Elsevier

American Heart Journal

Volume 263, September 2023, Pages 46-55
American Heart Journal

Clinical Investigations
Epidemiologic trends and risk factors associated with the decline in mortality from coronary heart disease in the United States, 1990-2019

https://doi.org/10.1016/j.ahj.2023.05.006Get rights and content

Background

Despite the decline in the rate of coronary heart disease (CHD) mortality, it is unknown how the 3 strong and modifiable risk factors — alcohol, smoking, and obesity —have impacted these trends. We examine changes in CHD mortality rates in the United States and estimate the preventable fraction of CHD deaths by eliminating CHD risk factors.

Methods

We performed a sequential time-series analysis to examine mortality trends among females and males aged 25 to 84 years in the United States, 1990-2019, with CHD recorded as the underlying cause of death. We also examined mortality rates from chronic ischemic heart disease (IHD), acute myocardial infarction (AMI), and atherosclerotic heart disease (AHD). All underlying causes of CHD deaths were classified based on the International Classification of Disease 9th and 10th revisions. We estimated the preventable fraction of CHD deaths attributable to alcohol, smoking, and high body-mass index (BMI) through the Global Burden of Disease.

Results

Among females (3,452,043 CHD deaths; mean [standard deviation, SD] age 49.3 [15.7] years), the age-standardized CHD mortality rate declined from 210.5 in 1990 to 66.8 per 100,000 in 2019 (annual change -4.04%, 95% CI -4.05, -4.03; incidence rate ratio [IRR] 0.32, 95% CI, 0.41, 0.43). Among males (5,572,629 CHD deaths; mean [SD] age 47.9 [15.1] years), the age-standardized CHD mortality rate declined from 442.4 to 156.7 per 100,000 (annual change -3.74%, 95% CI, -3.75, -3.74; IRR 0.36, 95% CI, 0.35, 0.37). A slowing of the decline in CHD mortality rates among younger cohorts was evident. Correction for unmeasured confounders through a quantitative bias analysis slightly attenuated the decline. Half of all CHD deaths could have been prevented with the elimination of smoking, alcohol, and obesity, including 1,726,022 female and 2,897,767 male CHD deaths between 1990 and 2019.

Conclusions

The decline in CHD mortality is slowing among younger cohorts. The complex dynamics of risk factors appear to shape mortality rates, underscoring the importance of targeted strategies to reduce modifiable risk factors that contribute to CHD mortality.

Section snippets

Study design and data source

We undertook a sequential time series analysis to examine temporal changes in mortality rates from CHD in the US between 1990 and 2019. We ascertained data on all deaths that occurred in the US as compiled and deidentified by the National Center for Health Statistics of the US Centers for Disease Control and Prevention. We ascertained data from the Survey of Epidemiology and End Results on annual mid-year population counts by age and sex between 1990 and 2019.18 Since all data used is publicly

Results

The number of CHD deaths as the underlying cause between 1990 and 2019 was 3,452,043 among females and 5,572,629 among males aged 25 to 84 years. The overall CHD mortality rate declined from 124.4 (95% confidence interval [CI] 123.8, 125.0) in 1990 to 42.7 (95% CI 42.4, 42.9) per 100,000 in 2019. Among females, the age-adjusted CHD mortality rate declined from 210.5 in 1990 to 66.8 per 100,000 in 2019; among males, the corresponding rates dropped from 442.4 in 1990 to 156.7 per 100,000 (Table I

Principal findings

Based on a large population-based study of CHD trends in the US over 3 decades, we show 68% and 64% declines in CHD mortality among females and males, respectively. We also found that the rate of CHD mortality decline has slowed since 2010, which was especially notable among younger birth cohorts and is an observation that warrants further attention. Additionally, we found that secular changes in rates of alcohol use, tobacco smoking, and high BMI are strongly associated with these trends,

Conclusions

Mortality rates from CHD have declined substantially in the US over the last 3 decades. These declines have occurred concurrently with similar declines in deaths from chronic ischemic heart disease, acute myocardial infarction, and atherosclerotic heart disease. This study underscores substantial reductions in the number of CHD deaths in the US that are attributable to changes in smoking, alcohol, and high BMI. Further reductions in CHD mortality may be achieved through an intentional campaign

Disclosures

None reported.

Funding

Drs. Ananth and Kostis and Ms. Graham are supported, in part, by the National Heart, Lung, and Blood Institute (grant R01-HL150065). Dr. Ananth is additionally supported, in part, by the National Institute of Environmental Health Sciences (grant R01-ES033190).

Data Availability Statement

Mortality data utilized in this study can be accessed from the Centers for Disease Control and Prevention (http://www.cdc.gov/) and the population counts from the Survey of Epidemiology and End Results, NIH (https://seer.cancer.gov/popdata/download.html).

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