The authors have declared that no competing interests exist.
Conceived and designed the experiments: HRR GAM. Performed the experiments: GAM IVL. Analyzed the data: GAM IVL NRS. Contributed reagents/materials/analysis tools: GAM IVL. Wrote the paper: NRS YC.
Ischemic heart disease (IHD) mortality has been on the decline in the United States for decades. However, declines in IHD mortality have been slower in certain groups, including young women and black individuals.
Trends in IHD vary by age, sex, and race in New York City (NYC). Young female minorities are a vulnerable group that may warrant renewed efforts to reduce IHD.
IHD mortality trends were assessed in NYC 1980–2008. NYC Vital Statistics data were obtained for analysis. Age-specific IHD mortality rates and confidence bounds were estimated. Trends in IHD mortality were compared by age and race/ethnicity using linear regression of log-transformed mortality rates. Rates and trends in IHD mortality rates were compared between subgroups defined by age, sex and race/ethnicity.
The decline in IHD mortality rates slowed in 1999 among individuals aged 35–54 years but not ≥55. IHD mortality rates were higher among young men than women age 35–54, but annual declines in IHD mortality were slower for women. Black women age 35–54 had higher IHD mortality rates and slower declines in IHD mortality than women of other race/ethnicity groups. IHD mortality trends were similar in black and white men age 35–54.
The decline in IHD mortality rates has slowed in recent years among younger, but not older, individuals in NYC. There was an association between sex and race/ethnicity on IHD mortality rates and trends. Young black women may benefit from targeted medical and public health interventions to reduce IHD mortality.
One of the great achievements of 20th century medicine has been the reduction in mortality from cardiovascular disease. This progress is attributed to advances in medical, percutaneous, and surgical therapies for ischemic heart disease and modification of established risk factors such as hyperlipidemia, hypertension and smoking.[
Unfortunately, in recent years improvements have not been universal. The rate of death from ischemic heart disease (IHD) in the United States did not decline among women aged 35–44 from 2000–2002, in contrast to men aged 35–44 and older individuals of both sexes.[
The population of New York City (NYC), the largest city in the United States, has a higher proportion of women and a lower proportion of elderly, rendering it desirable for in-depth analyses of trends in IHD mortality among young individuals without confounding by region or urbanization.[
The study was approved by the New York University School of Medicine Institutional Review Board with exemption from review. NYC vital statistics data were used to prepare mortality rates from 1980 to 2008. Causes of death, documented on the death certificate, were coded according to ICD-9 codes for years 1980–1998 and ICD-10 codes for years 1999–2008. The codes corresponding to IHD are 410–414 (ICD-9) and I20-25 (ICD-10). Age, sex, and race/ethnicity of decedents, typically provided by next of kin and documented on the death certificate by funeral directors, were obtained in aggregate without personal identifiers. Race/ethnicity categories were available for the period from 1990 to 2008 and were defined as non-Hispanic (NH) white (further referred to here as white), NH black (further referred to here as black), Hispanic, and Asian/Pacific Islander. Age-specific population mortality rates were estimated per 100,000 for each subgroup based on US Census data. Mortality trend curves for IHD were constructed by age, sex, and race/ethnicity and displayed on absolute and logarithmic scales. Age groups of 35–54 years and ≥55 were selected based on prior literature and ongoing studies.[
Trends in absolute and log-transformed mortality rates were explored using linear regression with the speed of change estimated by the regression line slope. We calculated annual proportional decline, i.e., the annual percent of rate reduction, for each underlying diagnosis and each comparison group based on the slope estimates from linear regression of log-transformed mortality rates. Differences in slopes were tested using two-sided t-tests of differences in slopes on the log scale. To adjust for multiple testing, we used a conservative Bonferroni adjustment. To examine deviations in the observed relationship between mortality rates and time from the linear regression line, we considered piece-wise linear regression. The piece-wise linear regression was fit within visually defined intervals. Regressions corresponding to the smallest deviation of the observed relationship from the linear fit within each interval were reported. Homoscedasticity and independence of the residuals assumptions were checked. To further explore nonlinearity and change-points in the relationship between mortality rates and time, we employed nonparametric, resampling-based technique available in Joinpoint 3.5.1 software.[
Four-way and all possible 2-way comparisons adjusted using Bonferroni multiple testing correction were performed to compare slopes of log-transformed mortality curves for each underlying cause category using the following comparisons: 1) women vs. men aged 35–54 by race/ethnicity; 2) women aged 35–54 by race/ethnicity; 3) women aged 35–54 vs. women ≥55 by race/ethnicity 4) women aged ≥55 by race/ethnicity, and 5) women vs. men aged ≥55 by race/ethnicity.
