Trends in Cause-Specific Mortality by Race and Hispanic Origin, 1999–2019

Diseases of the Circulatory System

In 2019, circulatory system diseases caused more deaths at ages 65 or older, and at all ages combined, than any other category. Among people aged 25–64, circulatory system diseases were the leading cause of death in the Black population, the second leading cause of death (after cancer) among the API and WNH communities, and the third leading cause of death for Hispanic individuals (after external causes and cancer). This section considers the 11 circulatory disease subcategories listed in Box 2.

Chart 11 shows the number and percentage distribution of circulatory system disease deaths by subcategory for 1999 and 2019, with detail by RE group and age. Ischemic heart disease was the leading cause of circulatory system disease–related death at ages 25–64, ages 65 or older, and all ages combined in 1999 and 2019. Ischemic heart disease reduces blood flow to the heart, preventing the heart muscle from receiving enough oxygen. It typically accounts for a higher share of circulatory system disease deaths in men than in women although that share declined for both sexes over the observation period. Ischemia typically caused higher shares of circulatory system disease–related deaths for WNH and Hispanic people than for the other RE groups. In 1999, ischemic heart diseases respectively accounted for 56.2 percent and 49.4 percent of circulatory system disease deaths among the WNH and Black populations. By 2019, the percentages had declined to 41.9 percent among WNH individuals and 36.4 percent in the Black community.

Chart 12 shows age-adjusted death rates for 1999–2019 by RE group, sex, and age group. Panel A shows the rates for circulatory system diseases overall.

Chart 12, Panel B shows that from 1999 to 2019, the all-ages ischemia death rate declined by more than half in every RE/sex group, with the mortality rates improving more rapidly in the first decade of the period than the second. In 2019, Black males had the highest all-ages ischemia mortality rate (134.2), followed by WNH and Hispanic males (125.0 and 91.4, respectively). Among females, the highest mortality rate was for those who are Black (75.4) and the lowest was for those who are API (35.5). The mortality gap between the Black and WNH populations narrowed considerably during the period, particularly at older ages. In fact, by 2017, the ischemia mortality rate of WNH men aged 65 or older surpassed that of Black men in that age group. In general, death rates improved more quickly for women than for men, resulting in a higher male-to-female mortality ratio over time.

Cerebrovascular disease refers to a variety of conditions affecting the supply of blood to the brain. It was the second leading cause of circulatory system–related deaths in 2019, accounting for 16.5 percent of those deaths among WNH people and 23.8 percent of those among the API community. The share of circulatory system–related deaths attributed to cerebrovascular disease changed little over the observation period and tended to be lower in the midlife years than at other ages. However, those shares were higher among women than men. For example, for WNH people in 2019, 13.4 percent of circulatory system–related deaths among men involved cerebrovascular disease, versus 19.9 percent among women.

Chart 12, Panel C shows that all-ages cerebrovascular disease mortality rates improved rapidly among all RE/sex groups from 1999 to 2012, then stalled. In 2019, the death rate was slightly higher than in 2012 for all groups except API males and WNH and API females. Black males and females had the highest mortality rates at all ages combined (55.4 and 46.9, respectively), as well as in every age group. WNH males and females and Hispanic males had similar all-ages mortality rates in 2019 (35.5, 35.1, and 35.3, respectively).

Hypertensive heart disease comprises heart conditions caused by high blood pressure. After a dramatic increase beginning in 1999, hypertensive heart disease accounted for the third largest share of circulatory system–related deaths in 2019, behind ischemia and cerebrovascular disease. The shares are also disproportionately high in the Black population. For example, from 1999 to 2019, the hypertension-related shares of circulatory system disease deaths rose from 3.7 percent to 10.7 percent among WNH individuals and from 9.8 percent to 16.6 percent in the Black population.

All-ages hypertensive disease mortality rates were higher in 2019 than in 1999 for all RE/sex groups except Black females (Chart 12, Panel D). The death rate for WNH males (12.7 in 1999) rose fastest, doubling to 25.7 by 2019. Black males and females had substantially higher mortality rates than other groups. In 1999, all-ages hypertension mortality rates for Black males and females (47.5 and 39.4, respectively), more than tripled those of their WNH counterparts, and the gap was even wider for the 25–64 age group. Hispanic males had higher all-ages mortality rates than WNH males until 2013. Hispanic females also experienced lower mortality rates than WNH females beginning in 2011. The gender mortality gap associated with hypertensive disease increased for every RE group (and almost every age group) over the 1999–2019 period, as mortality increased faster among males than females in each RE category.

Heart failure is a chronic, progressive condition in which the heart is unable to pump enough blood to the organs. In 2019, heart failure was the fourth leading cause of circulatory system disease–related deaths in every RE group. Its share of all circulatory disorder–related deaths ranged from 8.7 percent for Black people to 10.4 percent for WNH people. The percentage of circulatory system–related deaths caused by heart failure increased over the observation period and was higher among the aged (65 or older) and the WNH and Black populations than the other age and RE groups.

