Increasing Acute Coronary Syndrome Mortality in Cirrhosis After a Period of Decline: A National Analysis of Temporal and Demographic Disparities

How acute coronary syndrome (ACS) mortality has evolved among people with cirrhosis at the national level is unclear, and the clinical implications for cardio-hepatic care are underdefined. Using CDC WONDER mortality files (1999-2020), we identified deaths with ACS as the underlying cause and cirrhosis listed among multiple causes, computed age-adjusted mortality rates (AAMRs; per 100,000), and modeled trends with Joinpoint regression. Subgroups included sex, race/ethnicity, urbanization, and place of death. We identified 10,319 cirrhosis-associated ACS deaths; the overall AAMR was 0.22. Rates were higher in men than women (0.33 vs. 0.12) and higher in Hispanic than non-Hispanic individuals (0.31 vs. 0.20). American Indian/Alaska Native had the highest AAMR (0.34). Rural noncore counties had the highest AAMR (0.28). Joinpoint detected a national inflection in 2014: AAMR declined from 1999 to 2014 (APC - 3.49%) and increased thereafter (APC + 5.38%), with an overall AAPC of -1.03%. After years of decline, cirrhosis-associated ACS mortality has risen since 2014, with persistent disparities by sex, race/ethnicity, and rurality. These data support integrated cardio-hepatic pathways, targeted outreach to rural and historically underserved groups, and system-level quality improvement focused on time-sensitive ACS care in cirrhosis.