IHD mortality decreased for women and men of all age groups from 1980 to 2008. Absolute declines in IHD mortality were greater for the ≥55 age subgroup than the subgroup aged 35–54 during the study period Figs
Absolute and log transformed rates are shown (inset panel). Men 35–54 have higher rates of IHD mortality and faster decline in IHD mortality than women.
Absolute and log transformed rates are shown (inset panel). IHD mortality trends in men and women 55+ show two distinct rates of decline from 1980–1999. Trends in IHD mortality declines did not differ by sex from 1999–2008.
Population Subgroup | |||||||||
---|---|---|---|---|---|---|---|---|---|
Underlying cause of Death | 35–54 | ≥55 | P | Women 35–54 | Men 35–54 | P | Women ≥55 | Men ≥55 | P |
4.7% | 1.9% | 4.0% | 4.9% | 0.01 | 1.6% | 2.5% | |||
6.3% | 1.0% | 5.6% | 6.8% | 0.01 | 0.4% | 1.9% | 0.004 | ||
3.4% | 4.4% | 0.44 | 2.3% | 4.0% | 0.14 | 4.3% | 4.5% | 0.54 | |
P for 1980–1998 vs. 1999–2008 | 0.007 | 0.006 | 0.004 |
Female IHD Mortality | ||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Year | n = | All | White NH | Black NH | Hispanic | Asian | ||||||
35–54 | 55+ | 35–54 | 55+ | 35–54 | 55+ | 35–54 | 55+ | 35–54 | 55+ | 35–54 | 55+ | |
852,158 | 1,002,544 | 52.8 | 1517.0 | - | - | - | - | - | - | - | - | |
850,993 | 1,001,276 | 58.9 | 1477.2 | - | - | - | - | - | - | - | - | |
864,749 | 1,000,779 | 57.1 | 1526.4 | - | - | - | - | - | - | - | - | |
880,935 | 1,003,487 | 56.6 | 1530.2 | - | - | - | - | - | - | - | - | |
897,227 | 1,002,913 | 49.4 | 1539.5 | - | - | - | - | - | - | - | - | |
911,379 | 999,586 | 46.6 | 1468.9 | - | - | - | - | - | - | - | - | |
930,427 | 996,077 | 35.6 | 1349.2 | - | - | - | - | - | - | - | - | |
947,086 | 988,263 | 37.4 | 1263.6 | - | - | - | - | - | - | - | - | |
964,749 | 973,914 | 33.6 | 1291.0 | - | - | - | - | - | - | - | - | |
979,990 | 957,120 | 33.8 | 1273.7 | - | - | - | - | - | - | - | - | |
996,481 | 943,676 | 32.1 | 1333.4 | 28.2 | 1566.8 | 51.6 | 1035.4 | 21.1 | 516.7 | 8.7 | 887.9 | |
1,010,284 | 933,690 | 32.0 | 1411.6 | 28.9 | 1651.9 | 42.2 | 1079.5 | 24.4 | 581.6 | 10.7 | 975.2 | |
1,026,480 | 926,482 | 31.9 | 1481.1 | 27.0 | 1758.3 | 49.6 | 1153.2 | 19.4 | 587.0 | 7.4 | 568.5 | |
1,047,073 | 922,126 | 29.1 | 1594.1 | 23.1 | 1925.5 | 47.9 | 1190.5 | 16.5 | 594.8 | 9.1 | 390.0 | |
