# Regional Disparities in Mortality Trends for Hypertensive Heart Disease With and Without Heart Failure in the United States: A Negative Binomial Modeling and Forecasting Analysis

## TL;DR

This study finds rising mortality from hypertensive heart disease in the U.S., with the Midwest and South showing the fastest increases, suggesting a need for targeted regional interventions.

## Contribution

The study introduces a forecasting model using negative binomial regression to project regional mortality trends for hypertensive heart disease with and without heart failure.

## Key findings

- Mortality from HHD with heart failure increased most rapidly in the Midwest and South from 2018-2023.
- HHD without heart failure showed moderate increases, mainly driven by the Midwest.
- Forecasting predicts continued growth in mortality rates by 2030, especially in the South.

## Abstract

Introduction

Hypertensive heart disease (HHD) is a major contributor to cardiovascular mortality worldwide. In the United States, HHD mortality has risen in recent decades despite advances in antihypertensive therapy and cardiovascular care. This study aimed to evaluate the trends in age-adjusted mortality from HHD with and without heart failure across the four U.S. census regions (Northeast, Midwest, South, and West).

Methods

National mortality data for HHD with and without heart failure as the underlying cause of death from 2018-2023 were obtained from the Centers for Disease Control and Prevention (CDC) Wide-ranging Online Data for Epidemiologic Research (WONDER) database and stratified by U.S. census region. A negative binomial regression model was used to estimate annual percent changes (APC) in age-adjusted mortality rates for HHD with heart failure and HHD without heart failure across U.S. census regions. Age-adjusted mortality rates are standardized to the U.S. 2000 standard population and reported per 100,000 population. APC was derived with Wald 95% confidence intervals (CIs) and p-values. Pairwise slope contrasts were conducted to assess regional differences. Forecasting through 2030 was performed using gamma regression modeling, which extrapolates trends estimated from the observed 2018-2023 data.

Results

For HHD with heart failure, mortality increased significantly across all regions, with the steepest rise in the Midwest (+10.0%/year, 95% CI: 9.16-10.85; p = 2.1×10⁻¹³⁰) and South (+10.7%/year, 95% CI: 8.98-12.37, p = 2.46×10⁻³⁸). Pairwise contrasts confirmed steeper slopes in the Midwest and South vs. the Northeast (p < 1×10⁻⁷ and p < 1×10⁻¹⁰, respectively), and the South exceeding the West (p = 0.018). For HHD without heart failure, increases in APC were observed in the Midwest (+7.9%/year, 95% CI: 5.01-10.99, p = 6.1×10⁻⁸), South (+5.8%/year, 95% CI: 3.37-8.26 p = 1.81×10⁻⁶), and West (+6.1%/ year, 95% CI: 3.44-8.86, p = 5.15×10⁻⁶), while the Northeast showed no significant trend (1.7%/year, 95% CI: −2.67 to 6.32, p = 0.45 ). Pairwise slope analysis revealed that the Midwest was the only region that differed significantly from the Northeast (p = 0.049). Forecasted 2030 mortality rates reinforced these findings, with HHD with heart failure projected to be highest in the South (17.83 per 100,000 people; 95% CI: 14.64-21.73) and HHD without heart failure highest in the South and Midwest.

Conclusions

Mortality from HHD with heart failure is rapidly increasing nationwide and projected to rise further by 2030. There is a disproportionate burden in the Midwest and South, highlighting geographic disparities in these regions. In contrast, HHD without heart failure shows moderate increases, primarily driven by trends in the Midwest, and is also projected to grow by 2030. These results highlight the urgent need for region-specific interventions to mitigate hypertension and cardiovascular risk factors.