Increased Heart Failure Risk Experienced by Rural Populations in Southeastern US

Véronique L. Roger, MD, MPH

Rurality was associated with an increased risk of heart failure (HF) in a population of predominantly low-income individuals in the southeastern United States, according to new research.

Variations in heart failure risk were observed by race-sex groups, with rural Black men experiencing the highest rate of incident HF. This excess risk associated with rurality was observed to persist even after adjustment for cardiovascular risk factors and socioeconomic status.

“We did not expect to find a difference of this magnitude in heart failure among rural communities compared to urban communities, especially among rural-dwelling Black men,” said corresponding author Véronique L. Roger, MD, MPH, Division of Intramural Research, Epidemiology and Community Health Branch, National Heart, Lung, and Blood Institute, National Institutes of Health in a statement. “This study makes it clear that we need tools or interventions specifically designed to prevent heart failure in rural populations, particularly among Black men living in these areas.”

Particularly for heart failure, rural populations share a disproportionate burden of HF mortality. Black men living in rural areas are more likely to die of HF than those living in urban areas and White men in both rural and urban areas. It is less understood, however, whether these inequalities reflect higher HF incidence.

Investigators in the current study examined the incidence of HF by rurality status across race and sex in a large community cohort of Black and White adults in the southeastern United States. Their analysis collected data from Black and White participants of the Southern Community Cohort Study (SCCS).

Between March 2002 and September 2009, the SCCS enrolled 84,797 participants from 12 states across the southeastern United States. Investigators identified 33,003 participants who reported being covered by Centers for Medicare & Medicaid Services (CMS) at enrollment or within 90 days of enrollment.

Participant addresses were geocoded and linked to census tracts, to assign rurality as defined by Rural-Urban Commuting Area (RUCA) codes. The participants themselves were analyzed by rural-urban status with a priori stratification by race-sex group (Black men, White men, Black women, White women) in concordance with prior research within SCCS. Heart failure incidence rates were calculated by the number of HF cases by person-time of follow-up, presented per 1000 person-years, and were age-standardized to the eligible SCCS cohort.

Among 27,115 participants without HF at enrollment, 5556 (20%) resided in rural areas. Most participants (18.647 [68.8%]) were Black, without difference by rurality. Individuals in rural areas were older and more commonly female, with a slightly higher BMI and rates of hypertension.

A total of 7542 incident HF events occurred over a median 13-year follow-up, 1865 among rural participants, and 5677 among urban participants. The age-standardized HF incidence rate among rural participants was 36.5 (95% CI, 34.9 - 38.3) per 1000 person-years and the urban incidence rate was 29.6 (95% CI, 28.9 - 30.5) per 1000 person-years (P <.001).

After adjustments for demographic information, CV risk factors, health behaviors, and socioeconomic status, rural participants had a 19% greater risk of incident HF (hazard ratio [HR], 1.19; 95% CI, 1.13 - 1.26), compared to urban participants.

Investigators noted the risk of HF associated with rurality varied by race-sex group. Black men in rural areas had the highest risk of HF in every sequential model, including in the final model (HR, 1.34; 95% CI, 1.19 - 1.51).

Data show Black women (HR, 1.18; 95% CI, 1.08 - 1.28) and White women (HR, 1.22; 95% CI, 1.07 - 1.39) had a similar increased risk of HF attributable to rurality. Among White men, rurality was not associated with greater incident HF risk.

"These inequities highlight the intersectionality of race and sex and rurality and the need for further investigation into the rurality-associated risk of HF to guide public health efforts aimed at HF prevention among rural populations," Roger wrote in conclusion.

The study, “Association of Rurality With Risk of Heart Failure,” was published in JAMA Cardiology.