD-Related Deaths and Mortality Rates, Stratified by Demographic and Geographic Subgroups, in Texas and the United States, 1999-2019

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In the United States as a whole, AAMRs were 798.5 in 1999 (95% CI, 797.2-799.8) and 595.6 in 2019 (95% CI, 594.6-596.5). Mortality rates declined from 1999 to 2011 (APC, −2.4 [95% CI, −2.5 to −2.2]) before stabilizing in the 2011 to 2019 period (APC, −0.1 [95% CI, −0.4 to 0.1]) (Fig. 1, Supplemental Tables III and IV). The maps in Supplemental Figures 1A, 1B, and 1C and Figure 2 show CVD mortality rates across US states during the years 1999 to 2004, 2005 to 2009, 2009 to 2014, and 2015 to 2019, respectively.

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Mortality Trends Across Demographic Groups

Sex

In Texas, higher CVD-related AAMRs were observed in men (1999: 953.5 [95% CI, 943.7-963.3]; 2019: 736.5 [95% CI, 730.4-742.6]) than in women (1999: 690.4 [95% CI, 684.0-696.9]; 2019: 514.1 [95% CI, 509.7-518.5]) throughout the study period. In both men and women, the decline in the CVD AAMR was steeper between 1999 and 2009 (APC for men, −2.5 [95% CI, −2.9 to −2.2]; APC for women, −2.5 [95% CI, −2.9 to −2.1]), with flattening thereafter for men from 2009 to 2019 (APC, 0 [95% CI, −0.3 to 0.3]), and the decline in AAMR decreased for women from 2009 to 2019 (APC, −0.5 [95% CI, −0.9 to −0.1]) (Fig. 3, Supplemental Table IV).

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As in Texas, in the overall US population AAMRs were higher in men (1999: 963.6 [95% CI, 961.2-965.9]; 2019: 715.6 [95% CI, 714.0-717.2]) than in women (1999: 678.5 [95% CI, 676.9-680.0]; 2019: 496.6 [95% CI, 495.5-497.7]). In men, after the initial decline in CVD AAMR from 1999 to 2009, there was a subsequent flattening from 2009 to 2019 (APC for men, 0.0 [95% CI, −0.3 to 0.3]). In women, after the initial decline, the decrease in AAMR decelerated from 2011 to 2019 (APC, −0.3 [95% CI, −0.6 to 0]) (Supplemental Figure 2A, Supplemental Table IV).

Race and Ethnicity

When stratified by race and ethnicity, the highest AAMRs in Texas were reported among non-Hispanic Black or African American people (1999: 1,097 [95% CI, 1,075.6-1,118.4]; 2019: 801.8 [95% CI, 788.2-815.4]), followed by non-Hispanic White people (1999: 791.1 [95% CI, 784.8-797.4]; 2019: 643.3 [95% CI, 638.5-648.1]) and Hispanic or Latino populations (1999: 702.0 [95% CI, 688.8-715.3]; 2019: 517.6 [95% CI, 510.8-524.5]), aligning with the national trend. Trends in CVD-related mortality stratified by race and ethnicity in Texas and the United States are shown in Figure 4 and Supplemental Table V. Compared with the non-Hispanic White population in Texas and the United States, AAMRs were higher in the non-Hispanic Black population (rate ratio, 1.32 in Texas, 1.32 in the United States) and lower in the Hispanic population (rate ratio, 0.84 in Texas, 0.78 in the United States) (Supplemental Table VI). For all 3 groups, mortality was higher in Texas than in the United States.

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Age

In Texas, CVD-related mortality escalated with increasing age. The highest mortality rates were reported in people 85 years of age and older (1999: 11,196.2 [95% CI, 11,060.5-11,331.8]; 2019: 8,310.7 [95% CI, 8,222.3-8,399.2]). After an initial decline in CMRs for most age groups, a significant rise in mortality rates was seen in the 25 to 39 year (APC, 1.6 [95% CI, 0.8-2.5]) and 55 to 69 year (APC, 1.2 [95% CI, 1.1-1.4]) age groups from 2010 to 2019 and 2011 to 2019, respectively. Similar patterns of mortality were seen nationwide (Fig. 5, Supplemental Figure 2B, Supplemental Table VII).

