Deaths from heart failure have risen across the U.S. over the past decade, and the increase is worse in rural areas than in urban areas, according to a new paper by Northwestern University researchers published Wednesday. 

Heart failure-related deaths per 100,000 adults in rural regions surged from 65.3 in 2011 to 73.2 in 2018, the researchers wrote in an article for PLOS One. By comparison, heart failure-related deaths per 100,000 adults in urban areas increased from 51.8 to 57.2 over the same period of time. 

The work builds on a Journal of the American Heart Association article from December, which examined such deaths on a national level and showed that they increased from 1999 to 2018 across the U.S., with large disparities between Black and white Americans. 

Sadiya S. Khan, a co-author of both studies who works as a heart failure researcher and preventative cardiologist at Northwestern, told The Academic Times that the research reflects a “rural mortality penalty,” in which, “There is a shorter life expectancy in rural America compared with urban America.” 

“Because we had identified that there were national trends that were unfavorable and race-based disparities at the national level, we were interested to see if those trends extended to geographic area,” added Khan. 

While heart failure deaths surged across the board, the greatest increase occurred among Black men who lived in rural areas. This demographic group’s heart failure death rate increased from 106.4 per 100,000 in 2011 to 131.1 per 100,000 in 2018. 

By comparison, urban white women were the least affected, seeing deaths per 100,000 rise from 39.5 in 2011 to 40.5 in 2018. 

Khan said the disproportionate burden on Black Americans reflects economic and social factors. That goes along with the findings of a JAMA Network Open paper from February, in which researchers from the University of Pennsylvania and Harvard University showed connections between income inequality and heart health. 

“There are these upstream social factors that are driving this risk, especially when we think about structural factors like racism that could be contributing to what we observed,” Khan said. 

Khan wrote the paper alongside Northwestern colleagues Jacob B. Pierce, Nilay S. Shah, Lucia C. Petito, Lindsay Pool, Donald M. Lloyd-Jones and Joe Feinglass. 

Another concerning trend the researchers identified is that the increase in heart failure mortality has been driven more by deaths of people aged between 35 and 64 than by older Americans. That may be due to factors like smoking, diet and stress, which were not examined in this study. 

While the researchers only used data through 2018, Khan believes that the trends and disparities she and her co-authors identified could have contributed to the differences in urban-rural mortality during the COVID-19 pandemic, and that the aftermath of the pandemic could widen the disparities even further. 

“COVID-19 mortality rates have been higher among rural areas,” she said. “Some of that may be related to underlying health factors if there’s greater prevalence of heart failure in rural areas.”

Khan said that in the future she plans to study how the pandemic has affected changing trends in heart failure. Other researchers have identified cardiovascular problems as a symptom of “long-haul” COVID-19 infections. 

“The aftermath of the pandemic may actually lead to more cases of heart failure related to infection as well as the stress of the pandemic itself,” said Khan. 

In order to address the rise in heart failure deaths across the U.S., Khan said federal policymakers should bolster the Affordable Care Act and expand Medicaid in all 50 states. Currently, 39 states have expanded Medicaid, according to the Kaiser Family Foundation, with Florida and Texas among the outliers. 

“Science has tried to be apolitical, but unfortunately social policy and politics relate to health outcomes,” said Khan. 

She also said that tackling entrenched socioeconomic racism could help reduce health disparities. Policymakers should be “ensuring that we’re targeting structural and systemic barriers such as racism that could be adversely affecting outcomes,” Khan said. 

The paper, titled “Trends in heart failure-related cardiovascular mortality in rural versus urban United States counties, 2011-2018: A cross-sectional study,” was published in PLOS ONE in March 2021. The authors were Jacob B. Pierce, Nilay S. Shah, Lucia C. Petito, Lindsay Pool, Donald M. Lloyd-Jones, Joe Feinglass and Sadiya S. Khan of Northwestern University.