Abstract Body (Do not enter title and authors here): Background: Previous research has evaluated sex differences in ischemic heart disease (IHD) outcomes in the United States, but state-level disparities remain underexplored.

Objective: To quantify sex-specific IHD mortality rates across U.S. states from 2011 to 2021, and to examine variations by income level, geographic region, and risk factor burden using data from the Global Burden of Disease (GBD) Study 2021.

Methods: We conducted a state-level analysis of IHD in the United States from 2011 to 2021 using publicly available GBD mortality and population data. We examined age-standardized mortality (ASMR) and prevalence rates (ASPR) and computed mortality-to-prevalence ratios (MPRs) per 100,000 using the GBD reference population. Thirteen dietary and conventional risk factors were evaluated against theoretical minimum risk exposure levels. Hawaii was used as the reference state due to its consistently lowest ASMR and ASPR across sexes. Z-scores were used to identify significant deviations (|Z| > 1.96 for 95% CI; |Z| > 2.58 for 99% CI). Pearson’s correlation, following Shapiro-Wilk normality testing, assessed temporal trends and risk–outcome associations.

Results: Between 2011 and 2021, ASMR fell by 12.2% in men and 19.0% in women and ASPR declined by 6.8% in men and 8.9% in women. Despite these gains, Southern states continued to rank among the worst nationally, with ASMRs and ASPRs that remained within the highest decile across both sexes. In 2011, 30 states had significantly higher MPRs for women than for men (Z > 2.58), indicating a disproportionate mortality burden. By 2021, only Arkansas (6.7% [UI: 4.6–9.3]) and Mississippi (7.1% [UI: 4.8–9.7]) remained above this threshold, though moderate (Z > 1.96) disparities persisted in 11 states, primarily in the South. Higher MPRs were inversely associated with state GDP per capita. In 2021, high BMI, processed meat intake, low fiber, and low vegetable consumption were significantly linked to excess IHD mortality in women, but not in men (Z>1.96).

Conclusions: Despite an overall decline, sex disparities in IHD mortality persist, with Arkansas and Mississippi continuing to bear the highest burden. These disparities are largely driven by overweight/obesity and dietary risk factors in women, warranting the need for targeted, state-specific public health interventions.