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Geographic Trends in Mortality

Metropolitan and Nonmetropolitan

Cardiovascular disease–related AAMRs were persistently higher in nonmetropolitan areas (1999: 839.8 [95% CI, 827.6-852.0]; 2019: 732.3 [95% CI, 721.9-742.7]) of Texas as compared with metropolitan areas (1999: 794.4 [95% CI, 788.2-800.6]; 2019: 596.5 [95% CI, 592.6-600.4]). Greater overall mortality rates were noted in adults in Texas than in the United States, both in nonmetropolitan counties and in metropolitan counties (750.9 [95% CI, 748.5-753.3] vs 727.0 [95% CI, 726.4-727.6] and 659.4 [95% CI, 658.3-660.4] vs 638.9 (95% CI, 638.7-639.2], respectively). Despite an initial decline, a rise was observed in the AAMRs associated with nonmetropolitan areas from 2010 to 2019 in Texas (APC, 0.5 [95% CI, 0.2-0.9]) and from 2011 to 2019 in the United States (APC, 0.3 [95% CI, 0-0.7]). In contrast, after initial decline, AAMRs remained stable in metropolitan areas from 2009 to 2019 in Texas (APC, −0.3 [95% CI, −0.7 to 0.1]) and from 2011 to 2019 in the United States (APC, −0.2 [95% CI, −0.5 to 0.1]) (Fig. 6, Supplemental Table VIII).

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States

A wide variation in AAMR was identified across states, with the rates ranging from 530.4 (95% CI, 528.9-531.9) in Arizona to 902.2 (95% CI, 899.3-905.2) in Mississippi. States included in the upper 90th percentile were Mississippi, Oklahoma, West Virginia, Alabama, Kentucky, and Arkansas. In contrast, Texas was positioned at the 68th percentile (17th highest), with an AAMR of 674.1 (95% CI, 673.2-675.1). Alternatively, states that fell in the lower 10th percentile were Arizona, Minnesota, Utah, Hawaii, Colorado, and Alaska (Fig. 7 and Fig. 8, Supplemental Table IX).

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Counties

When stratified by counties in Texas, the AAMR varied from 359.9 (95% CI, 327.7-392.1) in Presidio County to 979.1 (95% CI, 958.3-999.9) in Liberty County. Notably, the 5 counties with the lowest AAMRs are Presidio, Borden, Glasscock, Jeff Davis, and Hudspeth. The 5 counties with the highest AAMRs are Orange, Red River, Newton, Winkler, and Liberty County (Fig. 9, Supplemental Table X).

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Discussion

This 20-year study of nationwide mortality data yielded multiple key findings. First, after an initial period of decline from 1999 to 2011, CVD-related mortality plateaued until 2019 in the United States. The CVD-related mortality stabilized in Texas from 2009 to 2019 after the initial decline. Texas had higher AAMRs than the United States, irrespective of demographic group. Second, higher AAMRs were noted in men nationwide, including in Texas. Third, non-Hispanic Black or African American people had the highest AAMRs compared with other ethnicities. In addition, nonmetropolitan counties had higher AAMRs than did metropolitan counties.

Despite an initial promising decline since 1999, the AAMRs started leveling out in 2009 in Texas and in 2011 in the United States. These results are congruent with the findings of Sydney et al,²¹ who first reported a deviation in the favorable downturn observed since the mid-1960s. This may be attributed in part to the surge in prevalence of CVD risk factors—namely, obesity and diabetes. Concern about the detrimental impact of obesity and diabetes on mortality rates has long been expressed, particularly in light of the national epidemiological data, which indicate a significant rise in adult obesity prevalence and a nearly 3-fold increase in diabetes prevalence around the same time.^22,23

The data demonstrate strikingly higher mortality in Texas across all population groups. Historically, Texas has been ranked among the 20 unhealthiest states since 1990, according to America's Health Rankings.²⁴ In 2017, Roth et al²⁵ found that 19 counties in Texas were among the regions with the highest rates of age-standardized CVD mortality rates, placing them in the top 10% nationwide. Within the United States, marked disparities exist in the mortality associated with CVD and its major risk factors.⁷ A county-level CVD risk factor analysis using data from the Behavioral Risk Factor Surveillance Survey showed wide variation in levels of obesity, tobacco smoking, hypertension, and physical inactivity in nearly all states.²⁶ Therefore, the relative difference in risk factor prevalence, social and environmental differences, and the care received across the country is a plausible explanation for these findings.