For all RE/sex groups, all-ages heart failure death rates declined from 1999 to 2010 then increased thereafter (Chart 12, Panel E). By 2019, all-ages mortality rates were higher than they had been in 1999 for all RE groups other than API people. Black males had the highest heart failure mortality rate, followed by WNH males, Black females, and WNH females. Hispanic and API males and females experienced substantially lower rates. For example, in 2019, the all-ages mortality rate from heart failure for each sex in the Black population was about twice as high as that of Hispanic individuals. From 1999 to 2019, heart failure mortality rates rose more for the midlife age group than for the aged, with Black men and women aged 25–64 exhibiting the highest mortality rates and API, Hispanic, and Black men experiencing the highest growth rates. At ages 65 or older, however, Black and WNH men had similar mortality rates in 2019 (189.0 and 181.1, respectively), as did Black and WNH women (143.2 and 146.7, respectively).

Pulmonary heart disease and diseases of pulmonary circulation involve severe dysfunction of the heart caused by lung disease. In 2019, the shares of circulatory system–related deaths caused by cardiopulmonary diseases ranged from 1.3 percent in the API population to 2.9 percent among Black people. The percentage of deaths is higher among females than males and increases substantially at younger ages, accounting for more than 10 percent of circulatory system–related deaths among those younger than 25.

For each RE group, the all-ages cardiopulmonary disease mortality rate was higher for females than males in 2019 (Chart 12, Panel F). From 1999 to 2010, mortality rates declined for all RE/sex groups; but for most groups, rates increased after 2010. Black females had the highest mortality rates, followed by Black males. In 2019, the mortality rates were more than 60 percent higher for Black males and females than for their WNH counterparts.

In 2019, diseases of the arteries, arterioles, and capillaries represented less than 3 percent of circulatory system–related deaths. The share of circulatory system–related deaths that was caused by arterial diseases declined over the observation period and tended to be slightly lower for those aged 65 or older than for the other age groups.

Chart 12, Panel G shows that from 1999 to 2019, all-ages arterial disease death rates declined by at least 49 percent in every RE/sex group. In 1999, WNH males had a higher all-ages mortality rate (19.0) than Black males (18.2). By 2019, Black males had the highest all-ages arterial disease mortality rate (9.2), followed by WNH males (7.4), Black females (6.2), WNH females (5.1), and Hispanic males (5.0). The steep decline in mortality attributed to arterial diseases was largely driven by mortality rate improvement at ages 65 or older.

Cardiac arrest is a sudden loss of heart function because of failure in the heart's electrical system. In 2019, the share of circulatory system–related deaths caused by cardiac arrest ranged from 1.3 percent for the Hispanic community to 2.7 percent among Black individuals.

From 1999 to 2019, cardiac arrest mortality rates improved substantially among all RE/sex groups (Chart 12, Panel H). In 2019, Black males had the highest all-ages mortality rate (9.2), followed by Black females (6.1) and WNH males (5.1). Through most of the period, Hispanic males and females experienced lower age-adjusted cardiac arrest mortality rates than those in the API community.

Cardiomyopathy refers to diseases of the heart that can cause the muscle to become enlarged, thick, or rigid. In 2019, across RE groups, cardiomyopathy accounted for 2–3 percent of circulatory system–related deaths at all ages combined. The cardiomyopathy share of circulatory system–related deaths is typically higher among men than women and in the Black community than for other RE groups. The percentage of circulatory system–related deaths associated with cardiomyopathy is higher at ages 25–64 than at older ages and is one of the leading causes of circulatory system–related deaths at younger ages. In 2019, cardiomyopathy accounted for about 16 percent of circulatory system disease deaths in the 0–24 age group for the WNH, Hispanic, and Black populations.

Cardiomyopathy mortality rates improved significantly over the 1999–2019 period among all population groups (Chart 12, Panel I). The all-ages death rate declined by nearly one-half for Hispanic males and WNH males and females, and by more than one-half for all other RE/sex groups. Nevertheless, cardiomyopathy mortality rates were substantially higher for Black males in all years than for any other RE/sex group. WNH males and Black females had either the second or third highest all-ages cardiomyopathy mortality rates over the observation period. In 1999, the all-ages cardiomyopathy mortality rate for Black males more than doubled that of WNH men (25.8 versus 12.8). By 2019, the gap had narrowed slightly, to a factor of 1.8 (12.4 versus 6.8). The mortality-rate gap between Black and WNH females also narrowed during this period. At ages 25–64, Black women had the second highest cardiomyopathy mortality rate after Black men. At ages 65 or older, the mortality rates of Black women and Hispanic men were similar; WNH women and API men also had similar mortality rates.