1,067,714 | 918,647 | 27.3 | 1467.3 | 24.5 | 1901.4 | 44.8 | 1141.5 | 19.5 | 583.6 | 3.2 | 440.5 | |
1,088,642 | 917,554 | 28.5 | 1491.6 | 24.9 | 1970.3 | 46.6 | 1139.0 | 21.2 | 602.9 | 9.9 | 478.7 | |
1,114,137 | 915,713 | 25.4 | 1448.5 | 23.0 | 1922.4 | 44.7 | 1125.6 | 14.8 | 597.0 | 6.4 | 519.0 | |
1,137,070 | 918,183 | 23.4 | 1350.5 | 23.6 | 1820.0 | 37.3 | 1037.5 | 15.9 | 575.7 | 4.3 | 447.5 | |
1,160,078 | 925,181 | 19.4 | 1277.3 | 18.2 | 1740.8 | 31.3 | 949.6 | 12.4 | 562.3 | 8.1 | 422.5 | |
1,179,899 | 942,551 | 24.4 | 1306.6 | 25.9 | 1739.4 | 38.1 | 1027.6 | 14.8 | 654.1 | 3.1 | 427.4 | |
1,197,069 | 959,269 | 24.2 | 1203.8 | 19.4 | 1634.0 | 45.6 | 977.3 | 15.7 | 584.5 | 6.1 | 407.2 | |
1,214,189 | 975,744 | 20.5 | 1178.5 | 20.7 | 1622.5 | 32.4 | 955.8 | 11.8 | 552.7 | 7.9 | 440.0 | |
1,223,532 | 993,336 | 23.0 | 1165.9 | 20.7 | 1630.4 | 41.9 | 957.7 | 14.7 | 525.0 | 4.2 | 424.0 | |
1,230,439 | 1,011,003 | 21.1 | 1111.1 | 23.1 | 1477.2 | 31.1 | 923.1 | 14.1 | 568.3 | 4.7 | 413.4 | |
1,233,950 | 1,026,823 | 20.8 | 1030.5 | 18.2 | 1387.9 | 37.5 | 887.4 | 13.9 | 518.3 | 4.7 | 407.0 | |
1,239,738 | 1,050,151 | 21.2 | 1017.0 | 18.9 | 1409.7 | 38.1 | 863.6 | 14.5 | 528.8 | 7.1 | 391.6 | |
1,249,760 | 1,061,828 | 20.1 | 951.8 | 14.1 | 1315.9 | 40.6 | 832.7 | 15.3 | 506.7 | 5.7 | 349.8 | |
1,267,877 | 1,079,080 | 20.1 | 907.5 | 14.3 | 1249.0 | 39.8 | 811.7 | 17.5 | 487.9 | 3.1 | 363.9 | |
1,278,542 | 1,105,479 | 19.9 | 875.5 | 17.3 | 1198.6 | 37.8 | 783.8 | 13.2 | 496.6 | 4.8 | 364.2 |
Male IHD Mortality | ||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Year | n = | All | White NH | Black NH | Hispanic | Asian | ||||||
35–54 | 55+ | 35–54 | 55+ | 35–54 | 55+ | 35–54 | 55+ | 35–54 | 55+ | 35–54 | 55+ | |
733,407 | 687,624 | 179.8 | 2049.1 | - | - | - | - | - | - | - | - | |
734,431 | 684,392 | 175.9 | 1978.3 | - | - | - | - | - | - | - | - | |
748,978 | 682,406 | 168.9 | 2049.8 | - | - | - | - | - | - | - | - | |
765,238 | 683,369 | 150.5 | 2001.1 | - | - | - | - | - | - | - | - | |
781,406 | 681,853 | 149.9 | 1930.9 | - | - | - | - | - | - | - | - | |
795,743 | 679,262 | 138.4 | 1849.9 | - | - | - | - | - | - | - | - | |
814,880 | 675,021 | 122.7 | 1703.2 | - | - | - | - | - | - | - | - | |
