Abstract Body (Do not enter title and authors here):
Background: Between 2011-2017, US rural adults experienced higher cardiovascular (CV) death rates than their urban counterparts, and rural-urban disparities in CV mortality widened. Little is known about these trends have evolved in the wake of the pandemic. In this study, we provide an updated analysis of rural-urban differences in CV mortality.

Methods: We used CDC WONDER to obtain national death data from 2010-2022. CV cause of death was identified by ICD-10 codes I00-99. Large metro, small/medium metro, and rural areas were defined using the National Center for Health Statistics Urban-Rural Classification. We calculated age-adjusted mortality rates (AAMRs) per 100,000 population and compared 2022 vs. 2010 using rate differences and two-sample t-tests. We then fit a Poisson regression model to estimate annual percent change (APC), evaluating trends from 2010-2019 and 2019-2022 due to reversal in CV mortality observed after 2019. We included an interaction term to assess differential trends by rurality, and repeated the analysis for younger (age 25-64) and older (age>64) adults.

Results: Between 2010-2022, AAMRs were consistently highest in rural areas (Figure 1, Table 1). AAMRs increased in rural areas (rate difference [RD] +3.4 [95% CI 0.4, 6.4]) but declined in urban areas (RD -23.8 [-25.3, -22.2]). This significant differential change was driven by a rise in AAMRs among younger, rural adults (RD +23.2 [21.2, 25.1). In contrast, older adults experienced a decline in AAMRs, though this reduction was greater in urban vs. rural areas (Table 2).

From 2010-2019, overall APCs in AAMR decreased for all areas. However, when stratified by age, younger rural adults saw a significant increase (+1.0% [95% CI 0.5, 1.5]), while those in large metro areas did not (-0.2% [-0.5, 0.1]). Older adults saw a significant decrease across all areas.

Between 2019-2022, the overall APC in AAMR increased significantly in rural areas (+3.1% [0.4, 6]), but in not large metro areas (+1.2% [-0.4, 2.9]). CV mortality rose in most subgroups, but younger rural adults experienced the largest increase (+4.2% [1.3, 7.1]) (Table 2).

Conclusions: Between 2010-2022, CV mortality increased in rural areas and decreased in urban areas. Younger, rural adults experienced the most pronounced rise in CV death, while older, urban adults experienced the steepest decline. These findings highlight an urgent need to address widening rural-urban disparities, particularly among younger adults.