Clinical Research Study|Articles in Press

Demographic and Regional Trends of Cardiovascular Diseases and Diabetes Mellitus-Related Mortality in the United States From 1999 to 2019



      The purpose of this research was to study the contemporary trends in cardiovascular disease (CVD) and diabetes mellitus (DM)-related mortality.


      We used the Centers for Disease Control and Prevention Wide-Ranging OnLine Data for Epidemiologic Research (CDC WONDER) database to identify adults ≥25 years old where both CVD and DM were listed as an underlying or contributing cause of death between 1999 and 2019. Crude and age-adjusted mortality rates per 100,000 population were determined.


      The overall age-adjusted mortality rate was 99.18 in 1999 and 91.43 in 2019, with a recent increase from 2014-2019 (annual percent change 1.0; 95% confidence interval [CI], 0.3-1.6). Age-adjusted mortality rate was higher for males compared with females, with increasing mortality in males between 2014 and 2019 (annual percent change 1.5; 95% CI, 0.9-2.0). Age-adjusted mortality rate was highest for non-Hispanic Black adults and was ∼2-fold higher compared with non-Hispanic White adults. Young and middle-aged adults (25-69 years) had increasing age-adjusted mortality rates in recent years. There were significant urban-rural disparities, and age-adjusted mortality rates in rural counties increased from 2014 to 2019 (annual percent change 2.2; 95% CI, 1.5-2.9); states in the 90th percentile of mortality had age-adjusted mortality rates that were ∼2-fold higher than those in the bottom 10th percentile of mortality.


      After an initial decrease in DM + CVD-related mortality for a decade, this trend has reversed, with increasing mortality from 2014 to 2019. Significant geographic and demographic disparities persist, requiring targeted health policy interventions to prevent the loss of years of progress.


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      1. Centers for Disease Control and Prevention (CDC). Prevalence of both diagnosed and undiagnosed diabetes. 2022. Available at: Accessed January 26, 2022.

        • Fox CS
        • Pencina MJ
        • Meigs JB
        • Vasan RS
        • Levitzky YS
        • D'Agostino RB
        Trends in the incidence of type 2 diabetes mellitus from the 1970s to the 1990s: the Framingham Heart Study.
        Circulation. 2006; 113: 2914-2918
        • Stratton IM
        • Adler AI
        • Neil HA
        • et al.
        Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study.
        BMJ. 2000; 321: 405-412
        • GBD 2015 Mortality and Causes of Death Collaborators
        Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015.
        Lancet. 2016; 388: 1459-1544
        • Fox CS
        • Coady S
        • Sorlie PD
        • et al.
        Trends in cardiovascular complications of diabetes.
        JAMA. 2004; 292: 2495-2499
        • Gregg EW
        • Gu Q
        • Cheng YJ
        • Narayan KMV
        • Cowie CC
        Mortality trends in men and women with diabetes, 1971 to 2000.
        Ann Intern Med. 2007; 147: 149-155
        • Martín-Timón I
        • Sevillano-Collantes C
        • Segura-Galindo A
        • del Cañizo-Gómez FJ
        Type 2 diabetes and cardiovascular disease: have all risk factors the same strength?.
        World J Diabetes. 2014; 5: 444-470
        • Krishnan U
        • Brejt JA
        • Schulman-Marcus J
        • et al.
        Temporal trends in the clinical acuity of patients with ST-segment elevation myocardial infarction.
        Am J Med. 2018; 131: 100.e9-100.e20
        • American Diabetes Association
        9. Pharmacologic approaches to glycemic treatment: Standards of Medical Care in Diabetes–2021.
        Diabetes Care. 2020; 44: S111-S124
        • Ibanez B
        • James S
        • Agewall S
        • et al.
        2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC).
        Eur Heart J. 2018; 39: 119-177
      2. Centers for Disease Control and Prevention (CDC). About multiple cause of death, 1999-2020. Available at: Accessed December 15, 2021.

