Rising mortality from chronic rheumatic heart disease-associated heart failure among older U.S. adults, 1999-2024

Background Chronic rheumatic heart disease (CRHD) remains a preventable cause of valvular dysfunction and late-stage heart failure (HF). Although often perceived as a declining entity in high-income settings, its contemporary contribution to HF-related mortality among older adults is not well characterised. Purpose To evaluate long-term national trends and demographic disparities in CRHD-associated HF mortality among adults aged ≥55 years from 1999 to 2024. Methods A population-based analysis of national mortality data was conducted. Deaths among adults aged ≥55 years with CRHD (International Classification of Diseases codes I05–I09) and HF (I50) listed in any cause-of-death field were included. Age-adjusted mortality rates (AAMRs) per 100,000 population were calculated using the 2000 standard population. Temporal trends were assessed using Joinpoint regression to estimate annual percent change (APC) and average annual percent change (AAPC) with 95% confidence intervals. Results Between 1999 and 2024, CRHD complicated by heart failure accounted for 73,657 deaths. Most deaths occurred in medical facilities (45.30%), followed by decedents’ homes (28.65%). The overall age-adjusted mortality rate (AAMR) increased from 4.40 per 100,000 in 1999 to 4.82 per 100,000 in 2024, with a pronounced and sustained acceleration over the last decade (APC 4.8%; 95% CI 4.05–5.50; p<0.05). Although females exhibited higher overall mortality than males (mean AAMR 4.23 vs 3.08), mortality increased more rapidly among males (AAPC 1.38%; p<0.05), whereas the trend among females plateaued (AAPC 0.32%; p>0.05), resulting in progressive narrowing of the sex gap. Racial disparities were evident. Mortality peaked among non-Hispanic White individuals (mean AAMR 4.04), followed by non-Hispanic Asian (2.75), non-Hispanic Black (2.40), and Hispanic individuals (2.40). Trends remained largely stable across racial groups, except for non-Hispanic Black adults, who experienced a significant, steep increase (AAPC: 2.10%; p < 0.05). Mortality rose sharply with advancing age, peaking among adults aged ≥75 years (mean AAMR 10.49). This group demonstrated steady overall growth (AAPC 1.13%; p<0.05) and marked post-2013 acceleration (APC 5.02%; p<0.05), substantially exceeding rates observed in those aged 55–74 years (mean AAMR 1.13). Geographically, the highest mortality rates were observed in the West (mean AAMR 5.10) and Midwest (4.23), with the Midwest exhibiting the steepest temporal increase (AAPC 1.12%; p=0.05). Conclusions CRHD-associated HF mortality among older adults has entered a phase of sustained resurgence, particularly over the past decade. The accelerating age-related burden, narrowing sex gap, and disproportionate rise among specific racial groups highlight evolving inequities and challenge the perception of CRHD as a resolved public health issue. Enhanced surveillance and targeted preventive strategies are urgently neededCHRD and HF AAPC table