Steady Rise in CVD Deaths Linked to Substance Abuse, US Data Show

Cardiovascular deaths tied to the use of alcohol, cocaine, opioids, and other substances are on the rise in the United States, increasing at a rate of 4% per year over the last two decades, according to a new analysis.

The increase was particularly pronounced in women and American Indian/Alaska Native people, as well as in younger individuals and those living outside major metropolitan areas, report investigators. However, no demographic was immune from the rising ride of substance use and CVD-related mortality.

“What was somewhat surprising to us was how across the board—for men and women, across race and ethnicities, and across all age groups—there was an increase in these rates over time,” senior investigator Dmitry Abramov, MD (Loma Linda University Medical Center, Redlands, CA), told TCTMD. “This includes people who are younger, those in their 20s and 30s, but also people who are older, such as those in their 70s and 80s, who demonstrate increases in [substance use -related CVD deaths] over time.”

Abramov, a clinical cardiologist, said the study was spurred by his own experiences.

“I myself have noticed, and I think my co-authors have as well, that during our careers over the last 10 years or so, we’ve definitely been seeing more and more substance use among patients who are presenting with heart disease, heart failure, and [other] cardiac conditions,” he said. “We’re also noticing that a lot of people are dying with significant contribution [from] their substance use. We wanted to see whether the national trends kind of mirrored what we were seeing in our own personal experience.”

Alcohol a Big Factor in CVD-Related Mortality

For the study, which was published today in the Journal of the American Heart Association, researchers identified deaths occurring in the US through the Centers for Disease Control and Prevention’s WONDER database. They obtained information through the Multiple Cause of Death database that listed both substance use and CVD as contributing or underlying reasons for death, as well as data on location of death, patient demographics, and regional information.

Between 1999 and 2019, there were nearly 52 million deaths in the US, of which nearly 60% were related to cardiovascular disease in people 25 years and older. For the CVD-related deaths, 2.2% listed substance use as a concomitant cause of death. Overall, 75.6% of all substance use/CVD-related deaths were men, with 15.9%, 9.8%, 1.9%, and 1.2% occurring in non-Hispanic white, non-Hispanic Black, American Indian/Alaska Native, and non-Hispanic Asian/Pacific Islander individuals.

I think the first step is realizing this problem is real. Dmitry Abramov

Alcohol was by far the biggest contributing factor to substance use/CVD-related deaths (65%), followed by opioids (13.7%), cocaine (9.8%), stimulants (6.5%), sedatives (4.1%), and cannabis (0.5%).

The overall substance use/CVD-related age-adjusted mortality rate (AAMR) per 100,000 individuals was 14.3 between 1999 and 2019. In men and women, respectively, the AAMRs were 22.5 and 6.8. The AAMR was highest in American Indian/Alaska Natives (37.7 per 100,000), followed by Black, white, Hispanic, and Asian/Pacific Islanders. The rates were higher outside major cities, with the District of Columbia having the highest and Virginia the lowest substance use/CVD-related AAMR per 100,000 individuals.

Between 1999 and 2019, deaths from CVD alone declined by an average of 1.5% while deaths solely from substance use increased 3.9%. Overall, the combined substance use/CVD-related AAMR increased from 9.9 to 21.4 per 100,000 people between 1999 and 2019, an average annual percent change of 4.0%. The combined AAMR increased by 2.8% per year between 1999 and 2012, then jumped by 6.2% annually between 2012 and 2019. The substance use/CVD-related AAMR increased in all ethnicities during the study period but increased the most in American Indian/Alaska Natives, in rural locations, and in those aged 25 to 39 years. 

Regarding specific substances, there was a 12.7% increase in mortality tied to cannabis use from 1999 to 2019, which was the largest increase observed during the study. It was followed by a 9.4% increase in the AAMR linked to sedatives, an 8.7% increase in CVD deaths related to opioids, and a 5.1% increase in CVD deaths related to cocaine. Regarding the marijuana finding, Abramov said the cannabis numbers need to be contextualized, noting that while relative rate increased over time, the absolute rate of cannabis-associated CVD mortality is very small and several orders of magnitude less than other substances.

Mindful to Screen for Substance Use

Abramov said that while many substances are directly cardiotoxic—cocaine, for example, can trigger arrhythmias and cause acute myocardial infarction, as well as lead to more chronic conditions such cardiomyopathy and coronary artery disease—there are likely socioeconomic and psychosocial factors at play. For example, people who are using drugs and alcohol might not be receiving adequate medical care for their cardiovascular condition because they are disengaged from the healthcare system, he said.

“I think the substance is probably contributing in both ways,” said Abramov. “I think there's some direct effect, and I think there's some indirect effect through disparities and socioeconomic disadvantages.”

To address this issue, Abramov said they are mindful to screen and discuss the possibility of substance use with patients as part of their routine interactions. If identified, they’ll attempt to connect them with addiction medicine or other public health intervention efforts.

“I think the first step is realizing this problem is real and as soon as we realize that we then need to better screen for it, both at the physician level and the services that we're able to provide,” he said, adding the long-term focus at the public-health level is necessary to curb the increases in substance use and CVD-related deaths. “Unless this is better addressed, I think these trends are probably only likely to continue, particularly with the social and economic challenges that have existed over the last few years.”