Cardiohepatic collision: escalating mortality, stark disparities, and pandemic surge in chronic liver disease and heart failure – a 25-year US analysis

Background Chronic liver disease (CLD) and heart failure (HF) represent intertwined epidemics in the United States, where cirrhosis drives hyperdynamic circulation and cirrhotic cardiomyopathy, while HF induces hepatic congestion and fibrosis. Amid rising prevalence of metabolic-associated steatotic liver disease (MASLD) and alcohol-related complications, profound disparities persist across demographics, geography, and socioeconomic lines. The COVID-19 pandemic exacerbated these burdens through disrupted care, increased alcohol use, and systemic vulnerabilities, underscoring the need for comprehensive epidemiologic insights to guide equitable interventions. Purpose To assess trends, disparities, and the impact of COVID-19 on mortality from CLD as the underlying cause with HF as a contributing factor in US adults. Methods Utilizing CDC WONDER data from 1999–2023, we analyzed 117,003 deaths where CLD was the underlying cause and HF a contributing factor among adults ≥25 years. Age-adjusted mortality rates (AAMRs) were calculated and stratified by age, sex, race/ethnicity, region, and urban-rural status. Joinpoint regression estimated annual percent changes (APCs), linear modeling quantified excess mortality during 2020–2023 against pre-pandemic trends, and age-period-cohort (APC) analysis disentangled temporal effects. Results AAMRs rose from 1.54 to 3.79 per 100,000 (AAPC: 3.91%), with an initial decline until 2009 followed by accelerations, peaking at 13.76% APC from 2018–2021. Disparities were stark: males (5.01 vs. females 2.62), older adults (≥65 years highest), non-Hispanic American Indian/Alaska Natives (8.57), Southern/Western regions, and rural areas exhibited elevated rates. Pandemic excess mortality averaged 58.2% above expected (1.31 per 100,000 annually), with younger adults showing the highest relative surge (91.8%). APC modeling revealed strong age gradients (RR 2.40 for ≥65), pandemic-driven period effects (147.9% increase 1999–2023), and higher risks in earlier cohorts (1920s–1940s). Conclusion This study illuminates the escalating CLD-HF mortality crisis, amplified by COVID-19 and entrenched inequities. Urgent calls for integrated hepatology-cardiology care, targeted prevention of MASLD and alcohol misuse, telemedicine expansion in underserved areas, and policy reforms to address disparities promise to stem this tide and foster health equity.