Rural Counties Bore Brunt of Worsening CV Mortality During Pandemic

Disparity in cardiovascular mortality between residents of rural and urban areas in the United States has only grown over the past decade, especially for younger adults and particularly during the COVID-19 pandemic, according to new observational data.

The findings are in line with past analyses showing elevations in deaths attributable to cardiovascular disease for rural versus urban residents. Others have shown that almost half of US counties have no practicing cardiologists as well as poor heart failure follow-up care among patients treated at rural hospitals.

“The pandemic created enormous disruptions in healthcare access, unemployment, and economic loss that disproportionately affected rural communities, and those changes may have exacerbated rural urban differences and cardiovascular death rates,” senior author Rishi K. Wadhera, MD (Beth Israel Deaconess Medical Center, Boston, MA), told TCTMD.

While it wasn’t surprising to find an uptick in cardiovascular death rates in rural areas and a downward trend in urban regions between 2010 and 2022, Wadhera said, “the most striking finding of our analysis was that these patterns were almost entirely driven by a near 20% relative rise in cardiovascular death rates among younger rural adults aged 25 to 64 years.”

The community should be “laser focused” on addressing the concerning rise in CV mortality in this age group, he said. “There's no reason that young adults in any parts of the country, rural or urban, should be experiencing an increase in cardiovascular death rates.”

Sadeer G. Al-Kindi, MD (Houston Methodist Hospital, TX), who commented on the study for TCTMD, called this finding a “signal of warning” that deserves further scrutiny. The pandemic obviously disrupted healthcare access, but the fact that its effects have lingered past the immediate stage of lockdown means “there is something going on that we don't fully understand,” he said. Prepandemic trends related to increasing obesity, electronic cigarette use, and socioeconomic status have likely contributed to the rising rates of cardiovascular mortality in younger individuals, but it’s hard to pinpoint causality, Al-Kindi added.

Typically, the thought is that it’s older people who get cardiovascular disease, “and it's an age-related disease primarily. But this report highlights that we should not forget about the young individuals, primarily those who are susceptible and vulnerable to various risk factors,” he said. “This would be especially for physicians who practice in rural areas. It should be a call for action in terms of understanding their patients.”

Rural-Urban Gap

For the study, published online ahead of print this week in the Journal of the American College of Cardiology, Lucas X. Marinacci, MD (Beth Israel Deaconess Medical Center), Wadhera, and colleagues, looked at national death data from the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiological Research (CDC WONDER) database between 2010 and 2022.

Overall, there were 11,017,255 cardiovascular deaths recorded in CDC WONDER over the study period, including 5,452,636 in urban counties (population ≥ 1 million), 3,461,996 in small/medium metropolitan counties (population 50,000-999,999), and 2,102,623 in rural counties (population < 50,000).

Annual age-adjusted cardiovascular mortality rates (AAMRs) were consistently higher in rural counties, rising from 431.6 to 435.0 per 100,000 from 2010 to 2022. For urban areas, AAMRs declined over the same time frame (from 369.3 to 345.5 per 100,000). This resulted in a significant rural-urban difference in AAMRs (P value for differential change < 0.001), which was driven by a substantial rise in AAMRs among rural adults between 25 and 64 years old (from 111 to 134.2 per 100,000).

Looking exclusively at the prepandemic period of 2010-2019, the AAMRs in rural counties went down overall by 30 per 100,000 but increased in the cohort of patients aged 25-64 by 8.1 per 100,000.

Between 2019 and 2022, AAMRs increased across all counties, but this effect was more pronounced in rural areas.

In 2022, the researchers noted a significantly higher risk of cardiovascular mortality in rural compared with urban dwelling adults (RR 1.53; 95% CI 1.41-1.65). This disparity was partially attenuated after adjustment for community poverty, education, and uninsurance (RR 1.25; 95% CI 1.14-1.35).

‘Magnified by the Pandemic’

“We know that rural communities experience higher rates of poverty, lower levels of educational attainment, as well as food insecurity and housing instability,” Wadhera said. “All of those issues were magnified by the pandemic, . . . and we see that with this widening of rural-urban disparities in cardiometabolic health that we documented in our study.”

A national rise in cardiometabolic risk factors could be partially to blame for the rise in AAMRs in the younger rural cohort, he said, as could the fact that they “have been disproportionately affected by diseases of despair, including substance use, depression, and suicidality, all of which worsened during the pandemic for multiple reasons and all of which also confer a higher risk of poor cardiovascular outcomes.”

All of the above are worsened by poor socioeconomic conditions, which were in turn also heightened by the pandemic, Wadhera added.

There's no reason that young adults in any parts of the country, rural or urban, should be experiencing an increase in cardiovascular death rates. Rishi K. Wadhera

Early on, the increased use of telehealth had some optimistic that inequalities in healthcare access might be ameliorated for rural patients, but this didn’t play out as anticipated, according to Wadhera.

“Telehealth has the potential to be an invaluable tool to bridge this gap,” he said. “But what we observed during the pandemic was that uptake of telehealth was actually greater in urban areas than in rural areas, paradoxically greater . . . . So we need to better understand how to use telehealth more effectively as a tool to get rural Americans the access healthcare that they need.” This could include investments in infrastructure so that all patients have high-speed broadband Internet, Wadhera suggested.

Ultimately, “addressing access in a vacuum is not going to be a panacea for rural health,” he concluded. “We really need to address the social risk factors that drive poor outcomes in these communities, many of which got worse during the pandemic.”

Al-Kindi agreed, adding that implementation studies are needed to improve care. “This report highlights the fact that, one, we should not forget about young individuals, primarily those who live in rural areas,” he said. “So the focus of the next decade of research or so should really be taking these individuals into consideration. . . . I think the future should be focused on implementation studies that focus on these populations to understand what are their community needs to understand more holistically what are the geographic and geospatial determinants of health in these regions.”