        • Aggarwal R
        • Chiu N
        • Loccoh EC
        • Kazi DS
        • Yeh RW
        • Wadhera RK
        Rural-urban disparities: diabetes, hypertension, heart disease, and stroke mortality among black and white adults, 1999-2018.
        J Am Coll Cardiol. 2021; 77: 1480-1481
        • Khan MS
        • Kumar P
        • Sreenivasan J
        • et al.
        Rural-urban differences in mortality from ischemic heart disease, heart failure, and stroke in the United States.
        Circ Cardiovasc Qual Outcomes. 2021; 14e007341
        • Sidney S
        • Quesenberry Jr, CP
        • Jaffe MG
        • et al.
        Recent trends in cardiovascular mortality in the United States and public health goals.
        JAMA Cardiol. 2016; 1: 594-599
        • Manemann SM
        • Gerber Y
        • Bielinski SJ
        • et al.
        Recent trends in cardiovascular disease deaths: a state specific perspective.
        BMC Public Health. 2021; 21: 1031
        • Ingram DD
        • Franco SJ
        2013 NCHS urban-rural classification scheme for counties.
        Vital Health Stat 2. 2014; : 1-73
        • Anderson RN
        • Rosenberg HM
        Age standardization of death rates: implementation of the year 2000 standard.
        Natl Vital Stat Rep. 1998; 47: 1-16, 20
      3. Joinpoint Regression Program, Version - March 2021; Statistical Methodology and Applications Branch, Surveillance Research Program, National Cancer Institute. Available at: Accessed November 22, 2021.

        • Tsao CW
        • Aday AW
        • Almarzooq ZI
        • et al.
        Heart disease and stroke statistics—2022 update: a report from the American Heart Association.
        Circulation. 2022; 145: e153-e639
        • Stark Casagrande S
        • Fradkin JE
        • Saydah SH
        • Rust KF
        • Cowie CC
        The prevalence of meeting A1C, blood pressure, and LDL goals among people with diabetes, 1988-2010.
        Diabetes Care. 2013; 36: 2271-2279
        • Fox CS
        • Coady S
        • Sorlie PD
        • et al.
        Increasing cardiovascular disease burden due to diabetes mellitus: the Framingham Heart Study.
        Circulation. 2007; 115: 1544-1550
        • Preis SR
        • Hwang SJ
        • Coady S
        • et al.
        Trends in all-cause and cardiovascular disease mortality among women and men with and without diabetes mellitus in the Framingham Heart Study, 1950 to 2005.
        Circulation. 2009; 119: 1728-1735
        • Rosenstock S
        • Whitman S
        • West JF
        • Balkin M
        Racial disparities in diabetes mortality in the 50 most populous US cities.
        J Urban Health. 2014; 91: 873-885
        • Osei K
        • Gaillard T
        Disparities in cardiovascular disease and type 2 diabetes risk factors in blacks and whites: dissecting racial paradox of metabolic syndrome.
        Front Endocrinol (Lausanne). 2017; 8: 204
        • Woolf SH
        • Schoomaker H
        Life expectancy and mortality rates in the United States, 1959-2017.
        JAMA. 2019; 322: 1996-2016
        • Roth GA
        • Dwyer-Lindgren L
        • Bertozzi-Villa A
        • et al.
        Trends and patterns of geographic variation in cardiovascular mortality among US counties, 1980-2014.
        JAMA. 2017; 317: 1976-1992
        • Cross SH
        • Mehra MR
        • Bhatt DL
        • et al.
        Rural-urban differences in cardiovascular mortality in the US, 1999-2017.
        JAMA. 2020; 323: 1852-1854
        • Harrington RA
        • Califf RM
        • Balamurugan A
        • et al.
        Call to action: rural health: a presidential advisory from the American Heart Association and American Stroke Association.
        Circulation. 2020; 141: e615-e644
        • Bucholz EM
        • Gooding HC
        • de Ferranti SD
        Awareness of cardiovascular risk factors in U.S. young adults aged 18-39 years.
        Am J Prev Med. 2018; 54: e67-e77
        • Svane J
        • Lynge TH
        • Pedersen-Bjergaard U
        • et al.
        Cause-specific mortality in children and young adults with diabetes mellitus: a Danish nationwide cohort study.
        Eur J Prev Cardiol. 2019; 28: 159-165
        • Ellis RP
        • Hsu HE
        • Song C
        • et al.
        Diagnostic category prevalence in 3 classification systems across the transition to the International Classification of Diseases, Tenth Revision, Clinical Modification.
        JAMA Network Open. 2020; 3e202280
        • Lloyd-Jones DM
        • Martin DO
        • Larson MG
        • Levy D
        Accuracy of death certificates for coding coronary heart disease as the cause of death.
        Ann Intern Med. 1998; 129: 1020-1026
        • McEwen LN
        • Karter AJ
        • Curb JD
        • Marrero DG
        • Crosson JC
        • Herman WH
        Temporal trends in recording of diabetes on death certificates: results from Translating Research Into Action for Diabetes (TRIAD).
        Diabetes Care. 2011; 34: 1529-1533
        • Ahmad FB
        • Cisewski JA
        • Miniño A
        • Anderson RN
        Provisional mortality data—United States, 2020.
        MMWR Morb Mortal Wkly Rep. 2021; 70: 519-522