Trends and Disparities in Mortality With Stroke as the Underlying Cause and Heart Failure as a Contributing Condition in the United States, 1999–2023

BACKGROUND: National mortality studies have examined deaths in which stroke and heart failure (HF) are listed together, but trends specifically in deaths assigned to stroke as the underlying cause with HF recorded as a contributing condition remain less well defined. METHODS: We analyzed CDC WONDER Multiple Cause of Death data for US decedents aged ≥15 years from 1999 to 2023. Stroke was defined by ICD-10 codes I60-I69 as the underlying cause of death, and HF by code I50 as a contributing condition. Age-adjusted mortality rates (AAMRs) per 100,000 population were assessed using Joinpoint regression. Analyses included sex, race, Hispanic origin, urbanization, and state. A sensitivity analysis restricted to 1999-2019, supplemented by AR(1) robustness analyses, evaluated whether the late-period reversal preceded COVID-19. RESULTS: Among 170,303 qualifying deaths, AAMR declined from 4.09 in 1999 to 2.74 in 2023 (AAPC: -1.51%; p < 0.001). Mortality declined through 2009, remained stable during 2009-2016, and increased during 2016-2023 (APC: +5.38%). The pre-pandemic sensitivity analysis confirmed a significant increase during 2014-2019 (APC: +3.04%; 95% CI: +2.06% to +4.77%; p < 0.001), which 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 male-to-female AAMR ratio increased significantly during 2009-2023, despite nonsignificant terminal APCs within the male series. Among racial groups retained in the primary analysis, Black individuals had the highest AAMRs. AAMRs were higher in less urbanized areas, and state-level AAMRs ranged from 1.05 in Arizona to 5.36 in Mississippi. CONCLUSIONS: Mortality with stroke as the underlying cause and HF as a contributing condition declined substantially before reversing in the mid-2010s. Rates increased more sharply during the pandemic-era years, superimposed on an increase that was already evident before 2020. Persistent racial, geographic, and urbanization disparities warrant continued surveillance and targeted prevention.