832,092 | 668,412 | 120.7 | 1597.8 | - | - | - | - | - | - | - | - | |
849,757 | 657,626 | 108.5 | 1552.7 | - | - | - | - | - | - | - | - | |
865,317 | 646,124 | 99.8 | 1511.2 | - | - | - | - | - | - | - | - | |
882,267 | 637,038 | 96.2 | 1552.2 | 98.4 | 1758.5 | 120.2 | 1261.6 | 68.5 | 702.5 | 35.2 | 1065.3 | |
896,854 | 632,222 | 90.9 | 1611.9 | 93.3 | 1836.4 | 115.7 | 1230.4 | 56.1 | 746.1 | 53.7 | 1155.1 | |
913,710 | 629,888 | 85.1 | 1685.7 | 89.2 | 1971.7 | 97.2 | 1311.4 | 56.8 | 724.8 | 44.2 | 724.5 | |
934,781 | 629,455 | 83.5 | 1741.2 | 94.0 | 2051.6 | 97.8 | 1361.2 | 53.6 | 729.8 | 24.9 | 620.9 | |
954,812 | 628,706 | 77.0 | 1616.8 | 88.1 | 2039.7 | 101.2 | 1200.8 | 45.3 | 804.4 | 34.4 | 611.2 | |
975,776 | 630,387 | 72.8 | 1643.0 | 84.8 | 2105.2 | 87.7 | 1304.2 | 46.2 | 735.9 | 43.9 | 620.4 | |
1,000,189 | 631,735 | 64.0 | 1578.4 | 81.0 | 2014.8 | 65.9 | 1278.3 | 38.0 | 783.5 | 36.8 | 640.1 | |
1,022,882 | 636,008 | 57.1 | 1436.3 | 67.0 | 1845.8 | 60.4 | 1172.7 | 42.2 | 730.0 | 34.2 | 583.1 | |
1,046,140 | 649,105 | 54.7 | 1322.9 | 70.4 | 1711.1 | 59.8 | 1048.2 | 33.0 | 659.0 | 29.8 | 605.4 | |
1,068,657 | 658,447 | 66.0 | 1389.6 | 76.6 | 1760.6 | 79.0 | 1150.2 | 48.7 | 742.8 | 25.6 | 641.3 | |
1,087,695 | 668,374 | 67.1 | 1345.7 | 86.6 | 1731.8 | 77.7 | 1179.6 | 40.5 | 714.4 | 31.9 | 563.3 | |
1,109,421 | 681,960 | 59.9 | 1253.6 | 75.3 | 1627.8 | 70.8 | 1091.4 | 38.4 | 713.4 | 32.6 | 529.4 | |
1,122,562 | 696,723 | 62.3 | 1249.4 | 80.0 | 1621.2 | 75.9 | 1111.9 | 37.6 | 704.3 | 31.4 | 530.2 | |
1,133,506 | 711,912 | 54.1 | 1208.6 | 67.2 | 1516.9 | 64.7 | 1061.6 | 33.1 | 696.2 | 28.5 | 520.2 | |
1,143,543 | 723,967 | 54.1 | 1094.9 | 55.6 | 1402.8 | 79.7 | 979.1 | 38.5 | 657.7 | 30.5 | 463.5 | |
1,155,788 | 742,757 | 55.5 | 1059.7 | 58.6 | 1370.8 | 70.6 | 1013.7 | 45.1 | 611.1 | 37.8 | 478.7 | |
1,172,581 | 763,423 | 50.3 | 1021.5 | 58.3 | 1325.4 | 64.6 | 943.8 | 36.8 | 635.1 | 27.5 | 457.0 | |
1,194,040 | 781,215 | 48.1 | 977.8 | 48.2 | 1275.3 | 70.3 | 901.8 | 34.4 | 618.4 | 32.9 | 447.2 | |
1,208,639 | 804,987 | 49.6 | 935.5 | 52.8 | 1206.0 | 72.9 | 896.5 | 40.2 | 582.2 | 22.3 | 461.6 |
Note that mortality data for race/ethnicity were not available before 1990. Population n refers to the population in NYC for women or men in the labeled age category by year.
