Mortality with stroke as the underlying cause and heart failure as a contributing condition declined substantially before reversing in the mid-2010s, with rates increasing more sharply during the pandemic-era years, superimposed on an increase that was already evident before 2020, and persistent racial, geographic, and urbanization disparities identified.
Key Findings
Results
Overall age-adjusted mortality rates for stroke as underlying cause with heart failure as contributing condition declined significantly from 1999 to 2023 but reversed in later years.
Among 170,303 qualifying deaths, AAMR declined from 4.09 per 100,000 in 1999 to 2.74 per 100,000 in 2023.
The overall Average Annual Percent Change (AAPC) was -1.51% (p < 0.001).
Study population was US decedents aged ≥15 years using CDC WONDER Multiple Cause of Death data.
Stroke was defined by ICD-10 codes I60-I69 as underlying cause; heart failure by code I50 as contributing condition.
Results
Mortality trends followed three distinct phases: decline through 2009, stability from 2009-2016, and increase from 2016-2023.
Mortality declined from 1999 through 2009.
Rates remained stable during 2009-2016.
Rates increased during 2016-2023 with an Annual Percent Change (APC) of +5.38%.
Joinpoint regression was used to identify trend segments.
Results
The mid-2010s reversal in mortality increase predated the COVID-19 pandemic, as confirmed by pre-pandemic sensitivity analysis.
A sensitivity analysis restricted to 1999-2019 confirmed a significant increase during 2014-2019 (APC: +3.04%; 95% CI: +2.06% to +4.77%; p < 0.001).
This increase remained significant in AR(1) robustness analyses, including with positive autocorrelation fixed at ρ = 0.30 (APC: +3.02%; 95% CI: +1.01% to +8.02%; p = 0.020).
The authors conclude rates increased more sharply during pandemic-era years, 'superimposed on an increase that was already evident before 2020.'
Results
The male-to-female age-adjusted mortality rate ratio increased significantly during 2009-2023, indicating growing sex-based disparity.
The male-to-female AAMR ratio increased significantly during the 2009-2023 period.
Despite this widening ratio, terminal APCs within the male series alone were nonsignificant.
This suggests the divergence was driven by relative trends across sexes rather than a statistically isolated male increase.
Results
Black individuals had the highest age-adjusted mortality rates among racial groups retained in the primary analysis.
Among racial groups included in the primary analysis, Black individuals had the highest AAMRs throughout the study period.
The analysis included race, Hispanic origin, urbanization, and state as subgroup variables.
Persistent racial disparities are identified as warranting continued surveillance and targeted prevention.
Results
Age-adjusted mortality rates were higher in less urbanized areas, with substantial state-level geographic variation.
AAMRs were higher in less urbanized areas compared to more urbanized areas.
State-level AAMRs ranged from a low of 1.05 per 100,000 in Arizona to a high of 5.36 per 100,000 in Mississippi.
This more than five-fold difference between states highlights substantial geographic disparities.
Urbanization level was one of the subgroup variables assessed using Joinpoint regression.
What This Means
This research examined deaths in the United States from 1999 to 2023 where stroke was the primary cause of death and heart failure was also recorded as a contributing factor. Using a large national database of over 170,000 such deaths, researchers tracked how these mortality rates changed over time and whether certain groups were more affected than others. Overall, death rates from this combination fell by about 1.5% per year across the full study period, but this overall trend masks an important reversal: after declining through 2009 and then plateauing, rates began rising again around 2014-2016, well before the COVID-19 pandemic began.
A key finding is that the upturn in mortality was not simply a pandemic effect. Statistical analyses restricted to data through 2019 still showed a significant increase starting around 2014, meaning the trend was already worsening before COVID-19 could have played a role. The pandemic years then appeared to accelerate an already-existing problem. The study also found persistent and significant disparities: Black individuals had the highest death rates among racial groups studied, people in less urbanized (more rural) areas faced higher rates than those in cities, and there was more than a five-fold difference in death rates between the lowest-rate state (Arizona) and the highest-rate state (Mississippi). Men also experienced a growing disadvantage relative to women over the later part of the study period.
This research suggests that the combined burden of stroke and heart failure as causes of death represents an ongoing and worsening public health challenge in the United States, particularly for Black Americans, rural residents, and people in certain states like Mississippi. The fact that the worsening trend predated the pandemic means that factors beyond COVID-19—such as rising rates of obesity, hypertension, and diabetes, or gaps in access to preventive care—may be driving the reversal. The authors call for continued monitoring and targeted prevention efforts aimed at the groups and regions most affected.
Bsharat A, Badawi A, Shalalfeh A, Odeh D, Jaber M, Abd-Alfattah D, et al.. (2026). Trends and Disparities in Mortality With Stroke as the Underlying Cause and Heart Failure as a Contributing Condition in the United States, 1999-2023.. Brain and behavior. https://doi.org/10.1002/brb3.71753