Atrial fibrillation and atrial flutter result from electrical discharge patterns that cause the heart's two upper chambers (the atria) to beat irregularly and out of coordination with the two lower chambers (the ventricles). In 1999, this was one of the least common causes of circulatory system–related deaths, accounting for about 0.5 percent of such deaths among Hispanic, Black, and API people and a little less than 1.0 percent of such deaths among WNH people. The share of deaths attributed to atrial malfunction increased rapidly thereafter, reaching 3.5 percent of circulatory system–related deaths in the WNH population in 2019. The percentage of circulatory system–related deaths that is caused by atrial malfunction tends to be higher among women than men and at older ages than in midlife. It is also disproportionately higher for WNH individuals than for other RE groups.

All-ages atrial malfunction death rates increased by 80 percent or more for all RE/sex groups from 1999 to 2019, and more than doubled for all but Black and Hispanic males and Black females (Chart 12, Panel J). WNH females and males respectively had the highest and second highest all-ages atrial malfunction mortality rates from 1999 until 2017, when the rate for males surpassed that of females. Black males had the third highest all-ages atrial malfunction mortality rates and Black females had the fourth highest rates each year except 2000, 2005, and 2008, when the rankings were switched. In 2019, the all-ages death rates among WNH and Black males were 7.3 and 4.6, respectively. The corresponding rates for females were 7.2 and 3.8.

The subcategory of circulatory system disorders designated as “other cardiac arrhythmias” accounted for little more than 1 percent of circulatory system–related deaths in the WNH and Black populations and smaller shares in the other RE groups in 2019. The shares of circulatory system–related deaths attributable to other arrhythmias were highest at ages 0–24 (for example, 7.4 percent in the WNH population) and declined as age increased.

All-ages other-arrhythmia mortality rates generally declined among all RE/sex groups in the 1999–2019 period (Chart 12, Panel K). Black males had the highest all-ages other-arrhythmia mortality rates throughout the period. Black females had the second highest rate until 2017, when it was surpassed by the rate for WNH males.

The final subcategory comprises all other circulatory system disorders. It includes a variety of diseases affecting the heart's valves and membranes, rheumatic heart disease, and diseases of the veins, lymphatic vessels, and lymph nodes. In 2019, the percentage of circulatory system–related deaths attributed to this subcategory at all ages ranged from 5.2 percent in the API community to 7.0 percent among WNH individuals (Chart 11). This subcategory accounts for a greater share of deaths at ages 25–64 than at ages 65 or older and it also represents the leading cause of circulatory system–related death among the young, constituting almost one-quarter of such deaths for the WNH, Hispanic, and Black populations at ages 0–24.

Black males had the highest all-ages mortality rate from other circulatory system disorders, followed by WNH males (Chart 12, Panel L). Black and WNH females had similar all-ages death rates in 2019 (13.8 and 13.9, respectively). At older ages, however, WNH people typically experienced higher mortality rates than did those in other RE groups. The all-ages other-circulatory-disorder death rates were higher in 2019 than in 1999 only among WNH males and females and Black males.

In summary, from 1999 to 2019, mortality caused by diseases of the circulatory system declined among all RE/sex groups, with much of the improvement taking place in the first decade of the period. The substantial decline in mortality caused by ischemic heart disease and cerebrovascular disease throughout the 2000s more than offset the increased mortality from other causes, such as hypertensive heart disease and heart failure, beginning in 2010. Chart 13 summarizes the contribution of each cause-of-death subcategory to the overall age-adjusted circulatory-system disease mortality rate in 1999 and 2019.

The racial disparities in circulatory system disease mortality can be understood in terms of the subcategory components the chart highlights. For instance, in 1999, the all-ages mortality rate from ischemic heart disease among Black males (278.9) exceeded the combined circulatory system disease death rate for API males (275.6). Further, the combined mortality caused by ischemic heart disease and hypertensive heart disease among Black males (326.4) was higher than the death rate from all circulatory system diseases among Hispanic men (322.1). For WNH men in 1999, combined mortality from three causes (ischemic, cerebrovascular, and hypertensive heart diseases) also exceeded that of Hispanic males from all circulatory system–related diseases (326.5 versus 322.1).

Over time, the mortality rates among all RE/sex groups declined and the mortality rate gaps between the groups narrowed. For instance, in 1999, 118.7 more Black males per 100,000 population died of circulatory system diseases than did WNH males. By 2019, the number declined to 79.4 additional deaths per 100,000. However, if the racial gap is defined as the ratio between two age-adjusted mortality rates, then it increased in most cases. This is because API males and females had the highest rates of mortality decline over the 1999–2019 period, followed by Hispanic males and females. Circulatory system–related mortality for WNH and Black males declined at similar rates. Only Black females experienced a modest reduction in the mortality gap with WNH females, as the mortality ratio decreased from 1.34 in 1999 to 1.29 in 2019. Black males had the highest age-adjusted mortality rates in nine of the eleven circulatory system disease subcategories (the exceptions, atrial fibrillation and pulmonary heart disease, are among the less prevalent causes). Black females often had either the second highest mortality rate or the third highest rate (after Black and WNH males).