Among younger individuals aged 35–54, men displayed higher absolute rates of IHD mortality than women. The annual percent declines in IHD mortality were more favorable for men than for women during the period from 1980–1999 (6.8% vs. 5.6% per year, p = 0.01; see
Men aged ≥55 displayed higher IHD mortality rates than women ≥55 at all time-points of the study, but sex differences narrowed due to a faster decline in IHD mortality in men from 1980–1998 (1.9% vs. 0.4% per year, p = 0.004; see
IHD mortality decreased between 1990–2008 for all race/ethnicity categories. Among women aged 35–54, the absolute IHD mortality rate was higher among blacks than other race/ethnicity groups
p (vs. white) | ||
---|---|---|
White NH | 3.2% | - |
Hispanic | 2.3% | 0.81 |
Black NH | 1.5% | 0.03 |
Asian | 3.5% | 0.28 |
White NH | 3.4% | - |
Hispanic | 2.6% | 0.13 |
Black NH | 2.6% | 0.28 |
Asian | 2.0% | 0.27 |
White NH | 2.1% | - |
Hispanic | 0.8% | 0.09 |
Black NH | 2.1% | 0.89 |
Asian | 3.7% | 0.01 |
White NH | 2.7% | - |
Hispanic | 4.0% | 0.06 |
Black NH | 2.1% | 0.13 |
Asian | 1.2% | <0.001 |
† p<0.01 with Black in same age—sex category
Among individuals age ≥55, black women and men had lower rates of mortality than whites (but higher than Hispanics and Asians)
We identified a slowing rate of decline in ischemic heart disease mortality among young (35–54) but not older (≥55) New Yorkers in recent years. We also identified a striking relationship between age, sex, and race/ethnicity and IHD mortality rates in NYC, with slower declines of IHD mortality in young black women than young women of other race/ethnic groups. Trends in IHD mortality in NYC are of particular interest because IHD mortality in NY State is among the highest in the nation and IHD mortality is higher in large metropolitan areas.[
Ischemic heart disease is the leading cause of cardiovascular death among young individuals in the United States, accounting for approximately half of all cardiovascular deaths.[
Among younger individuals, women experienced a slower annual proportional decline in IHD mortality than did men. Declines in IHD mortality favoring men have also been reported in Finnish registries.[
This is the first study to assess trends in IHD mortality by sex and race/ethnicity in young women and men in NYC. Young black women, but not young black men, were found to be at a higher IHD mortality risk than white men and women in the same 35–54 age group. Black women experienced the slowest rate of decline in IHD mortality among all women aged 35–54.
There are several potential explanations for these concerning findings. Black women have higher prevalence of cardiovascular disease risk factors, including obesity, hypertension, and diabetes, when compared to white women.[
We recognize several limitations. First, race and ethnicity reported on death certificates could not be verified for accuracy. Race misclassification was unlikely to affect the designation of non-Hispanic white and black individuals, although ethnicity errors and census undercounting could affect both cohorts.[
Despite improvements in medical therapy and aggressive interventions to treat IHD, the rate of decline in IHD mortality among younger individuals in NYC has slowed in recent years. IHD mortality trends in younger black women were particularly unfavorable and black women under age 55 are at increased risk of premature IHD death. Further investigation is warranted into targeted medical and public health interventions to reduce IHD mortality in this vulnerable population.