Trends and widening inequities in cardiovascular-kidney-metabolic involvement in cardiovascular mortality: A national...

Cardiovascular-kidney-metabolic (CKM) conditions increasingly contribute to cardiovascular disease (CVD) mortality, but temporal trends in social inequities and geographic priorities remain unclear. We quantified trends, disparities and county-level priority areas for CKM-involved CVD mortality in the USA.

Using 2014-2023 US vital statistics, we estimated age-standardised CKM-involved CVD mortality. Negative binomial regression estimated Social Vulnerability Index (SVI) quintile-specific relative risks (RRs) and SVI × time interactions. Inequity was measured by the slope (SII) and relative (RII) index of inequality. Bayesian spatiotemporal smoothing identified 2022-2023 county-level RRs and worsening probability (P[increasing]). High-priority areas were defined by current risk (RR ≥ 1.43) and P[increasing] ≥0.80.

National crude mortality rose from 36.37 per 100,000 (2014-2015) to 47.90 (2022-2023). Disparities significantly widened: the SVI Q5 vs Q1 RR increased from 1.23 (95% CI, 1.18-1.28) to 1.34 (1.29-1.40) (interaction p = 0.0197). Both absolute and relative gradients strengthened (SII: 10.48-21.12; RII: 1.30-1.45). County-level RRs (2022-2023) ranged from 0.24 to 4.87 with regional clustering. Overall, 356 counties (11.4%) were classified as high-risk and worsening. We identified 85 Tier 1 counties and estimated 1,721 national excess deaths.

CKM-involved CVD mortality is increasing, and social inequities are widening. Geographically clustered counties face both high current risk and a high likelihood of worsening. These Tier 1 counties represent critical, actionable targets for place-based CKM prevention and treatment strategies.