Heart Failure Mortality Before and After COVID-19: Demographic Variations and Urbanization Patterns in the United States (2018-2023)

Background: Contemporary evidence on heart failure (HF) recorded as the underlying cause of death remains fragmented across demographic groups and levels of urbanization.The 2018-2023 interval includes two years before the emergence of COVID-19 (2018COVID-19 ( -2019) ) and four years after its emergence (2020-2023).Objective: We aim to characterize the national underlying cause of HF mortality among US adults aged 45 years or older from 2018 through 2023; describe differences by sex, age, race, and Hispanic origin; and quantify changes in absolute death counts across the six National Center for Health Statistics (NCHS) urbanization categories.Hypothesis: We hypothesized that the national age-adjusted HF mortality rate would increase and that demographic differences and variation in geographic death counts would persist.Methods: This retrospective, population-based, serial cross-sectional study used Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) Underlying Cause of Death data (International Classification of Diseases, 10th Revision (ICD-10) I50).Age-adjusted mortality rates (AAMRs) per 100,000 were evaluated overall and across demographic groups; age-specific crude rates were used for age groups.Zero-joinpoint log-linear models estimated annual percent change (APC) for the overall population, race categories, and Hispanic-origin categories.Race and Hispanic origin were analyzed separately and may overlap.Urbanization analyses used death counts and percentage changes; urbanization-specific population-adjusted rates were not estimated.Deaths listing HF only as a contributing cause were outside the case definition.Results: There were 512,960 deaths with HF as the underlying cause; the aggregate AAMR was 59.6 per 100,000.No statistically significant overall temporal trend was detected (APC: 0.59%; 95% confidence interval (CI): -0.37 to 1.57; p = 0.227).Men had a higher aggregate AAMR than women (68.1 versus 53.0), and Black adults had the highest racial AAMR (70.9).Asian adults had a lower aggregate AAMR than White and Black adults (22.9);Hispanic adults had a lower AAMR than non-Hispanic adults (35.2 versus 61.9).In their respective analyses, Asian and Hispanic groups had increasing trends at the nominal 0.05 significance level (APC: 1.30%, p = 0.047, and 1.96%, p = 0.030, respectively).Age-specific mortality increased sharply with age.Death counts increased across all six urbanization categories, most in Medium Metro counties (+11.0%).Conclusions: No statistically significant national trend was detected during 2018-2023, while descriptive demographic differences and nominally significant increases in the Asian race and Hispanic-origin analyses were observed.These separate analyses do not establish differences between subgroup slopes or narrowing mortality gaps.Geographic findings describe absolute burden, not population-adjusted risk.The results concern HF as the underlying cause and do not measure total HF-associated mortality.