Mariell Jessup, M.D., FAHA; Chief Science and Medical Officer, American Heart Association
Women and heart failure patients in rural areas face health disparities, according to two studies published today in the Journal of the American Heart Association.
Premature death from coronary artery disease among rural women
In one study, living in rural areas in the U.S. was associated with premature death from heart disease in women.
Researchers examined variation in death rates from coronary artery disease (CAD) between 1999 and 2017, using the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) database.
The researchers were particularly interested in trends in premature death (dying before age 65 for women and before age 55 for men) and differences between urban and rural areas.
- Age-adjusted CAD death rates decreased for men and women during the study.
- Overall premature CAD mortality was consistently higher in rural than urban areas, regardless of sex, race and age group.
- Premature CAD deaths had stagnated among women in rural areas, but when the data were broken down by age, they revealed significant increases in CAD death rates in those 55-64 (since 2009) and 45-54 (since 1999).
These startling trends in CAD death rates among rural women ages 45-64 call for a greater focus among this population for detecting, preventing and controlling heart disease risk factors such as smoking, unhealthy eating habits, a sedentary lifestyle, obesity, high blood pressure, high cholesterol and diabetes. Though depression and perceived stress are less traditional risk factors for heart disease and are common in younger women, they may also need to be addressed.
Premature CAD results from exposure to risk factors in adolescence and early adulthood. Early interventions to modify existing risk factors are important (i.e., primary prevention), but efforts to prevent risk factors from developing in the first place (i.e., primordial prevention) should also be considered.
Social determinants of health associated with 90-day mortality after hospitalization for heart failure
The other study assessed the impact of single or multiple social determinants of health (SDOH) on death during the 90-day period following a heart failure hospitalization.
Researchers analyzed data from participants with heart failure in the Reasons for Geographic and Racial Differences in Stroke Study (REGARDS) who were at least 65 and Medicare beneficiaries. They reviewed age-adjusted associations between dying within 90 days of discharge and nine social determinants of health described in the Healthy People 2020 conceptual framework: black race; social isolation (having 0–1 visits from a family or friend in the past month); social network (having someone to care for them if ill); low educational attainment (< high school education); low annual household income (<$35,000); living in rural areas (isolated or small rural areas based on Rural Urban Commuting Area Codes); living in a zip code with high poverty (>25% of residents below the federal poverty line); living in a Health Professional Shortage Area (HPSA); and living in a state with poor public health infrastructure (i.e., states in the bottom quintile for their ranking [using data from the America’s Health Rankings] for ≥8 years between 1993 and 2002).
Four determinants—black race, living in an HPSA, no social network and rural residence—had a positive association (based on p-values <0.20) with 90-day mortality after a heart failure hospitalization. Participants were categorized as having 0 SDOH (28.4%), one SDOH (39.5%) or two or more SDOH (32.1%).
Of 690 participants in the study, 79 died within 90 days of hospital discharge. Compared with people who had no SDOH, people who had one SDOH were almost three times more likely to die, as were people with two or more SDOH. The increased risk remained after researchers adjusted for several demographic, clinical and hospitalization variables associated with poor outcomes among older adults after heart failure hospitalization.
Though researchers were anticipating that having multiple SDOH would be associated with a proportionate increase in mortality risk, the findings still have implications for the post-discharge care of heart failure patients. For example, if a patient has just one of the four SDOH associated with 90-day mortality, strategies for monitoring the patient post-discharge might be customized to address that risk. This might include coordinating with community-based services to arrange continued care or connect patients with other resources to manage their health.
Implications of the studies
The findings add to growing evidence of how living in rural areas affects health. Further research to clarify the specific pathways and drivers that contribute to this connection will help narrow the focus for identifying those most at risk and developing interventions to prolong healthy life expectancy.