The southeastern region of the United States is known as the “stroke belt” because of excess stroke mortality in this region compared to the rest of the country. However, whether a similar geographic variation in heart failure mortality exists is unknown. Using the Center for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research publicly available compressed mortality data files and 2000 United States population as the standard, we estimated age-adjusted heart failure and stroke mortality rates per 100,000 for patients of all ages, men and women, and all races during 1979 through 1998 in the United States and mapped rates at the state level. Age-adjusted heart failure mortality rate for the 6 contiguous southeastern states (Alabama, Arkansas, Mississippi, Oklahoma, Louisiana, and Georgia) was 31.0/100,000, which was 69% higher than the national rate of 18.3/100,000. This geographic disparity was similar in African-Americans (32.9/100,000 in the southeast vs 21.7/100,000 nationally) and whites (30.8/100,000 in the southeast vs 18.1/100,000 nationally). These findings suggest that, in addition to the stroke belt, the southeastern region of the United States may also be burdened by a “heart failure belt.” To better understand the causes of excess stroke mortality in the stroke belt, the National Institutes of Health has funded the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study (n = 30,239, >1/2 from the southeastern region), which provides a unique opportunity to study the underlying causes of excess heart failure mortality in the heart failure belt.
The southeastern region of the United States has the highest stroke mortality rate and is often referred to as the “stroke belt” of the country. However, whether a similar geographic variation in heart failure mortality exists remains unknown. Several studies have reported that the rate of heart failure hospitalization is highest in the southeastern region of the country. The purpose of the present study was to examine if heart failure mortality is also highest in the southeastern region of the United States.
Methods
We used publicly available compressed mortality data files from the Center for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research website ( http://wonder.cdc.gov/ ) for the present study. The Wide-ranging Online Data for Epidemiologic Research site contains county-level national mortality data from all 50 states and the District of Columbia but excludes deaths occurring abroad and those of foreign residents occurring in the United States. Data on death were obtained from death certificates and causes of death were determined by conditions listed by physicians as the cause of death on the death certificate. Data on population estimates are based on United States Census Bureau estimates at national, state, and county levels and were available for census regions and divisions.
Death from heart failure was determined based on International Classification of Diseases, Ninth Revision codes 428.0, 428.1 and 428.9, and death from stroke was defined by International Classification of Diseases, Ninth Revision codes 430 to 438. Using the 2000 United States population as the standard population, we estimated age-adjusted mortality rates per 100,000 patients for heart failure and stroke in the United States for all ages, men and women, and all races during 1979 through 1998 and mapped those rates at the state level. We then repeated our estimation of age-adjusted mortality rates for heart failure in the United States separately for African-Americans and whites and mapped those rates at the state level. We further estimated age-adjusted mortality rates for heart failure for all ages, men and women, and all races during 1979 through 1998 in the 6 contiguous southeastern states of Georgia, Alabama, Mississippi, Louisiana, Arkansas, and Oklahoma and mapped those rates at the state level. We estimated age-adjusted mortality rates for heart failure for all ages, men and women, and all races during 1979 through 1998 in Alabama, the state with the highest heart failure mortality rate, and mapped those rates at the county level.
Results
Similar to stroke mortality, heart failure mortality varied by region and was highest in the southeastern region of the United States ( Figure 1 ). Six of the contiguous southeastern states were among the 9 states with the highest heart failure mortality rates: Alabama (39.2/100,000), Arkansas (34.8/100,000), Mississippi (34.2/100,000), Oklahoma (29.9/100,000), Louisiana (26.3/100,000), and Georgia (24.6/100,000). Compared to the national age-adjusted heart failure mortality rate of 18.3/100,000, the corresponding overall rate for these 6 southeastern states was 31.0/100,000, representing an excess 69% heart failure mortality. Regional variation in age-adjusted heart failure mortality rates was similar for African-Americans and whites ( Figure 2 ). In African-Americans, age-adjusted heart failure mortality rate for the 6 contiguous southeastern states was 32.9/100,000, which was 52% higher than the national rate of 21.7/100,000. In whites, age-adjusted heart failure mortality rate for the 6 contiguous southeastern states was 30.8/100,000, which was 70% higher than the national rate of 18.1/100,000. In Alabama, although 1 of the 2 counties with the highest heart failure mortality rate was predominantly white, the other was predominantly African-American ( Figure 3 ).
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