In the US, COVID Reversed CV Mortality Gains, Hitting Black Americans Hardest

It’s “going to take many, many years to get back to where we were in 2019 before the pandemic,” Mamas Mamas predicts.

In the US, COVID Reversed CV Mortality Gains, Hitting Black Americans Hardest

When the arrival of COVID-19 reversed a long-running decline in cardiovascular mortality in the United States, racial/ethnic minority groups—particularly Black Americans—were disproportionately affected, data from the US Centers for Disease Control and Prevention (CDC) show.

After an overall 38.8% decline in age-adjusted CV mortality between 1999 and 2019, which was seen across demographic groups, there was an uptick of 4.6% between 2019 and 2020 consistent with prior studies conducted during the pandemic, researchers report.

The increase was especially large among Hispanics (9.4%), Black individuals (10.6%), and people younger than 55 (11.9%).

Of the four leading causes of CV mortality, deaths related to three—ischemic heart disease, hypertensive disease, and cerebrovascular disease—increased, while heart failure-related mortality declined slightly. Younger adults and Hispanic and Black individuals bore the brunt of these trends, as well.

The findings were published in the European Heart Journal – Quality of Care and Clinical Outcomes, with lead authors Ofer Kobo, MD (Hillel Yaffe Medical Center, Hadera, Israel, and Keele University, Stoke-on-Trent, England), and Dmitry Abramov, MD (Loma Linda University Health, CA).

Prior to the pandemic, there had been some progress made in reducing racial/ethnic disparities in CV outcomes, but these data show that the spread of SARS-CoV-2 in 2020 expanded those gaps, likely because of the effects on social determinants of health like employment and food security, senior author Mamas Mamas, BMBCh, DPhil (Keele University), noted to TCTMD.

“That’s one of the important reasons why we see a disproportionate impact on the Black American population,” Mamas said. “We have a perturbation to the system, and then suddenly you have all these social determinants of health coming into play and you see that a lot of the good work that’s happened in reversing these disparities over 20 years has almost evaporated overnight. We’re seeing these big increases in excess deaths among Black Americans, and I think that it’s going to take many, many years to get back to where we were in 2019 before the pandemic.”

Uneven Impact

Previous research already has established that CV mortality increased with the onset of the COVID-19 pandemic, but less information is available on how that impact has been distributed across groups defined by age, sex, and race/ethnicity and on how that trend might differ across specific causes of death.

To find out, and to put the pandemic’s effects into the context of longer-term trends, the investigators dug into the CDC WONDER database, which contains death certificate data from all US counties. Between 1999 and 2020, about 18.8 million death certificates listed CVD as an underlying cause of mortality, for an age-adjusted rate of 254.4 per 100,000 population. Roughly half of these deaths (49%) were attributed to ischemic heart disease, 17% to cerebrovascular disease, 8% to hypertensive disease, and 8% to heart failure; the remainder were related to other CV conditions.

The general decline in age-adjusted CV mortality seen in the two decades before the COVID-19 pandemic was mostly due to drops in deaths related to ischemic heart disease and cerebrovascular disease, which were partially offset by increases in mortality related to heart failure and hypertensive disease. Less progress was seen in the second half of that period, but there was still an overall reduction in CV mortality.

If not for the spread of SARS-CoV-2, that trend would have been expected to continue. Instead, CV mortality went in the other direction, with an estimated excess of 62,802 deaths related to CV diseases in 2020.

The relative increase in CV death from 2019 to 2020 was greater in people younger than 55 (11.9%) than in those ages 55 to 74 (7.9%) and those 75 and older (3.8%). It was also higher in Hispanics versus non-Hispanics (9.4% vs 4.3%) and lower among white individuals (3.5%) than in those who were American Indian/Alaska Native (6.1%), Asian/Pacific Islander (8.8%), or Black (10.6%).

From 2019 to 2020, there was a 4.3% increase in deaths related to ischemic heart disease, a 15.9% jump in those related to hypertensive disease, and 4.9% rise in those related to cerebrovascular disease. Heart failure-related mortality declined by 1.4%. People from racial/ethnic minority groups fared worse than others when it came to these patterns.

How to Get Back on Track

Mamas said he was surprised that the relative increase in CV mortality was greater in younger versus older people, noting that absolute risks remained higher in the older age groups. One possible explanation is that individuals below the age of eligibility for Medicare may have had less support from the healthcare system when they lost their jobs—and their health insurance—due to the pandemic, he said, adding that many younger people also may have turned to substance abuse and smoking to cope with social isolation stemming from COVID-19-related restrictions.

As for the overall increase in CV mortality in 2020, Mamas said it likely has more to do with the impact of COVID-19 on the delivery of cardiovascular services than on any direct effects of the virus. Early on, patients were avoiding hospitals and doctors’ offices for fear of infection while healthcare systems were curtailing elective procedures. So some patients weren’t presenting with acute events like MI and stroke, and management of those with chronic conditions worsened, Mamas said.

In the UK, this has resulted in a backlog for many procedures, which could make a difference in prognosis for patients who require time-sensitive interventions like aortic valve replacement for severe aortic stenosis or CABG for left main coronary disease, Mamas said. How to address this problem isn’t entirely clear, as the pandemic is continuing and hospitals remain strained. “I think it will be very challenging to overcome this without a complete restructure of services,” Mamas said.

He also sees a long road ahead when it comes to mitigating racial/ethnic disparities that have worsened during the COVID-19 pandemic. After Hurricane Katrina, for example, the greatest impact on cardiovascular health was observed in the hardest-hit Black communities. Detrimental effects were seen for years after the hurricane, and it’s likely that fallout from the COVID-19 pandemic, still going after more than 2-and-a-half years, will cause even longer-lasting damage, Mamas said.

Thus, focusing more efforts on addressing social determinants of health—and bolstering access to healthcare in the community—will probably have greater benefits in terms of reducing overall CV mortality than looking for improvements elsewhere, such as through increased adoption of telemedicine, Mamas said.

Todd Neale is the Associate News Editor for TCTMD and a Senior Medical Journalist. He got his start in journalism at …

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Disclosures
  • Abramov, Kobo, and Mamas report no relevant conflicts of interest.

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