May 3, 2024 — Americans are dying of heart failure today at a higher rate than they did in 1999, reversing years of progress in reducing the death rate.
That is the stark message of a new JAMA Cardiology study, which finds that the current mortality rate from heart failure is 3% higher than it was 25 years ago. Based on data from death certificates, the study says, the mortality rate fell significantly from 1999 to 2009, then plateaued for a few years before sharply increasing from 2012 to 2019. During the pandemic years of 2020 and 2021, the latest year for which data is available, heart failure deaths accelerated.
“These data are striking,” said Veronique Roger, MD, MPH, chief of the epidemiology and community health branch of the National Heart, Lung, and Blood Institute. “They really constitute an urgent call for action to reverse this trend.”
Roger, who was not involved in the study, noted that during the 2000s, the mortality rate from cardiovascular disease declined and that now it has leveled off, largely because of the burst in deaths attributed to heart failure. “This paper shows that not only are we are not making progress, but our gains are being eroded. So it’s a major deal.”
According to the National Institutes of Health, about 6.7 million Americans have heart failure today. That’s just a snapshot in time, of course: About 1 in 4 Americans will develop heart failure during their lifetimes, the NIH said. About half of those with the condition die within 5 years after diagnosis.
People who are 65 or older have a far greater chance of dying of heart failure than younger people do. However, the relative increase in the death rate was most marked among younger Americans, according to the study. Among people younger than 45, there was a ninefold rise in heart failure deaths from 2012 to 2021, and there was almost a fourfold increase among people aged 45-64.
Comorbidities Lead to Heart Failure
In the view of study co-author Marat Fudim, MD, an associate professor of cardiology at Duke University in Durham, NC, the increase in heart failure deaths among younger people is probably related to the fact that obesity and diabetes have become more prevalent among young adults. It’s not surprising, he said, that an increasing number of people with these disorders develop heart failure in middle age.
Otherwise, he said, “the reversal of [heart failure mortality] trends seems to have hit men and women and the different races in a very similar fashion. It didn’t discriminate in that or in rural versus urban residents. While there were stark differences between racial groups and between rural and urban in heart failure mortality rates, the reversal trend is very similar among all these groups.”
“What we see in practices is that comorbidities drive heart failure,” said Fudim, whose own cardiology practice specializes in this condition. “Heart failure is rarely a single disease problem. Usually, heart failure patients have obesity, diabetes, cardiac artery disease, hyperlipidemia — all these diseases are driving heart failure, which leads to mortality.”
The increase in heart failure mortality predated the COVID-19 pandemic, but COVID accelerated the increase in deaths from this condition. From 2012 to 2019, the average annual percentage change in mortality was 1.82%; during 2020 and 2021, it was 7.06%.
Fudim said there were two reasons for this. First, patients who were hospitalized for a COVID-related pneumonia had a roughly 20% higher chance of developing heart failure than did other people, after adjusting for their health status. In addition, COVID worsened health disparities related to race and income level, and it made the health system focus on COVID-related care rather than on heart failure prevention or management.
Factors in Mortality Rate Increase
A co-author of an earlier paper that showed an increase in the rate of heart failure deaths agreed that COVID was “like throwing fuel on the fire” of heart failure mortality.
Sadiya S. Khan, MD, the Magerstadt Professor of Cardiovascular Epidemiology at the Feinberg School of Medicine at Northwestern University in Chicago, also agreed that the increase in the number of middle-aged people dying of this condition is probably related to comorbidities they developed earlier in life. Khan added kidney disease to the list of potential disorders related to death from heart failure. And, she said, she is also seeing earlier onset of heart failure.
Khan’s research group published a paper showing that the mortality rate for heart disease from hardening of the arteries — known as ischemic heart disease, which often leads to heart attacks — declined even as the heart failure death rate rose. She attributes this mainly to there being better treatments for the underlying heart disease.
“For ischemic heart disease, there has been a lot of progress in effective therapies, particularly related to stenting and effective lipid-lowering therapies with statins and some new therapies. We haven’t seen the same progress for heart failure.”
Another factor that might have contributed to the increased mortality rate is the prevalence of heart failure. If more people develop heart failure, more of them will die of it. On the other hand, said Roger and Fudim, a higher death rate might result from patients with heart failure being sicker than they used to be, even without increased prevalence. Fudim said the data show the heart failure rate is fairly flat but gradually ticking up.
Where Did We Go Wrong?
Khan’s 2019 study suggested that the earlier decline in cardiovascular disease deaths reflected the success of policies aimed at increasing control of blood pressure and cholesterol, along with higher rates of people quitting smoking and effective medication use.
“However, the prevalence of obesity and diabetes has increased dramatically, the decline in overall CVD death rates has stalled, and heart failure-related CVD mortality rates are rising,” the paper said.
If so many of the right things were being done, why did the heart failure mortality trend reverse?
Roger doesn’t blame doctors, who continue to do the right things, in her view.
“What we haven’t done right is our failure to control obesity and diabetes. Diabetes travels with obesity, so if we focus solely on obesity, the choices that you and I and everyone make when we eat are not in the doctor’s office,” Roger said.
“I think we’ve done the best we could with the things that are within our control,” she said. “But that’s offset by the trends in obesity, which are related to the consumption of ultra-processed foods, sugar-sweetened beverages, and so on.”
Fudim, in contrast, believes the health system is at least partly to blame for the reversal of the heart failure mortality trend. Partly because of the shortages in primary care, he said, access to care is limited in many areas, prevention and chronic care are being under-emphasized, and some heart failure patients are not getting the care they need.
Roger agreed. She cited the substantially higher heart failure death rate among Black people as evidence that “difficulties in accessing the health care system and the quality of health care both play a role.”
On the other hand, she said, health systems have placed a priority on improving the care of heart failure patients, partly because of Medicare incentives. The increase in the rate of heart failure deaths, despite all of these efforts, she said, should be “an urgent wake-up call. There are new avenues of research, prevention, and clinical practice that should be synergized to address or mitigate this trend because we can’t let it go on like this.”