Throughout the study period, AAMRs were statistically significantly higher in men in Texas and the rest of the country. This finding correlates with previous research conducted on sex differences and hypertension prevalence in the United States. In most age groups, a higher prevalence of hypertension has been detected in men.²⁷ Sex-based variations in telomerase activity and the influence of genes, particularly those regulating insulin resistance and fat distribution, could diminish men's tissue repair capacity and amplify their susceptibility to vascular disease.^28,29 This finding, along with higher rates of cigarette smoking, alcohol consumption, and suboptimal dietary habits among men compared with women within the United States, may contribute to the noted sex differences in mortality rates in this study.³⁰

In concordance with numerous national studies, these findings also indicate significant disparities between races. In the United States, including Texas, non-Hispanic Black patients had the highest mortality, which persisted throughout the study. Worse cardiovascular health markers in these people combined with an earlier age of disease onset and disparities in health care may provide an explanation for this difference. Furthermore, Black people have been found to have the lowest comprehensive cardiovascular health index scores.^31–33 Moreover, in contrast to other racial groups, there was a slightly wider gap in the mortality rates among Hispanic people in Texas compared with the entire United States. Despite having a lower than average median household income and a higher prevalence of obesity and diabetes than non-Hispanic White people, Hispanic people had the lowest rates of CVD-associated mortality.^34–36 The underlying cause remains unclear and mandates further research for clarification.

In contrast to other age groups in which the mortality rates have recently stabilized or even declined, there was an increase in crude mortality rates in adults aged 25 to 69 years in the latter part of the study nationally and in Texas (statistically significant in most age categories between 25 and 69 years). This concerning phenomenon was first observed in a cross-nation study of CVD mortality trends in Australia and the United States, where an increase was observed between 35 and 74 years of age. The United States was in the tier of nations with the highest prevalence of premature mortality.³⁷ The concurrent, adverse trends in obesity and diabetes among young adults, along with increases in sedentary behavior, suggest that these trends play a key role in increasing premature mortality.^38,39

In addition, there were substantial geographic variations in mortality rates on a national and state level in this study. Nonmetropolitan areas bear the highest burden of CVD-related deaths. In the United States, disparities in CVD mortality by geographic location, education level, and socioeconomic status have been pervasive,^7,40a pattern that can be explained by the lack of uniformity in access to health care, the higher incidence of comorbidities, and a sedentary lifestyle.⁴¹ Similar to Texas, the states ranked in the upper 90th percentile are also located in the South. Notably, southern states demonstrate the highest prevalence of smoking, obesity, and physical inactivity, with increases in obesity rates more pronounced in this region.^42,43

These findings underscore the need to address the higher mortality rates in Texas and indicate a need for more state-specific targeted interventions. Moreover, given the multitude of disparities in CVD mortality by age, sex, race, and geographic location, it is important to consider how prospective demographic changes could affect the composition of future CVD cases. These findings have critical policy-making implications because they highlight the need to develop tailored strategies and mindful allocation of resources to ensure equitable and effective prevention and management of CVD.

To reduce this national health burden, it is imperative to further evaluate the regional variation in risk factors that contribute to varying trends in CVD-related deaths. Future studies should aim to identify the interactions between these factors and their impact on CVD outcomes in Texas. It is recommended to develop multidisciplinary state-specific interventions tailored to the unique population of Texas.

Conclusion

These results show that after the initial decline, CVD-related mortality has plateaued in the United States, including Texas. The AAMRs were higher in Texas than in the overall United States. Disparities also exist based on age, sex, race, and rural-urban designation. Further investigation of these disparities and targeted efforts are needed to equitably counter these varying levels of mortality.